What is the recommended dose of Norco (hydrocodone bitartrate and acetaminophen) for a patient with gum and jaw infection pain?

Norco Dosing for Gum and Jaw Infection Pain

For gum and jaw infection pain, start with Norco 5 mg/325 mg, one to two tablets every 4-6 hours as needed (maximum 8 tablets daily), but only after NSAIDs like ibuprofen 400-600 mg have failed or are contraindicated, since nonopioid therapies are equally or more effective for dental pain. 1, 2, 3

Why NSAIDs Should Be First-Line

• Nonopioid alternatives such as ibuprofen are superior to or comparable with opioid-acetaminophen combinations for dental pain, and should be tried first unless contraindicated. 1, 3
• Ibuprofen 400-600 mg provides equivalent or better analgesia than hydrocodone combinations for moderate to severe dental pain, with fewer side effects like nausea and vomiting. 4, 5
• The evidence consistently shows that dental pain responds well to NSAIDs alone, making opioids unnecessary in many cases. 4, 3

When Norco Is Appropriate

• Norco is appropriate only when NSAIDs are contraindicated (GI bleeding risk, renal impairment, allergy) or have demonstrably failed to control pain. 1, 2
• Opioids have a role for severe acute pain related to invasive surgeries or severe traumatic injuries, but dental infections typically respond to nonopioid therapy. 1

Specific Norco Dosing Regimen

Starting Dose for Opioid-Naïve Patients

• Begin with Norco 5 mg/325 mg (hydrocodone/acetaminophen), one to two tablets every 4-6 hours as needed, with a maximum of 8 tablets per 24 hours. 1, 2
• This provides 30-60 morphine milligram equivalents (MME) daily at maximum dosing, which is below the 50 MME/day threshold requiring heightened monitoring. 1, 6

Alternative Strengths

• Norco 7.5 mg/325 mg: one tablet every 4-6 hours as needed (maximum 6 tablets daily). 2
• Norco 10 mg/325 mg: one tablet every 4-6 hours as needed (maximum 6 tablets daily), but this higher strength should be reserved for patients with more severe pain or inadequate response to lower doses. 6, 2

Critical Dosing Principles

• Prescribe as "as needed" (PRN) rather than scheduled dosing to minimize total opioid exposure and reduce side effects. 1, 2
• The lowest effective dose for the shortest duration should always be the goal. 1, 2

Acetaminophen Safety Limits

• The maximum daily acetaminophen dose from ALL sources must not exceed 4,000 mg (preferably limit to 3,000 mg) to prevent hepatotoxicity. 1, 2
• Explicitly counsel patients to avoid all other acetaminophen-containing products (over-the-counter cold medications, other pain relievers). 1
• Each Norco tablet contains 325 mg acetaminophen, so at maximum dosing (8 tablets of 5 mg/325 mg), total acetaminophen is 2,600 mg—well within safe limits. 2

Duration of Therapy

• Limit prescribing to 3-5 days for acute dental pain, as this is typically sufficient for pain severe enough to require opioids. 1, 6
• If Norco is taken around the clock for more than a few days, implement a taper to minimize withdrawal symptoms. 1
• Most gum and jaw infections should improve with appropriate antibiotic therapy and dental intervention within this timeframe. 4

Special Populations

• Elderly patients (≥65 years) or those with hepatic/renal impairment should start with lower doses (one tablet of 5 mg/325 mg every 6 hours) and careful titration. 1
• Monitor closely for respiratory depression, especially within the first 24-72 hours of initiating therapy. 2

Monitoring and Side Effect Management

• Prescribe prophylactic laxatives (senna, docusate) to prevent opioid-induced constipation, which occurs in the majority of patients taking opioids. 1
• Common side effects include nausea (18-40%), vomiting (6-23%), dizziness, and somnolence. 7, 5
• Hydrocodone combinations cause significantly more nausea and vomiting compared to NSAIDs alone. 5, 8

Common Pitfalls to Avoid

• Do not use Norco as first-line therapy when ibuprofen or other NSAIDs may be effective—this is the most common prescribing error for dental pain. 1, 4
• Do not prescribe on a scheduled basis rather than as-needed, as this unnecessarily increases opioid exposure and side effects. 1, 2
• Do not fail to account for total acetaminophen from all sources when calculating daily limits. 1
• Do not prescribe for longer than necessary—most acute dental pain resolves within 3-5 days with appropriate treatment. 1, 6

Combination Therapy Option

• If NSAIDs alone provide insufficient relief, consider prescribing both ibuprofen 400-600 mg and Norco 5 mg/325 mg on alternating schedules (e.g., ibuprofen every 6 hours with Norco available for breakthrough pain). 4
• This approach maximizes analgesia through different mechanisms while minimizing opioid consumption. 4