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What is the duration and severity of withdrawal symptoms for NORCO?

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Hello, I was perscribed Norco ( 325 acetamenaphan/ 10 mg hydrocodone) for a rib injury. They gave me enough for the on label 4-6 hours as needed, but i only ever took ONE at night always after 9 pm. I did this for a few months, taking the occasional night where i didnt work (i teach mma and martial arts) when i would just leisurely relax. Essentially, i couldnt take advil because it was harsh on my stomach. So whenever i would get done training, the pain would get kinda bad and i would take one to ease it so i could sleep (sleeping with a rib injury blows). Long story short, it is one norco a night, for a few months, without ever increasing the dosage, never during the day, always about 24 hours (i would always wait alteast 6 half lives to pass before taking another doses, no exceptions) between each dose. I asked a pharmacist and a few doctors how it would be and they said withdrawal is very unlikely and if so it would be very mild. Should withdrawal occur, how long would it last? What would be the symptoms and the severity? Should it even occur even though there has been 6 half-lives in between doses, with it being such a low dose? Thanks


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Expert:  Dr. Deepu Sebin Sebastian replied 4 Days.

Hello.

Thank you for your query at DoctorSpring.com.

I understand your concern.

If you have taken 1 tablet of Norco(10 mg Hydrocodone + 325 mg Acetaminophen), every night for a few months, withdrawal can occur if you stop it abruptly. Even though 24 hours can include 6 half lives, there is still the potential for dependency and mild withdrawal if stopped abruptly.

Therefore I suggest that you taper the dose before stopping it completely. You can take once every alternate night, instead of every night for a week from now. After this, once every 3 nights for another week. In the third week, just take one tablet after 5 days of last dose. After this you do not have to take it anymore. This way you do not have to worry about any withdrawal.

Withdrawal is very subjective and varies with each individual. With your dose and time period, if you were to experience withdrawal, it would be mild and it could last for about 4-7 days.

Symptoms can include agitation, anxiety, muscle aches, increased tearing, insomnia, runny nose, sweating, or yawning in the initial period, for a day or two. If you develop a full fledged withdrawal, which is unlikely, you may experience abdominal cramping, diarrhea, dilated pupils, goose bumps, nausea or vomiting.



Again, my suggestion for you is to taper your dose and stop it 3 weeks from now and you would not have to worry about withdrawal.

I hope this was helpful.



Feel free to ask queries.



Thank you.



Patient replied :

Well each subsequent day there has been none of the full fledged withdrawal symptoms you described. I get occassional yawning but my sleep quality is garbage. I do experience anxiety and agitation only on some of the days, but ironically they tend to subside after about 19 hours after the last dose. The physical withdrawal symptoms dont concern me, because if they occur i know they will be very mild given my dosage. Only the anxiety and agitation concerns me. 1. You say at my dose the anxiety shouldnt last for more than a day? So by that logic, the anxiety should dissipate once the drug is fully cleared from my system? 2. How could withdrawal last for 4-7 days if after 19 hours there is almost no traceable amount of the drug left in my system? I was told withdrawal traditionally happens between the 3rd and 5th half life. So how is it even scientifically possible to experience withdrawal from a medication at such a low dose, after it has been completely eliminated from my system? 3. Are you saying that withdrawal is almost garunteed to occur or is there an equal chance that it probably will not occur. Would you agree that I have been very responsible about the dosage? Most people develop tolerance, and i have none, i have NEVER increased the dosage, 10 mg is still very therapeutic. 4. Would you say by the end of day 2 i should be over the hump? P.S. I was just hoping for you to corroborate the statement my prescribing doctor and pharmacist said that there should be 0% chance of PAWS. I know its a dumb question (I am a med student myself) but im also a hypochondriac, so i feel the need to just double confirm. Post acute withdrawal syndrome in my research and from my doc and pharmicist said only occurs from people who abuse the medication like frequent and high doses such as people who are under constant influence of the drug, and more likely to occur on harder drugs like heroin or oxycontin. I never once abused this medication, always taken as perscribed (actually significantly less than perscribed with no tolerance development). Please corroborate if you can, it would put me at ease.


Expert:  Dr. Deepu Sebin Sebastian replied 3 Days.

Hello.



As you might already know, drug withdrawal occurs due to lower levels or complete absence of a drug which was previously available at regular and stable levels. When our body no longer receives this drug which it has been accustomed to, there is dysfunction of our autonomic system and psychological distress.



-When was the last dose of Narco you have taken? If you have already stopped taking it and its been longer than 24 hours after your last missed dose already, without any major symptoms, you may not experience any other symptoms of withdrawal. So please relax.



Now, let me answer each of your questions specifically.



1. You say at my dose the anxiety shouldnt last for more than a day? So by that logic, the anxiety should dissipate once the drug is fully cleared from my system?



Answer- Yes, the anxiety should not last for more than a day after your last missed dose. What you should know is that withdrawal is caused by the absence/clearance of stable levels of a previously available drug in your system.



2. How could withdrawal last for 4-7 days if after 19 hours there is almost no traceable amount of the drug left in my system? I was told withdrawal traditionally happens between the 3rd and 5th half life. So how is it even scientifically possible to experience withdrawal from a medication at such a low dose, after it has been completely eliminated from my system?



Answer- Although the exact mechanisms of drug withdrawal is still a matter of research, it is generally accepted that absence/abnormally low levels of a drug is what kicks in a withdrawal. Initial withdrawal symptoms appear between 3rd and 5th half-life, when your body detects lowered levels of the drug. From here, depending on the dose which the body is accustomed to, the withdrawal can subside(low doses) or become full blown(higher doses). Also you should know that half-life elimination refers to the elimination of a drug from your bloodstream, not its complete removal from your system. In case of hydrocodone, half life being about 4 hours, it will reach a negligible levels in the blood after 24 hours. However, in 72 hours after intake, only 26 % of the total hydrocodone from a single dose is excreted through urine. Rest of the drug is metabolized in the liver and several of these metabolites are pharmacologically active opiates themselves. So it is scientifically(theoretically) possible to experience withdrawal from low doses too. However, this is not seen practically and you need not worry about all this.



3. Are you saying that withdrawal is almost garunteed to occur or is there an equal chance that it probably will not occur. Would you agree that I have been very responsible about the dosage? Most people develop tolerance, and i have none, i have NEVER increased the dosage, 10 mg is still very therapeutic.



Answer- I am only saying that you may have a chance of developing withdrawal but there's also an equal chance that you may not. Yes, I do know that you have been very responsible about the dosage and I appreciate it.



4. Would you say by the end of day 2 i should be over the hump?



Answer-Yes, in all probability you will, given that you are already better from the psychological symptoms. So please relax and do not worry.



I hope I have addressed all your concerns adequately. Let me know if you have any queries.



Thank you.



Patient replied :

It has been over 72 hours since my last dose (not my last missed dose, but my last dose). The last 2 nights i have not been able to stay asleep. But i think its more due to the fact that i drank a 16 oz energy drink at 7 o clock for MMA training. You said i should only have about 1-2 days of insomnia right? Would melatonin help at all and diphendramine help at all?

Also, although everyone i have asked has told me so already, there is no way that i should experience Post Acute Withdrawal Syndrome or PAWS at such a low dose right? thats only if i was abusing opioids to the points where it actually damaged or significantly altered my brain chemistry right?


Expert:  Dr. Deepu Sebin Sebastian replied 2 Days.

Hello.

The sleeplessness you are experiencing is, like you mentioned, due to the caffeine in the energy drink. Before any drugs for the insomnia, I suggest you practice a good sleep hygiene regimen. This includes:

- Working out during the day preferably aerobics, in the morning.

- Having a light dinner.

- Completely avoiding coffee/tea/alcohol/energy drinks/coke/ or smoking.

- Having a warm shower before going to sleep.

- Not trying very hard to go to sleep. If you are not sleepy then sit elsewhere and do some reading and go to your bed only when you are sleepy.

-  Avoiding TV or working on a computer or bright screens at night.

- Keeping the lighting of your bedroom dim and making your bed every morning after you wake up, so that you get a cozy bed to sleep at night.

- Using your bed only for sleeping and resting and not doing any other work there.

- Avoiding any naps during the day for any reason.

In case insomnia persists even after following these measures, you can take Diphenhydramine 50 mg once, before going to bed.

And please do not worry about Post Acute Withdrawal Syndrome, you are not suffering from that and neither will you in the future. This is seen in individuals with history of long term abuse, more commonly with Benzodiazepes.

I hope this was helpful.

Thank you.



Patient replied :

Thank you so much. You answered all my questions. I detoxed successfully without any withdrawal minus the insomnia.
My final question is such. I have been on Dexedrine Spansules (the Extended Release), as i have ADHD. 10mg for about 3 months. (But have been on stimulants for years due to ADHD). Recently (within the past week) i increased the dosage to about 15 then 20 (two 10mg capsules titrated 2-3 hours apart for full day coverage). I ALWAYS TAKE AS PRESCRIBED. NEVER ABUSED THIS MEDICATION. Should i expect withdrawal if i were to stop? I have taken drug vacations years ago when my responsibilities were less during the summer, but in the last few years i always have work so i have been on it every day, same exact dose, with no tolerance. Never taken above what is prescribed (as a i never needed to). So again, is the literature that says if used under the supervision of a doctor, at low-moderate prescribed doses, taken exactly as prescribed, you can expect minimal withdrawal? Or is withdrawal imminent when stoping cold turkey? How long would the withdrawal last if stopped cold turkey? If a taper is needed, what is typical and how long till im done? Will a taper ensure that i will not experience major withdrawal such as Anhedonia?


Expert:  Dr. Deepu Sebin Sebastian replied 1 Day.

Hello.



It's good to hear that you did not experience any withdrawal.



Withdrawal is not imminent but can expect some form of withdrawal if you were to stop Dexedrine abruptly, even at a dose of 10 mg since you have been taking it regularly for 3 months. The withdrawal can be mild to moderate. So it is best that you taper it before you stop. Tapering will definitely ensure that you do not have any withdrawal symptoms including anhedonia .



Since you are on 20 mg a day now, when you want to stop, you can reduce to 10 mg per day, for a week. The next week you can take 10 mg on alternate days and in the third week you can take twice a week and then stop.



I hope this was helpful.



Thank you.



Dr. Deepu Sebin Sebastian
Category: Sexually Transmitted Diseases(STD)Specialist
Experience: 
MD, Internal Medicine - Stanley Medical School
Medical School - MBBS - Govt. Medical College, Kottyaam

Diagnostic Prediction - Stanford School of Medicine
Received Specialty training in Critical Care, Cardiology, Neurology, Gastroenterology, Nephrology from Stanley Medical College and in Endocrinology, Rheumatology.

Hematology and Geriatrics from Madras Medical College.
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