Now that you have discussed tapering and discontinuing opioids with your patient, this section will provide some guidance on how to do the taper.
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 impairment2,3
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 taper1,3
- 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 centre1,2
- For some this can be gradual and take months and for others years
- 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 month1–3
- Optimize alternative (non-opioid) pain management strategies2,3
- Anticipate and treat withdrawal symptoms as needed2,3
- 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
|Early symptoms (hours to days)||Late symptoms||Prolonged Symptoms|
Rapid short respirations
Rhinorrhea, tearing eyes
Dilated reactive pupils
Brief increase in pain
|Rhinorrhea, tearing eyes
Rapid breathing, yawning
Diffuse muscle spasms
Nausea and vomiting
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 therapy1,2
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.
64 year old male comes into the clinic to discuss his pain. He has been on opioids for 2 years - and is now on 60mg morphine SR BID for back pain. He has recently had some other health issues, with a new diagnosis of obstructive sleep apnea and diabetes. He is requesting a higher dose of opioids, but with further discussion you determine that he has never had much pain relief with his opioids. You discuss tapering his morphine and he is agreement. In collaboration you decide upon a gradual taper. You calculate his total daily morphine dose as 120mg/day. You determine that 5-10% of that dose is 6-12mg, however the available doses are only in 15mg increments. You agree to decrease him to 45mg in am and 60mg in pm to start, and follow-up with him in 2 weeks to reassess his pain and see how he is tolerating the taper.
- Tapering should be individualized and plans made in collaboration with the patient.
- A slow taper should be followed unless otherwise indicated (e.g. patient preference).1,2
- A dose reduction of 5-10% of morphine equivalent dose every 2- 4 weeks with frequent follow up is reasonable in the community.
- 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.
- Busse J. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. 2017.
- Centre for Effective Practice. Opioid Tapering Template. February 2018. https://cep.health/media/uploaded/20180305-Opioid-Tapering-Tool-Fillable.pdf. Accessed August 14, 2019.
- Rx Files. Tapering Opioids. How to Explore and Pursue the Option for Patients Who Stand to Benefit. Chronic Pain/Opioids Part 2. Spring 2018. https://www.rxfiles.ca/rxfiles/uploads/documents/Opioid-Tapering-Newsletter-Compilation.pdf. Accessed August 14, 2019.
- Centers for Disease Control and Prevention (CDC). Pocket Guide: Tapering Opioids for Chronic Pain. https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf.