Hydrocodone Dosing for Humerus Fracture
For an opioid-naïve adult with a humerus fracture, start with hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 4-6 hours as needed for pain, with a maximum of 8 tablets per day (40 mg hydrocodone/2600 mg acetaminophen daily). 1
Initial Dosing Strategy
Begin with the lowest effective dose: The FDA-approved starting dose for opioid-naïve patients is hydrocodone 5 mg/acetaminophen 325 mg, taken every 4-6 hours as needed, not to exceed 8 tablets in 24 hours. 1
Prescribe as PRN (as-needed) rather than scheduled dosing to minimize total opioid exposure and reduce the risk of tolerance and dependence. 2
The CDC recommends starting opioid-naïve patients at the lowest dose, typically 20-30 morphine milligram equivalents (MME) per day; hydrocodone 5 mg taken 4 times daily equals 20 MME/day (using the 1.0 conversion factor for hydrocodone). 3
Expected Consumption Patterns
Most patients with acute fractures consume far less than prescribed: Real-world data using digital pill tracking shows patients with acute fractures ingested a median of only 6 oxycodone 5-mg pills (30 mg total) over 7 days, with 82% of consumption occurring in the first 3 days. 4
Patients with humerus fractures specifically consumed approximately 9.1 opioid pills over 3.7 days in a prospective study of nonoperatively treated fractures. 5
Prescribe only what is needed: Given these consumption patterns, prescribing 10-15 tablets of hydrocodone 5 mg/acetaminophen 325 mg for 3-5 days is typically sufficient for most humerus fractures. 2
Critical Safety Considerations
Maximum acetaminophen dose: Ensure total daily acetaminophen does not exceed 3,900 mg from all sources; explicitly counsel patients to avoid other acetaminophen-containing products to prevent hepatotoxicity. 2, 1
Monitor closely in the first 24-72 hours for respiratory depression, especially after initiating therapy or increasing doses. 1
Avoid scheduled dosing: Do not prescribe opioids on a fixed schedule, as this unnecessarily increases total opioid exposure and risk of adverse effects. 2
Alternative Considerations
Consider oxycodone if hydrocodone is ineffective: A randomized trial in fracture patients found no difference in pain scores between hydrocodone 5 mg/acetaminophen 325 mg and oxycodone 5 mg/acetaminophen 325 mg at 30 and 60 minutes, though constipation was higher with hydrocodone. 3
Nonopioid alternatives should be considered first: NSAIDs or acetaminophen alone may be equally effective for many musculoskeletal injuries and should be tried before opioids when not contraindicated. 2
In older studies, hydrocodone demonstrated fewer CNS side effects and treatment failures compared to codeine for acute musculoskeletal pain. 6
Operative vs. Nonoperative Management
Operative repair increases opioid duration: If the humerus fracture requires surgical fixation, expect longer opioid use; 86% of patients requiring operative repair continued opioids at 1 week versus earlier cessation in nonoperative cases. 4
Regional anesthesia paradoxically increases both inpatient and outpatient opioid consumption after humerus fracture surgery, likely due to rebound pain when the block wears off. 7
Common Pitfalls to Avoid
Do not overprescribe: The median consumption is 6-9 pills over 3-7 days; prescribing 30-60 tablets creates unnecessary surplus for diversion. 4, 5
Do not use extended-release formulations: These are only for opioid-tolerant patients with chronic pain, never for acute fracture pain. 2
Do not fail to counsel on safe storage and disposal: Unused opioids are a major source of diversion and nonmedical use. 3
Do not prescribe without reassessment: Reevaluate pain control within 3-5 days and discontinue opioids as soon as pain is manageable with nonopioid analgesics. 1