Appendix VIII: Tapering and Discontinuing Opioid Medication

Reasons to consider tapering opioids:

• Patient request¹
• Problematic opioid behaviour (see Appendix V: Monitoring for red flags beyond UDT)
  • Nonadherence to treatment plan¹
• Clear evidence of opioid use disorder (see Appendix VII: Opioid use disorder)
• Adverse effects
  • Overdose or early warning signs for risk of overdose such as sleep apnea, hyperalgesia, and withdrawal mediated pain
  • Adverse effects are impairing functioning
  • Intolerable adverse effects
• Opioid doses exceed 90 MED¹
• Lack of improvement in pain or function1¹
• Opioid in combination with benzodiazepines

Exercise CAUTION when tapering opioids in the following populations. Consider seeking expert opinion or additional consultation.²

• Pregnancy (premature labour, abortion with severe withdrawal)³
• Concerns taper will destabilize mental illness
• Concerns taper will destabilize or unmask substance use disorders (e.g. opioid use disorders)
• Medically unstable conditions such as severe hypertension or unstable CAD
• Diabetes mellitus – sick day management³
• Decreased cognitive function/cognitive impairment^2,3

The Canadian guidelines¹ recommend discussing tapering in individuals (with CNCP) who are currently using ≥ 90 mg MME per day of opioid to lowest effective dose, and potentially discontinuing use.¹ Guidelines suggest doing so using an individualized approach to tapering.^2,4 Patients should be involved in the discussion that addresses benefits (better pain control and quality of life)¹ and harms of current opioid use, as well as the approach to the taper. In addition to the reason for the individual’s taper, discussions should also include patient’s goals and expectations. These conversations require empathy and mutual agreement for buy-in and adherence. If patients are not ready, the conversation can be revisited.²

It is of benefit to prepare the patient for the taper by optimizing non-opioid strategies for pain management, optimizing psychosocial support, and creating a schedule and plan for follow-up visits as well as managing withdrawal symptoms.¹

General approach to tapering opioids as provided by the Centre for Effective Practice Opioid Tapering Template (2018) and the Canadian guidelines (2017):

• Establish the opioid formulation to be used for tapering
  • Switching from immediate release to controlled release opioids on a fixed dosing schedule may assist some patients with adherence¹
• Establish the dosing interval
  • Scheduled doses help with pain control and withdrawal versus PRN doses
  • Maintain consistent dosing intervals (e.g. twice daily)
• Establish the rate of taper based on patient health, preference and other circumstances
• Individualize tapering schedule
  • For some this can be gradual and take months and for others years
    • Generally the longer the duration of previous opioid therapy, the more gradual the taper should be. For those with long-term use (> 5-10 years) or comorbid psychiatric conditions, a taper of >6 months may be required³
  • A slow taper should be followed unless otherwise indicated (e.g. patient preference), especially if on >90mg ME/day¹
    • A dose reduction of 5-10% of morphine equivalent dose every 2- 4 weeks with frequent follow up is reasonable in the community depending on how the patient tolerates the taper and their desire to taper^1,3
    • The taper should be more gradual once the total daily dose reaches a lower dose range. For example reduce to 5% reductions every 4-8 weeks once at 1/3 of previous used daily dosage³
  • A rapid taper may be completed over 2–3 weeks²
    • CAUTION as reducing the dose immediately or rapidly over a few days or weeks may result in severe withdrawal symptoms. This is best completed under medical supervision at a withdrawal centre^1,2
• Follow up with the patient frequently (e.g. every 1–4 weeks)²
• Adjust the rate, intensity, and duration of the taper according to the patient’s response (e.g. pain, function, withdrawal symptoms)
  • Tapering may be paused and reassessed or potentially abandoned in patients who experience distressing pain, decreased function or withdrawal symptoms that persists for more than 1 month^1–3
• Optimize alternative (non-opioid) pain management strategies^2,3
• Anticipate and treat withdrawal symptoms as needed^2,3
• Taper to the lowest effective dose

It may be useful to utilize a tapering plan form/document with patients to delineate a plan that is agreed upon by both the patient and practitioner. Ensuring the patient is engaged and part of the planning process is important for buy-in and adherence to the agreed upon plan. Although a tapering schedule is established initially it may need to be revised throughout the taper depending on how the patient responds to the taper. For an example of a tapering plan document see the CEP opioid tapering template.

SAFETY/CAUTION while tapering:

• Warn patients that tolerance can be reduced after as little as 1-2 weeks of a dosage taper.
• Give patients a naloxone kit or refer them to a pharmacy to obtain a kit so that in the event they relapse or resume their pretaper dose they won’t overdose³

Chart adapted from Rx Files

Other strategies to reduce, taper or discontinue opioids:

• Switch current opioid to another opioid and reduce MED by 25% to 50%³
• Switch to opioid agonist therapy such as buprenorphine-naloxone or methadone and then gradually taper1. A consult or referral may be required if the clinician is unfamiliar with the protocol for use of opioid agonist therapy^1,2

The above approach to tapering has been summarized from the CEP Opioid Tapering Template.

For those patients (with CNCP) who have significant challenges with tapering (ie, re-emergence of new functional or psychological impairment or aberrant behaviours around opioid use), the Canadian guidelines recommend a formal multidisciplinary tapering program and consultation with local experts.¹ However, the availability of multidisciplinary team members may be limited to larger centres.