Can You Take Butrans and Norco Together?
No, you should not take Butrans (buprenorphine) and Norco (hydrocodone) together because buprenorphine's exceptionally high affinity for mu-opioid receptors will block hydrocodone's analgesic effects, potentially precipitating withdrawal symptoms and rendering the Norco ineffective for pain relief. 1, 2
Pharmacologic Basis for Contraindication
Buprenorphine is a partial mu-opioid agonist with exceptionally high receptor affinity but low intrinsic activity, meaning it binds tightly to opioid receptors but only partially activates them, which displaces full agonists like hydrocodone and blocks their analgesic effects 1, 3
The FDA drug label for hydrocodone explicitly warns against combining it with partial agonist opioids like buprenorphine, stating that mixed agonist/antagonist and partial agonist analgesics may reduce the analgesic effect of hydrocodone and/or precipitate withdrawal symptoms 2
Buprenorphine's mechanism can precipitate acute withdrawal when given to patients dependent on full opioid agonists, similar to its effect when combined with hydrocodone, because it displaces the full agonist from receptors without providing equivalent activation 1, 4
Clinical Risks of Combination
Adding hydrocodone to a patient on buprenorphine maintenance risks undermining recovery and precipitating relapse in patients being treated for opioid use disorder 1
Patients should avoid concomitant use of these drugs as the combination reduces therapeutic efficacy and creates unnecessary risk 2
Multiple drug-drug interactions can result in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms 1, 5
What to Do Instead
Continue the buprenorphine (Butrans) and prioritize non-opioid analgesics first-line for breakthrough pain, including NSAIDs, acetaminophen, or adjuvant medications 1, 6
If opioids are absolutely necessary for acute pain, higher doses of full agonists may be required to overcome buprenorphine's receptor blockade, but this should be done under close supervision and typically requires discontinuing the buprenorphine first 1, 6
For patients on Butrans requiring additional pain control, consider splitting the daily buprenorphine dose into every 6-8 hour administration to maximize its analgesic properties rather than adding another opioid 6
Critical Monitoring if Combination Occurs
Monitor for signs of precipitated withdrawal including agitation, anxiety, muscle aches, increased pain, sweating, and tachycardia 1
Watch for reduced effectiveness of either medication and assess for respiratory depression, particularly if other CNS depressants are involved 1
The CDC guideline recommends avoiding dangerous opioid combinations that put patients at high risk for overdose, and this combination creates unpredictable pharmacologic effects 7
Common Pitfall to Avoid
The most critical error is assuming that adding Norco will provide additional analgesia on top of Butrans—in reality, the buprenorphine will competitively block the hydrocodone from binding to receptors, making the Norco essentially ineffective while potentially causing withdrawal symptoms 1, 2. This wastes medication, increases costs, and creates unnecessary risks without therapeutic benefit.