What are the guidelines for prescribing Norco (hydrocodone and acetaminophen) to a patient for pain management?

Norco (Hydrocodone/Acetaminophen) Prescribing Guidelines

Indications and Appropriate Use

Norco should be reserved for pain severe enough to require an opioid analgesic when alternative treatments have failed, are inadequate, or are not tolerated. 1

• Opioid therapy is appropriate for acute pain from severe traumatic injuries, invasive surgeries, and other severe acute pain when NSAIDs and other therapies are contraindicated or likely ineffective 2
• Nonopioid therapies (NSAIDs, acetaminophen) are at least as effective as opioids for many common acute pain conditions including low back pain, neck pain, musculoskeletal injuries, minor surgeries, dental pain, kidney stone pain, and headaches 2
• Acetaminophen should be considered the preferred first-line pharmacologic treatment for mild to moderate pain 3

Standard Dosing Recommendations

The CDC recommends using the lowest effective dose for the shortest duration, such as hydrocodone 5 mg/acetaminophen 325 mg, one to two tablets every 4-6 hours as needed for pain, with a maximum daily limit of 8 tablets. 2

FDA-Approved Dosing by Strength:

• Norco 5 mg/325 mg: 1-2 tablets every 4-6 hours as needed; maximum 8 tablets daily 1
• Norco 7.5 mg/325 mg: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 1
• Norco 10 mg/325 mg: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 1

Critical Prescribing Principles

Prescribe Norco "as needed" rather than on a scheduled basis (e.g., one tablet not more frequently than every 4 hours as needed for moderate to severe pain). 2

• Prescribe only for the expected duration of pain severe enough to require opioids 2
• Use a conservative approach when initiating therapy—it is safer to underestimate dosage than to overestimate and manage overdose 1
• Follow patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy and following dosage increases 1

Morphine Milligram Equivalent (MME) Monitoring

Hydrocodone has a 1:1 conversion to morphine milligram equivalents (1 mg hydrocodone = 1 MME). 2

• At maximum dosing of Norco 10 mg/325 mg (6 tablets daily), this equals 60 MME, approaching the 50 MME/day threshold requiring heightened monitoring 2
• Dosages ≥50 MME/day require careful reassessment of benefits versus risks 2
• Dosages ≥90 MME/day show progressively diminishing returns in pain relief with escalating overdose risk 2
• Before increasing total opioid dosage to ≥50 MME/day, pause and carefully reassess individual benefits and risks 2

Acetaminophen Safety Considerations

Total daily acetaminophen intake must not exceed 4 grams from all sources to prevent severe liver injury. 3

• The NCCN suggests limiting chronic administration of acetaminophen to 3 grams or less per day due to hepatotoxicity concerns 3
• Calculate total daily acetaminophen intake from all sources, including over-the-counter medications, to avoid hepatotoxicity 2
• The FDA has issued a boxed warning about the risk of severe liver injury associated with acetaminophen, which can lead to liver failure and death 3
• Acetaminophen should be used with caution or not at all when prescribing combination opioid-acetaminophen products to prevent excess dosing 3

Special Populations

For elderly patients or those with hepatic or renal impairment, start with lower doses and careful titration. 2

• In patients with renal impairment, use opioids with caution and at reduced doses and frequency 2
• Elderly persons are at high risk for side effects of NSAIDs and opioids, including gastrointestinal, platelet, and nephrotoxic effects 3

Mandatory Side Effect Management

Prescribe prophylactic laxatives to prevent opioid-induced constipation in all patients taking Norco. 2

• Common opioid adverse effects include constipation, somnolence, nausea, and vomiting 4
• Consider prescribing preventive medications for common opioid side effects 2

Duration of Therapy and Discontinuation

If Norco is taken around the clock for more than a few days, implement a taper to minimize withdrawal symptoms. 2

• Do not abruptly discontinue Norco in patients who may be physically dependent on opioids 1
• Rapid discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide 1
• Continually reevaluate patients to assess maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for development of addiction, abuse, or misuse 1

Common Pitfalls to Avoid

Do not use opioid-acetaminophen combinations as first-line therapy when nonopioid alternatives may be effective. 2

• Avoid prescribing Norco on a scheduled basis rather than as-needed 2
• Do not fail to taper Norco if used around the clock for more than a few days 2
• Never exceed maximum daily acetaminophen limits when patients are taking other acetaminophen-containing products 3, 2
• Avoid high doses for long periods of time, particularly in elderly patients 3

Comparative Efficacy Evidence

Research demonstrates that hydrocodone/acetaminophen provides comparable analgesia to other opioid combinations:

• Hydrocodone/acetaminophen (5 mg/325 mg) provides equivalent pain relief to oxycodone/acetaminophen (5 mg/325 mg), with both reducing pain scores by approximately 50% 5
• Hydrocodone may be more effective than codeine in acute musculoskeletal pain, with significantly fewer treatment failures and fewer CNS side effects 6
• Codeine/acetaminophen and hydrocodone/acetaminophen demonstrate comparable efficacy and tolerability in chronic cancer pain over 23 days of treatment 4