Why is hydrocodone always combined with acetaminophen?
February 14, 2020 2:00 PM   Subscribe

My husband has a brand new knee and is taking Norco for the post op pain. This is a combination drug with hydrocodone and acetaminophen (Tylenol). He is trying to take as little narcotic as possible.

So, he wants to take two Tylenol and then take Norco only if the Tylenol isn’t working. But he can’t, because the Norco has more Tylenol in it. That’s the way it comes.

By way of contrast, OXYcodone is available plain or with aspirin or with Tylenol.
Does hydrocodone come as a single agent drug? Why is Tylenol so commonly added to it?
posted by SLC Mom to Health & Fitness (20 answers total)
My understanding is that it is intended to limit the amount of the opioid you need to manage your pain and thereby reduce the risk of addiction, essentially already doing what your husband wants to do.
posted by kindall at 2:09 PM on February 14 [2 favorites]

He could take a different OTC NSAID such as naproxen (Aleve) and then take the hydrocodone when needed.
posted by yclipse at 2:12 PM on February 14 [3 favorites]

My understanding is that there's something about the combination of the two that is particularly effective with pain management.
posted by bile and syntax at 2:14 PM on February 14 [4 favorites]

The Tylenol (Acetaminophen) increases the effectiveness of the Hydrocodone so you need less of it when taken together. He could take an NSAID such as ibuprofen or naproxen, if he wanted to leave the combo pill for a fallback position as it where as it is safe to take Acetaminophen & Ibuprofen together as long as you don't exceed daily recommended doses of each(and they too increase the effectiveness of each other if taken together).
posted by wwax at 2:29 PM on February 14 [2 favorites]

bile, that's what I was told, too, when I was postop for this.

I hated it, which was a surprise given how much Greg House loved it on TV (Vicodin and Norco are the same thing). It made me sweaty and nauseous.
He is trying to take as little narcotic as possible.
Assuming he's not someone with a history of addiction, let me share with you what everyone I know who has a trauma story shared with me:

Take what they give you for as long as they tell you to take it, because it's WAY easier to keep pain away than it is to make it go away again if you let it come back.

For me, this meant a solid week of Norco (and then, uh, laxatives, not to go all TMI on you), and then a longer period of Tramadol and Ibuprofen. It sucked, but I never hurt, so there's that as a data point.

Don't be a hero. Pain sucks.
posted by uberchet at 2:34 PM on February 14 [15 favorites]

Alor is a combination drug of hydrocodone and aspirin. There's many listed here; many of which are not acetaminophen.

To combat recreational use, hydrocodone is paired with something that will give toxic effects if too much is used. I would imagine that if hydrocodone is more susceptible to abuse (whether by history, potency, or what not) that might be why it's more regularly paired with something else. I remember hearing about vicodins well before oxy was a thing, so I suspect that just as doctors are likely not prescribing oxy without abuse deterrents (Er: combination products), that's why hydrocodone is often a combination product. And if there truly isn't a non-combination available in hospital use only, it's probably because for a use case like that something like morphine might be better suited.

If your doctor won't prescribe a different combination product, as others have said I'd suggest trying a different NSAID. Or asking your doctor for a different prescription NSAID if you've already found other OTC ones are inappropriate for you for various reasons.
posted by nobeagle at 2:36 PM on February 14 [1 favorite]

I've been told that making hydrocodone available only with acetaminophen added was a measure aimed at opioid abuse deterrence. I'm trying to research that, but I have to go right now, so suggest googling "abuse deterrence" along with terms you're interested in.

(So far all I've found is this outdated article which mentions in passing that "the Drug Enforcement Agency classifies hydrocodone, in combination with acetaminophen or ibuprofen, as a Schedule III drug, because the adjuvant analgesic medication (the acetaminophen) supposedly precludes excessive usage." (This was before it was changed to be Schedule II, to limit ease of refills.) The idea was that they knew perfectly well that too much Tylenol can kill your liver, and they'd rather you risked that then got too high without paying a piper.

(Read about the history of what public health authorities knowingly did re allowing alcoholics to poison themselves during Prohibition, if you don't think that this puritanical approach can and has been a touchstone of our drug policy.)
posted by fingersandtoes at 2:40 PM on February 14 [1 favorite]

Please consult with your husband’s ortho before he starts taking an NSAID. I am assuming he has been prescribed an anticoagulant (“blood thinner”) to prevent clot formation around the new joint. Depending on that anticoagulant and its dosage, he might not be able to also take an NSAID safely at this juncture.
posted by little mouth at 3:34 PM on February 14 [8 favorites]

Take what they give you for as long as they tell you to take it, because it's WAY easier to keep pain away than it is to make it go away again if you let it come back.

I disagree. Doctors are generally not that well informed on how much exposure to pain killers it takes to form an addiction, or how to avoid that, or how to recognize it and deal with it if it happens. Although some of the opioid epidemic stems from people who are abusing meds, a lot of it comes from people who take their prescribed medication and end up addicted.

I was also told that the primary reason it was combined was to limit abuse - excessive doses of acetominapen being harmful
posted by RustyBrooks at 3:38 PM on February 14 [1 favorite]

Acetaminophen can be used for mild pain relief, but it has a narrow window for effectiveness before it causes liver damage. Taking enough will overwhelm the liver's ability to metabolize it, causing liver failure and the real risk of coma and possible death.

The sole reason the two medications are put together is to effectively present the person taking the drug with the real threat of death, if too much is taken:
The combination of hydrocodone with acetaminophen or other products helps to prevent its recreational use and administration by injection.
Adulteration with a poison forces an upper limit on the amount of pain medication taken.
posted by They sucked his brains out! at 3:44 PM on February 14 [6 favorites]

He can take Tylenol alone at first if he wants to. As long as he doesn't exceed 3000mg total per 24 hours he will be fine. So he could take up to 4 Extra Strength Tylenol (500mg/ea) and two hydrocodone (10/325) a day and still be ok. Note, some sources say up to 4000mg a day is ok, but the latest thinking has doctors erring on the safe side, hence 3000mg/day recommended limit.

PS: Watch for Acetaminophen from other sources (cold/flu meds, etc.)

Edited to add: I am not a doctor, I am a pain management patient married to an RN.
posted by Grumpy old geek at 4:47 PM on February 14 [1 favorite]

Take what they give you for as long as they tell you to take it, because it's WAY easier to keep pain away than it is to make it go away again if you let it come back.

I agree with this. Staying ahead of the pain is absolutely better than letting it come back. My experience of this with surgical pain was that I had pain way, way beyond what my doctor wanted to prescribe for (I heal slowly due to an immune issue) and doctors are often quite paranoid about the potential for addiction.
posted by bile and syntax at 5:18 PM on February 14 [2 favorites]

If it is a deterrent, why is oxycodone prescribed solo? Isn’t that supposed to be more addictive?

Husband can’t take NSAIDS. Any of them. It is Tylenol and opioids.
posted by SLC Mom at 5:51 PM on February 14

I recently had a surgery as in still recovering and my dr said the Tylenol was a replacement for the Norco and you can also “layer” them- basically take one or the other every few hours if you are experiencing severe pain, basically what grumpy old geek said. I got a prescription of 30 10 mg oxycodone that I took for the first 3 days and didn’t need anymore after that.
posted by The_Vegetables at 7:08 PM on February 14

IANYD. I prescribe oxycodone in which I am not able to give Tylenol, or if I need to give a higher dose of oxycodone to control someone's pain than I would be able to do with the inclusion of the acetaminophen in the Percocets. For example, people who rely on feeding tubes are generally not able to take extended-release medications, and for fentanyl to be absorbed, must have body fat underneath the patch (so not always a viable solution for someone who is chronically malnourished).

There have been extended release Hydrocodone preparations. I have never written for them and I'm not even sure they're clinically available at this point, as I have never had a patient on them for as long as I have been a physician. I do remember that the FDA caught a ton of flack when Zohydro was approved.
posted by honeybee413 at 7:51 PM on February 14 [2 favorites]

Seconding uberchet on everything (especially the laxatives …)
posted by scruss at 8:02 PM on February 14 [1 favorite]

Mr. SLC had surgery and the acetaminophen or asprin just might perform some function in addition to pain-killing that is beneficial. Antiinflamitory, anticoaguant, reduce swelling, prevent blood clots. The hydrocodone might just be for pain-killing but does not much else on it's own. You should be able to ask the doctor about this. It might boil down to needing that acetaminophen for good healing but you can't take enough of it to stop the hurt, but this thing with enough acetaminophen to do the job and something with no other purpose than to stop the hurt usually works out pretty well. To a first approximation, take what was prescribed until you find out. Be honest with the doctor if your really want to avoid the "does nothing but kill pain" part and are willing to be a bit miserable over being drugged-up. There's a middle ground where you should be able to tell them that the bit of pain is OK without causing yourself harm from not following doctor's orders.
posted by zengargoyle at 8:04 PM on February 14

Okay, I am a pharmacologist and pain relief is on this week's lecture schedule. Bits of the correct answers have appeared.
Acetaminophen adds to the relief of opioids. Some physicians will prescribe acetaminophen plus opioid in the same pill because it penalizes overuse. Acetaminophen is a schizophrenic drug. It is virtually without toxicities unless you overdose and it's damned easy to overdose. Combining to prevent too much opioid is a horrid strategy. Addicts won't care about risk and will ruin their livers.
There are a variety of reasons why patients don't want to take a full dose of opioids. Addiction potential, mentioned. It is correct that the best way to avoid addiction is to not be in and out of pain. Some patients experience dysphoria from opioids. Some don't want to be "out of it." Some patients don't mind a little pain.
You can get the drugs individually, or if NSAIDs are not contraindicated, get NSAIDs plus opioid. NSAIDs plus acetaminophen will not get you any more effect than the max of NSAIDs or acetaminophen alone.
posted by dances_with_sneetches at 5:32 AM on February 15 [4 favorites]

I may be weird but taking ibuprofen is more helpful for pain than oxycodone or the Norco. This is primarily for swelling and shooting pains due to chemo.
posted by mickbw at 8:39 PM on February 16

I disagree. Doctors are generally not that well informed on how much exposure to pain killers it takes to form an addiction, or how to avoid that, or how to recognize it and deal with it if it happens.
On MeFi generally, any discussion of a potentially habit-forming substance inevitably arrives at ZOMG ADDICTION.

Yes, negligent dispensing of opioids is a contributor to the problem we have. But so too is insufficient medication of pain.
I was also told that the primary reason it was combined was to limit abuse - excessive doses of acetominapen being harmful
That doesn't sound true to me, given that drugs like Vicodin have been around for far longer than we've had an Opiod Crisis (FDA approval of the combo dates to 1982), plus the previously-noted fact that these opioids are broadly available in non-combination forms.

The article They Sucked links doesn't say this is the sole reason, or even that it's a reason for the combination; it just notes that the presence of acetaminophen in the drug helps prevent some recreational use.

This is a textbook example of the post hoc ergo propter hoc fallacy.
posted by uberchet at 7:10 AM on February 17

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