How should I taper hydrocodone 10 mg/acetaminophen 325 mg in a patient with fracture pain who is experiencing opioid‑induced urinary retention and is currently taking mirabegron?

Tapering Hydrocodone 10 mg/Acetaminophen 325 mg for Fracture Pain with Opioid-Induced Urinary Retention

Given the opioid-induced urinary retention, you should implement a gradual taper reducing the hydrocodone dose by 10-25% every 2-4 weeks while simultaneously optimizing multimodal analgesia with scheduled acetaminophen, regional nerve blocks if feasible, and addressing the urinary retention with continued mirabegron. 1

Immediate Assessment and Optimization

Before initiating the taper, establish the baseline:

• Document current total daily hydrocodone dose and frequency of administration 1
• Assess pain intensity using a numeric rating scale (0-10) and functional status 1
• Confirm the urinary retention is opioid-induced (onset correlating with opioid use, absence of other causes) 2
• Obtain patient agreement and collaboration for the tapering plan, as patient consent is a key component of successful tapers 1

Multimodal Analgesia Foundation

Immediately optimize non-opioid pain management before reducing opioids:

• Initiate scheduled intravenous or oral acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) as the cornerstone of multimodal analgesia 1
• Consider adding NSAIDs (e.g., ibuprofen 400-600 mg every 6-8 hours) if no contraindications exist, particularly no renal impairment 1
• Implement regional anesthesia techniques (peripheral nerve blocks) if the fracture location permits and skills are available, as these significantly reduce opioid requirements 1
• Add gabapentinoids (gabapentin or pregabalin) for neuropathic pain components if present 1

Specific Tapering Protocol

For a patient on hydrocodone 10 mg/acetaminophen 325 mg, use this structured approach:

Initial Dose Reduction (Weeks 1-2)

• Reduce to hydrocodone 7.5 mg/acetaminophen 325 mg at the same frequency (representing a 25% reduction in opioid component) 1
• Monitor for withdrawal symptoms: anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia 1
• If withdrawal symptoms emerge, pause the taper and maintain the current dose until symptoms resolve 1, 2

Subsequent Reductions (Every 2-4 Weeks)

• Continue reducing by 10-25% of the current dose every 2-4 weeks, as slower tapers (10% per month) are better tolerated than rapid tapers 1
• Example progression: 7.5 mg → 5 mg → reduce frequency (e.g., from every 6 hours to every 8 hours) → extend intervals further 1, 2
• The FDA label specifically recommends small increments (no greater than 10-25% of total daily dose) to avoid withdrawal symptoms 2

Final Discontinuation

• Once the smallest available dose is reached, extend the interval between doses (e.g., every 12 hours, then once daily, then every other day) 1
• Discontinue when taken less frequently than once daily 1

Monitoring and Follow-Up

Establish close surveillance throughout the taper:

• Follow up at least monthly during active tapering, with more frequent contact (weekly) during initial dose reductions 1
• Utilize team members (nurses, pharmacists) for telephone or telehealth check-ins between visits 1
• Reassess pain scores, functional status, and urinary symptoms at each contact 1, 2
• Monitor for signs of anxiety, depression, or aberrant drug-seeking behaviors 1

Managing the Urinary Retention

Address the urinary retention concurrently:

• Continue mirabegron as prescribed, as it does not interact with the tapering process 2
• Expect improvement in urinary retention as opioid dose decreases, as this is a dose-dependent side effect 2
• If urinary retention persists despite opioid reduction, consider urology consultation for alternative etiologies 2

Critical Pitfalls to Avoid

Never abruptly discontinue opioids, as rapid discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain, suicide attempts, and patients seeking illicit opioids 1, 2

Do not abandon the patient or make "cold" referrals to other clinicians during the taper 1

Avoid using the high opioid dose alone as the sole determinant for tapering speed; individualize based on duration of prior use, with longer duration requiring slower tapers 1

Do not proceed with planned dose reductions if clinically significant withdrawal symptoms emerge; instead, slow or pause the taper 1, 2

Never use opioids as monotherapy for fracture pain in any patient; multimodal analgesia is essential for optimal outcomes and successful tapering 1

Special Considerations for Fracture Pain

For elderly patients with fractures specifically:

• Opioid dosing should consider a 20-25% dose reduction per decade after age 55, as older trauma patients require fewer opioids than younger patients with similar pain scores 1
• Opioids should be reserved for breakthrough pain only, not as first-line treatment 1
• The presence of fracture pain does not preclude tapering when adverse effects (like urinary retention) outweigh benefits 1

Naloxone Provision

Provide naloxone and overdose education before initiating the taper, as there is increased risk for overdose if the patient returns to a previously prescribed higher dose due to loss of opioid tolerance 1