What is the appropriate dose of Norco (hydrocodone/acetaminophen) for an opioid‑naïve adult with a pelvic fracture?

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Norco Dosing for Pelvic Fracture

For an opioid-naïve adult with a pelvic fracture, prescribe Norco 5 mg/325 mg, one to two tablets every 4-6 hours as needed for pain, with a maximum of 8 tablets daily (40 mg hydrocodone/2,600 mg acetaminophen per day). 1

Starting Dose and Administration

  • Begin with the lowest effective dose: Norco 5 mg/325 mg, 1-2 tablets every 4-6 hours as needed, not to exceed 8 tablets in 24 hours 1, 2
  • Prescribe as PRN (as-needed) rather than scheduled dosing to minimize total opioid exposure and reduce risk of tolerance and dependence 1, 3, 4
  • This starting regimen provides 20-40 morphine milligram equivalents (MME) per day, which is appropriate for opioid-naïve patients 3

Critical Safety Thresholds

  • Maximum daily acetaminophen must not exceed 4,000 mg from all sources to prevent hepatotoxicity 1, 3, 2
  • Explicitly counsel patients to avoid other acetaminophen-containing products including over-the-counter medications 1, 4
  • At maximum dosing (8 tablets of 5 mg/325 mg), this equals 40 MME/day, which remains well below the 50 MME/day threshold requiring heightened monitoring 1, 3

Duration and Monitoring Considerations

  • Prescribe only for 3-7 days for acute fracture pain, as this is typically sufficient for most orthopedic fractures 3, 4
  • Pelvic fractures carry higher risk for long-term opioid use: Patients receiving ≥50 MME per inpatient day have 3-fold increased odds of long-term opioid use after pelvic fractures 5
  • If opioids are used around-the-clock for more than a few days, implement a taper to minimize withdrawal symptoms 1

When to Consider Alternative Dosing

  • If Norco 5 mg is ineffective after appropriate trial, consider Norco 10 mg/325 mg, one tablet every 4-6 hours as needed, maximum 6 tablets daily (60 MME/day) 3, 2
  • At 60 MME/day, this approaches the 50 MME/day threshold requiring careful reassessment of benefits versus risks and heightened monitoring 1, 3
  • Check the prescription drug monitoring program (PDMP) before prescribing to identify patients at risk for opioid misuse 3

Evidence Supporting This Approach

  • Oxycodone 5 mg and hydrocodone 5 mg provide equivalent analgesia for acute fractures at 30 and 60 minutes, with no clinically significant difference in pain relief 6, 7
  • Strong opioids (oxycodone) are not superior to mild opioids (codeine/acetaminophen) for subacute pain after surgically managed fractures, despite 6-fold higher opioid doses 8
  • Nonopioid alternatives should be considered first when not contraindicated, as NSAIDs or acetaminophen alone may be equally effective for many musculoskeletal injuries 1, 4

Common Pitfalls to Avoid

  • Do not prescribe Norco 10 mg as initial therapy for opioid-naïve patients—start with the 5 mg formulation 1, 3
  • Do not prescribe on a scheduled basis (e.g., "take every 4 hours")—always prescribe as-needed to minimize unnecessary opioid exposure 1, 3, 4
  • Do not overprescribe: 10-20 tablets of Norco 5 mg/325 mg for 3-5 days is typically sufficient for most pelvic fractures 4
  • Do not use extended-release formulations for acute fracture pain—these are only for opioid-tolerant patients with chronic pain 4
  • Do not fail to counsel on safe storage and disposal of unused opioids, as they are a major source of diversion 4

Special Population Adjustments

  • Elderly patients (≥65 years) and those with hepatic or renal impairment require dose reduction and more cautious titration 1, 3
  • Prescribe prophylactic laxatives to prevent opioid-induced constipation, as hydrocodone has higher constipation rates than oxycodone 1, 7

References

Guideline

Hydrocodone-Acetaminophen Dosing Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Opioid Prescribing Guidelines for Norco 10mg

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Hydrocodone Dosing for Humerus Fracture

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Comparison of oxycodone and hydrocodone for the treatment of acute pain associated with fractures: a double-blind, randomized, controlled trial.

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2005

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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