Hydrocodone acetaminophen doesn’t work for everyone. Belbuca, Methadose, Cymbalta, Naprosyn, and Qdolo are some hydrocodone acetaminophen alternatives. Get the full list here.
Compare hydrocodone acetaminophen alternatives | Belbuca | Methadose | Cymbalta | Naprosyn | Qdolo | Natural alternatives | How to switch meds
The management of pain is a sensitive and sometimes controversial topic. Pain is subjective and is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with, or resembling, actual or potential tissue damage.” It is a personal experience, and access to pain management is a basic right. Pain management depends on adequately identifying the type of pain one is experiencing, which can be broken down into 4 broad categories: acute, chronic, neuropathic, and radicular pain.
Lortab (hydrocodone-acetaminophen) is a type of opioid medication. Opioids are prescription drug painkillers that are typically reserved for certain types of moderate to severe and sometimes chronic pain, and rarely for acute pain that is unresponsive to non-opioid medications like non-steroidal anti-inflammatory drugs (NSAIDs), Tylenol (acetaminophen), and certain antidepressants or anti-seizure medications. Opioids should not be used as first-line therapy for short-term or chronic pain—with the exception being in end-of-life or palliative care, during active cancer treatment, and with sickle cell disease. Non-opioids should always be maximized before trialing opioids. If opioid therapy is initiated, it should be done in conjunction with non-pharmacologic and non-opioid therapy, and ideally, it should be used short-term.
Lortab, which is hydrocodone co-formulated with acetaminophen, is a good option when pain cannot be managed by non-opioids alone since it contains a non-opioid to minimize the need for higher doses of opioids. With that said, the total dose of Lortab must be closely monitored since the maximum total daily dose of acetaminophen can be met, which is associated with liver damage. While opioids can be highly addictive, they are efficacious in providing immediate and adequate relief of severe pain, and there is often no substitute for granting satisfactory pain relief for one’s quality of life. However, one must be aware of the potential side effects and their drug-addicting properties. Guidance for appropriate prescribing and use of opioids is available; opioids must be dosed safely and strategically with significant oversight by a healthcare professional. Based on the response, opioids may warrant dose titrations as well as trials of different medications within the class to control pain.
What can I take in place of hydrocodone acetaminophen?
There are other options available to treat pain that does not improve with hydrocodone-acetaminophen or in patients who experience adverse events. These alternative prescription medications include other types of opioids, NSAIDs like Advil or Motrin (ibuprofen) or Aleve (naproxen), and some medications used for depression or seizures, like Cymbalta (duloxetine) or gabapentin. These options may be more suitable for certain individuals due to the type of pain experienced, their side effect profiles, the avoidance of specific drug allergies, the routes of administration available, and dosages.
Compare hydrocodone acetaminophen alternatives
|Lortab (hydrocodone/ acetaminophen)
|(Based on hydrocodone content): 5 mg to 10 mg every 4 to 6 hours as needed
|75 mcg once daily; if tolerated, can increased up to 150 mcg twice daily
|Individualized; starting dose based on equianalgesic conversion from morphine equivalent
|Fibromyalgia, generalized anxiety disorder, major depressive disorder, chronic musculoskeletal pain, neuropathic pain associated with diabetes mellitus
|30 mg once daily for 1 week, then 60 mg once daily
|Anti-inflammatory, dysmenorrhea, fever, gout, pain
|500 mg once, followed by 250 mg to 500 mg every 12 hours as needed
|25 mg to 50 mg every 6 hours as needed; may increase to 50 mg to 100 mg every 4 to 6 hours
|MS Contin (extended-release morphine)
|Chronic pain (including chronic cancer pain) in opioid tolerant individuals
|Total daily oral immediate-release morphine dose, administered in 2 divided doses (every 12 hours) or in 3 divided doses (every 8 hours)
|MS Contin coupons
|Acute and chronic pain in opioid-naïve or opioid-tolerant individuals, acute pain in sickle cell disease, neuraxial analgesia
|Oral: 1 mg to 2 mg every 4 to 6 hours as needed; maximum of 8 mg per day to 12 mg per day
IV: 0.2 mg to 2 mg every 4 hours as needed – adjust according to response
IM, SubQ: 0.2 mg to 0.5 mg every 2 to 3 hours as needed – adjust according to response
Rectal: 3 mg (1 suppository) every 6 to 8 hours as needed
|Acute and chronic pain in opioid-naïve or opioid-tolerant individuals
|5 mg every 4 to 6 hours as needed – adjust according to response
Typical dosage range: 5 mg to 15 mg every 4 to 6 hours
|(Based on oxycodone content): 5 mg (moderate pain) or 10 mg to 20 mg (severe pain) every 4 to 6 hours as needed
|Oxycontin (extended-release oxycodone)
|Acute and chronic pain in opioid-naïve or opioid-tolerant individuals
|Total daily dose of immediate-release oxycodone, administered in 2 divided doses
Other alternatives to hydrocodone acetaminophen
Top 5 hydrocodone acetaminophen alternatives
The following are some of the most common alternatives to hydrocodone acetaminophen.
1. Belbuca (buprenorphine)
Belbuca is a buccal film of the active ingredient, buprenorphine, that is approved for chronic pain. The mechanism of action of buprenorphine differs from that of hydrocodone in that it is both a partial agonist at mu opioid receptors and an antagonist at kappa opioid receptors. Given the partial agonist activity, there may be less abuse potential than with full agonists—as the dose increases, subjective effects like euphoria, which often drive abuse, plateau. This is also beneficial by allowing for a wider safety margin, since other effects, like respiratory depression, would also plateau despite increasing doses.
Some additional formulations of buprenorphine exist, including a transdermal patch in a product called Butrans, as well as an injectable formulation. These alternative formulations from an oral tablet might be necessary for certain patients who are unable to take a medication like Lortab that is only available by the oral route. In patients with poor pain control on other opioids, some data suggest that switching to one of these alternative buprenorphine formulations may improve pain control. The buccal film has a delayed peak concentration of a couple of hours to achieve the pain control effect and provides a relatively long duration of action. Belbuca is a good alternative to opioid treatment that needs to be taken around the clock, but it may come with a hefty price tag. If cost is a concern, using a SingleCare prescription discount card can aid in saving you money at your local pharmacy.
RELATED: Belbuca side effects
2. Methadose (methadone)
Methadose is an option for patients with chronic pain as an alternative to hydrocodone-acetaminophen for a few different reasons. It may be an appropriate alternative when side effects have limited further dosage escalations, as well as in situations of opioid-induced hyperalgesia. Methadose may also be a good option for a person experiencing an allergic reaction to Lortab since methadone is in a different class of opioids that should exhibit limited cross-reactivity. Methadone, however, exhibits high interpatient variability in absorption, metabolism, and relative analgesic potency, so that available conversion ratios between it and other opioids are not always accurate and dependable. Therefore, methadone must be dosed carefully in even opioid-tolerant individuals. It also can be the cause of many drug-drug interactions, so if starting methadone, it is best to make sure your pharmacist is aware of all the prescription and over-the-counter medications you are taking so any potential issues can be avoided.
RELATED: Methadose side effects
3. Cymbalta (duloxetine)
Cymbalta is an effective alternative pain reliever to Lortab in the management of certain types of chronic pain, which can be categorized as neuropathic pain, inflammatory or joint-related pain, and non-inflammatory/non-neuropathic pain (e.g., fibromyalgia). Cymbalta is a non-opioid medication and was actually originally labeled as an antidepressant, more specifically a serotonin/norepinephrine reuptake inhibitor (SNRI). Today, it is approved by the Food and Drug Administration (FDA) for chronic musculoskeletal pain—like low back pain, neuropathic pain associated with diabetes mellitus, and fibromyalgia; it is used off-label for chemotherapy-induced peripheral neuropathy. The pain relief associated with Cymbalta is believed to be a result of increased activity of serotonin and norepinephrine within the central nervous system (CNS), which has downstream effects in decreasing pain signals. Cymbalta is overall safe and tolerable, but its packaging does include a black box warning for increased suicidal thoughts and behavior. When initiating Cymbalta, close monitoring for the emergence of such thoughts and behaviors is important.
RELATED: Cymbalta side efefcts
4. Naprosyn (naproxen)
Naprosyn is a type of NSAID and may serve as a good alternative to opioid pain medications like hydrocodone-acetaminophen in several clinical scenarios. All alternatives discussed thus far are prescription medications; certain formulations of naproxen are available over-the-counter. As a non-opioid, one can avoid side effects more specific to opioids, like constipation and drowsiness. NSAIDs like Naprosyn do come with their own set of potential side effects. NSAID use is associated with an increased risk of cardiovascular events, including the development of high blood pressure. Risk factors for the development of cardiovascular events include age greater than or equal to 65, higher doses, longer duration of use and frequency of use, pre-existing cardiovascular disease, or presence of other risk factors for cardiovascular disease. NSAIDs can also increase bleeding event risk, so while not an opioid, it is not an entirely safe medication to initiate.
RELATED: Naprosyn side effects
5. Qdolo (tramadol)
Qdolo (tramadol) is an alternative to stronger opioids in certain patients. It is a synthetic codeine analog; it is a weak agonist at mu opioid receptors, and it is a weak SNRI. Given its weak activity at opioid receptors, it became a controlled substance in 2014 because available data suggests it has abuse potential similar to other controlled substances. The maximum total daily dose of Ultram is 400 mg; doses that exceed this amount may produce subjective effects like morphine. In patients with impaired renal function, dose reductions should be employed. In addition to the typical side effects seen with opioids, tramadol can additionally cause seizures and low blood sugar, among other adverse events.
RELATED: Qdolo side effects
Natural alternatives to hydrocodone acetaminophen
The management of pain should be approached from all angles, and non-pharmacologic and more natural approaches may provide some real relief. Depending on the source of the pain, physical therapy may be one way to help manage it, especially in chronic pain after injuries or surgeries. By employing therapeutic exercise, physical therapy aims to achieve optimal neuromuscular and skeletal function. Other holistic approaches, such as acupuncture or the use of aromatherapy with different essential oils like peppermint oil or lavender oil, may also provide some pain relief and are generally safe, natural options to try. Turmeric is a spice with an active component known to have anti-inflammatory properties; supplementation with turmeric may provide natural pain relief. Other natural products, such as topical capsaicin or taking magnesium supplements, may provide additional pain relief as they reduce inflammation over time.
RELATED: 8 non-narcotic pain meds and other pain management tips
How to switch to a hydrocodone acetaminophen alternative
If discontinuation of hydrocodone-acetaminophen is necessary, whether it be to move to another prescription, because the drug is no longer necessary, or because it is having negative side effects, tapering the dose under the direct supervision of a healthcare provider is critical. Tapering helps to avoid unwanted side effects and minimize withdrawal symptoms—particularly in patients who have been on opioids long-term. A standard tapering schedule for all patients is yet to be established, and proposed schedules range from slow (e.g., 10% reductions per week) to more rapid (e.g., 25% to 50% reduction every few days). With that said, tapering should be an individualized process.
It’s important to keep in mind that patients might not realize that chronic opioid use can cause increased pain sensitivity, another reason why tapering doses slowly is very important. The same can be said when switching to a new medication; while equianalgesic dose information is available, it isn’t always possible to switch from hydrocodone-acetaminophen to an alternative without under- or over-shooting the dosage. This is why medication changes should always be executed under direct medical advice and supervision, and it is encouraged that naloxone be offered with each opioid prescription. As an example of how complicated switching can be: switching to Belbuca requires tapering an opioid to no more than morphine 30 mg or equivalent daily, only at which time Belbuca can be started. Patients may need short-acting analgesics for breakthrough pain, and non-opioids like tramadol are the best.
Switching to Metadose is more of an art than a science, and deaths have occurred during the conversion from chronic high-dose pain management with other opioids. Very close attention is required during the treatment initiation of methadone, during the conversion from another opioid like Lortab, and during dose titration. It takes 3-5 days on a dose of methadone to realize its full analgesic effects, so changes to doses should be minimized until those full effects are realized.
Given the nuance and complexity, any medication changes related to opioids like Lortab or its alternatives should be discussed in detail with a healthcare provider.