Opioid Tapering: Tips for Success

Full update February 2023

With careful patient selection, education, and monitoring, opioids can be safe and effective tools to improve function and reduce pain intensity in chronic noncancer pain. However, discontinuation may become necessary, either because of lack of efficacy, adverse effects, or misuse. This FAQ provides information to help clinicians deal with this challenging patient care situation.

Clinical Question

Suggested Approach/Pertinent Information

What are some situations in which opioid tapering might be considered?

Situation

Alternatives to Discontinuation (if Benefit Outweighs Risk), and Other Considerations

Use of opioid around-the-clock for more than a few days.11

  • Continue opioid with frequent evaluation to ensure that opioids are meeting individualized patient goals of pain and function and have an exit strategy if goals aren’t met.11

Misuse (e.g., subthreshold opioid use disorder, aberrant behaviors)

  • Re-evaluate pain.11 Optimize the treatment regimen.11
  • Discuss risk/benefit with patient.11
  • Increase frequency/intensity of monitoring.1 Prescribe limited quantities.1
  • Address psychiatric comorbidities.11
  • Consider switching to buprenorphine for pain.11
  • Egregious misuse (e.g., injecting tablets) or signs of impending overdose will likely require discontinuation.1,11
  • See our chart, Management of Opioid Use Disorder, for help identifying opioid use disorder and information on pharmacotherapy options.

Use of illicit drugs or nonprescribed opioids

  • Refer, ideally to a specialized program that can provide directly observed therapy.1

Diversion

  • Tapering is not needed if they are diverting all opioids they obtain.11
  • Alternative is to refer to a specialized program that can provide directly observed therapy.1

Nonadherence to opioid agreement

  • Restructure therapy (e.g., more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment).1

Overdose

  • Taper relatively quickly (e.g., over two to three weeks).8

Use of high doses (e.g., ≥50 MME) without evidence of benefit.

  • Taper to reduced dose or taper and discontinue.11

Adverse effects that affect function or quality of life (e.g., drowsiness, dry mouth, constipation, cognitive slowing, reduced libido, fatigue)1,8,11

  • Consider opioid rotation (i.e., switching patient from one opioid to another).1
  • Consider tapering to a dose where functional benefits outweigh risk and continuing.11

Use of CNS depressant (e.g., benzo, alcohol)8,11

  • Taper to lower dose, then switch to buprenorphine.11 (Note that this will not eliminate risk but may reduce it.)

No progress toward therapeutic goals

  • If there is no sustained, clinically meaningful improvement (≥30%) in pain AND function, compared to baseline or dosage increase, using validated tools, then:2
    • discontinue.2
      OR
    • go back to previous (i.e., lower) dose if it provided some benefit.5
  • Tools recommended to assess progress in this context include the Three Item PEG Assessment Scale and the Two Item Graded Chronic Pain Scale, available at http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf.

Reduced analgesia

  • Restructure therapy (e.g., more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment).1

Hyperalgesia

  • Discontinuation probably necessary.5

Repeated dose escalation or need for high doses

  • Evaluate risk versus benefit by assessing:1
    • underlying diagnosis and concomitant conditions.
    • psychological issues and social situation.
    • pain control, function, quality of life, and progress toward therapeutic goals.
    • adverse effects.
    • adherence.
  • Rule out misuse and/or diversion.1
  • Restructure therapy (e.g., more intense monitoring, opioid tapering, addition of non-opioid or psychiatric treatment).1
  • Consider opioid rotation.1
  • Consider dose reduction rather than complete discontinuation if opioid is providing some benefit.5
  • Consider overdose education and naloxone.8 See our Naloxone Quick Start Guide, and FAQ, Meds for Opioid Overdose.

How do I prepare patients for opioid discontinuation?

  • When starting chronic opioid therapy, set clear expectations. This may help prevent opposition to discontinuation if it is indicated later.2
  • Use motivational interviewing techniques to identify reasons for patient opposition to discontinuation.2
  • Ask the patient for their perceptions of the risks and benefits of opioid continuation.8
  • Unless the patient is at immediate risk, take time to get patient buy-in before starting the taper.8,11
  • Elicit patient input into design of the taper to improve tapering success.Examples:
    • Patients can help decide which med to discontinue first, and how fast to taper.8
    • Elicit patient concerns (see below) and address them in the tapering plan.8
    • Patients can help decide if the initial goal is a dose reduction or complete discontinuation.11 This goal can be changed as the taper continues.6
  • Address depression and other psychiatric comorbidities (e.g., anxiety, post-traumatic stress disorder) to improve pain control and improve taper success.8
  • Address common patient fears:
    • Withdrawal: taper will be slow to minimize this, and medications can be used to treat symptoms.8,11
    • Pain: might worsen at first, but usually improves.11 Pain will be addressed during the taper with non-opioid medications or other nonpharmacologic therapies.
    • Abandonment: they will be supported through the process.11

What can be expected if the opioid is tapered or discontinued?

  • Patients being tapered due to lack of efficacy may or may not experience a worsening of pain.1 In a veteran population (n = 50) being tapered for reasons other than aberrant behavior, 70% of patients had no change or less pain vs baseline despite a 46% average dose reduction.3
  • Function and quality of life may improve [Evidence level B-2].10
  • Most patients report improved anxiety and mood, but some experience anxiety, depression, or insomnia.11 
    • Patients should plan ahead for not feeling well.4
  • Increased pain is an early symptom of withdrawal; pain with opioid dose reduction is not a sign that the opioid is effective for the patient’s pain.4,9 Pain due to withdrawal should resolve after the first week.4
  • Unmasking of psychiatric conditions may occur.11

How should the opioid be tapered/ discontinued?

General concepts:

  • No trial has compared different tapering rates; individualize.11
  • The reason for discontinuation, dose, and duration of use will influence the rate of taper.8,11
  • Adjust taper based on response, such as appearance of withdrawal symptoms.2
  • Consider referral for patients who have risk factors for failure: high-dose, substance use disorder, active psychiatric disorder, previous outpatient taper failure, or benzodiazepine use.2
  • Consider consolidating the patient’s opioids into a single long-acting formulation.(See our chart, Equianalgesic Dosing of Opioids for Pain Management, for help). Choose a product that offers small dose increments (e.g., morphine 10 mg, morphine SR 15 mg) to facilitate a slow taper.5,6 A short-acting formulation can be used once the lowest dose of the long-acting formulation is reached.9
    • Fentanyl patch can be tapered in decrements of 12 mcg/hr.9
  • If benzodiazepine discontinuation is indicated, individualize the decision to taper the opioid or benzodiazepine first.11
  • Before constructing the taper, check for insurance coverage limitations, and availability of specific opioid products/strengths at your local pharmacy. Flexibility may be needed.
  • Consider incorporating physical therapy or cognitive behavioral therapy (especially with concomitant benzodiazepine use) into the treatment plan to help patients manage chronic pain during the taper.9,11 Some patients report that self-directed exercise or other physical activity, meditation, or massage therapy has helped them cope during the taper.12
  • The taper can be paused to allow the patient to adjust to the new, lower dose; start non-opioid therapies; or allow the patient to learn skills for managing pain or address psychological symptoms.8

Tapering protocol examples:

  • Common tapers involve dose reductions by 5% to 20% every four weeks.8
  • Taper over two to three weeks in the event of severe adverse effects, overdose, or substance abuse disorder.2,8
  • A slow taper of 10% per month (or even slower) is likely better tolerated than more rapid tapers in long-term opioid users (e.g., a year or longer).11
  • Otherwise, a decrease of 10% of the original dose per week is a reasonable starting point.11 Once 30% of the original dose is reached, reduce by 10% of the remaining dose weekly.11
  • Keep in mind that a more rapid taper may be possible. The minimum dose to prevent withdrawal may be only 25% of the previous dose.9
  • Generally, reduce dose before reducing frequency.Patient perception of benefit of chronic opioid use may be related to interdose withdrawal.13
  • Once the smallest available dose is reached, the dosing interval can be extended.The opioid can be stopped, if appropriate, when taken less than once daily.8
  • An opioid taper calculator is available at https://www.agencymeddirectors.wa.gov/Calculator/TaperDoseCalculator.html.
  • A sample “Opioid Tapering Template” is available at http://www.rxfiles.ca/rxfiles/uploads/documents/Opioid-Taper-Template.pdf.

How should the patient be monitored during dose reduction or discontinuation?

  • Consider weekly, and at least monthly, monitoring.8,11
  • Check pain control and functional status at each visit.2
    • Manage increased pain with non-opioids.2
  • Monitor for psychiatric disorders such as depression or panic disorder.2
  • Monitor for withdrawal (e.g., flu-like symptoms, insomnia, anxiety, abdominal cramps and other gastrointestinal symptoms, goose bumps, fatigue, malaise).4
    • If withdrawal symptoms occur, manage the symptoms (see below) and slow the taper (e.g., to 5% per week) or suspend the taper; do not increase the dose (i.e., don’t “backpedal”).2,4
  • Warn patients that they are at risk of overdose if they try upping the dose on their own. Opioid tolerance can be lost after as little as a week of abstinence.8 Provide overdose education and naloxone.11 See our Naloxone Quick Start Guide, and FAQ, Meds for Opioid Overdose.

What adjunctive medications may help with withdrawal symptoms?

  • Muscle aches: acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], or topical salicylates.8
  • Nausea: ondansetron, prochlorperazine, or promethazine.11
  • Insomnia: trazodone.8
  • Diarrhea (not usually an issue with gradual tapers): loperamide or bismuth subsalicylate.8,11
  • Abdominal cramps: dicyclomine.11
  • Hydroxyzine may be helpful for a variety of symptoms (e.g., anxiety, itching, lacrimation, cramps, sweating, rhinorrhea).5
  • Clonidine and lofexidine have not been studied in the context of withdrawal during tapering of opioids used long-term for pain.8,11 However, information on use of clonidine for treatment of autonomic symptoms is available at https:www.pbm.va.gov/AcademicDetailingSErvice/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf.

What are some opioid alternatives for common types of pain?

See our resources:

Abbreviations: CNS = central nervous system; MME = morphine milligram equivalents.

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality randomized controlled trial (RCT)
  2. Systematic review (SR)/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.  https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]

References

  1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009 Feb;10(2):113-30.
  2. Washington State Agency Medical Directors Group. Interagency guideline on prescribing opioids for pain. 3rd edition, June 2015. http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. (Accessed January 9, 2023).
  3. Harden P, Ahmed S, Ang K, Wiedemer N. Clinical Implications of Tapering Chronic Opioids in a Veteran Population. Pain Med. 2015 Oct;16(10):1975-81.
  4. University of British Columbia. Squire P, Jovey R. Managing opioid withdrawal-information for patients. 2013. http://med-fom-tcmp.sites.olt.ubc.ca/files/2014/06/For-Patients-TCMP-2014-Managing-Opioid-Withdrawal.pdf. (Accessed January 10, 2023).
  5. Rx Files. Opioid tapering template. June 2018. http://www.rxfiles.ca/rxfiles/uploads/documents/Opioid-Taper-Template.pdf. (Accessed January 9, 2023).
  6. US Department of Veterans Affairs. Opioid taper decision tool. October 2016. https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf. (Accessed January 10, 2023).
  7. Dave VH. A patient’s guide to opioid tapering. May 21, 2018. https://www.hss.edu/conditions_patient-guide-opioid-tapering.asp. (Accessed January 10, 2023).
  8. US Department of Health and Human Services Working group on Patient-Centered Reduction or Discontinuation of Long-term Opioid Analgesics. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. October 2019. https://www.hhs.gov/system/files/Dosage_Reduction_Discontinuation.pdf. (Accessed January 10, 2023).
  9. Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clin Proc. 2015 Jun;90(6):828-42.
  10. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017 Aug 1;167(3):181-191.
  11. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71(3):1-95.
  12. Henry SG, Paterniti DA, Feng B, et al. Patients' Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians. J Pain. 2019 Feb;20(2):181-191.
  13. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666.

Cite this document as follows: Clinical Resource, Opioid Tapering: Tips for Success. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter. February 2023. [390202]



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