From the Guidelines
The concurrent use of Norco (hydrocodone/acetaminophen) and Suboxone (buprenorphine/naloxone) is generally contraindicated due to the potential for precipitated withdrawal and reduced efficacy of both medications. Suboxone is specifically designed to treat opioid dependence, while Norco is a full opioid agonist used for pain management. Using them together is problematic for several reasons. Suboxone contains buprenorphine, which has a higher binding affinity for opioid receptors than hydrocodone, meaning it will displace hydrocodone from receptors and potentially trigger withdrawal symptoms in opioid-dependent individuals 1. Additionally, Suboxone contains naloxone, an opioid antagonist designed to prevent misuse, which can further precipitate withdrawal if Suboxone is taken after Norco.
From a medical perspective, these medications work in opposing ways - one aims to maintain opioid receptor occupation at steady levels to prevent withdrawal (Suboxone), while the other provides full opioid effects for pain relief (Norco) 2. Patients transitioning from Norco to Suboxone must typically wait until they are in mild to moderate withdrawal before starting Suboxone to avoid precipitated withdrawal. If you're seeking pain management while on Suboxone, consult your healthcare provider about appropriate non-opioid alternatives or specialized approaches. The CDC guideline for prescribing opioids for chronic pain also recommends offering or arranging evidence-based treatment, usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies, for patients with opioid use disorder 3, 4.
Some key considerations when managing patients on Suboxone include:
- Assessing for opioid use disorder using DSM-5 criteria
- Offering or arranging evidence-based treatment for patients with opioid use disorder
- Considering the use of non-opioid alternatives for pain management
- Coordinating care with mental health professionals and substance use disorder treatment specialists
- Being aware of the potential for drug-drug interactions and precipitation of withdrawal symptoms when using Suboxone with other medications.
Overall, the use of Norco and Suboxone together is not recommended due to the potential risks and lack of medical evidence supporting their concurrent use. Instead, healthcare providers should focus on providing evidence-based treatment for opioid use disorder and exploring alternative pain management options for patients on Suboxone.
From the Research
Opioid Combination Therapy
There is limited evidence to support the use of Norco and Suboxone together. However, some studies discuss the combination of opioids and non-opioids for pain management:
- Combination therapy may increase the analgesic potency of opioids, reduce the development of tolerance and dependence, and reduce the risk of diversion and abuse 5
- Buprenorphine, a partial opioid agonist, is often combined with naloxone to reduce the potential for misuse, but this combination may have adverse effects and create barriers to care 6
Medication-Assisted Treatment
Medications such as methadone, buprenorphine, and naltrexone are effective for treating opioid use disorder:
- Methadone has the strongest evidence for effectiveness, but treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication 7
- Buprenorphine is a well-established treatment for opioid use disorder, but access to treatment is limited by lack of access and stigma 8, 9
Safety and Efficacy
The safety and efficacy of combining Norco and Suboxone are not well-established:
- There is no direct evidence to support the use of Norco and Suboxone together, and the combination may increase the risk of adverse effects and overdose
- Further research is needed to determine the safety and efficacy of this combination therapy 5