Table 1.
Characteristics of unique guidelines and protocols for deprescribing opioids or benzodiazepines.
| Source | Target Population | Deprescribing Rate | Organizations Using the Guideline | Elements in the Guidelines/Protocols (Y = Yes; N = No): (a) Risk of Concurrent Use; (b) Criteria for Considering Tapering Opioid/Benzodiazepine Therapy; (c) Shared Decision-Making with Pts; (d) Withdrawal Management; (e) Nonpharmacological Approaches; (f) Alternative Medication Therapies. |
|||||
|---|---|---|---|---|---|---|---|---|---|
| Opioids (N = 16) | (a) | (b) | (c) | (d) | (e) | (f) | |||
| CDC, 2022 [38] | Pts with CNCP | 1. OPI use ≥1 year: reduce dose 10% or less per month. 2. OPI use for shorter durations: reduce initial dose 10% or less per week until ~30%, followed by 10% per week. |
* | Y | Y | Y | Y | Y | Y |
| VA/DoD, 2022 [39] | Pts with CNCP | Gradual and individualized taper: reduce dose 5–20% every 4 weeks or longer. | Y | Y | Y | Y | Y | Y | |
| Minnesota Department of Human Service, 2021 [37] | Pts with CNCP | Individualized taper based on patient tolerance: 1. Slower: reduce dose 5–10% per month to start but may need to reduce rate to less than 5% per month over 2–3 months as tolerated. 2. Faster: reduce initial dose 10% per week or longer; not preferred but used when risk of continuing therapy outweighs risk of rapid taper or when part of treatment program for short time period. 3. May taper BZD first for pts with high daily MME and intermittent BZD. |
Y | Y | Y | Y | Y | Y | |
| Oregon Health Authority, 2020 [40] | Pts on OPIs | Individualized: generally, reduce dose 5–10% per month. | Y | Y | Y | Y | Y | Y | |
| Arizona Department of Health Services, 2018 [41] | Pts on LTOT | Individualized taper based on risk assessment: 1. Slowest (over years): reduce dose 2–10% every 4–8 weeks with pauses in taper as needed. 2. Slow (over months to years): reduce dose 5–20% every 4 weeks with pauses in taper as needed. 3. Faster (over weeks): reduce dose 10–20% every week. 4. Rapid (over days): reduce first dose 20–50%, then 10–20% every day. |
Y | Y | Y | Y | Y | Y | |
| Cigna, 2019 [42] | Pts on LTOT | Individualized taper based on pt health history, preferences, and risk factors, e.g., reduce dose 5–10% per month. | Y | Y | Y | Y | Y | Y | |
| FDA, 2019 [16] | Pts physically dependent on OPIs | Gradual and individualized taper: 1. No more than 10–25% reduction every 2–4 weeks. 2. More rapid taper: pts on opioids for shorter time periods. |
UnitedHealthcare [43] | N | Y | Y | Y | Y | N |
| HHS, 2019 [44] | Pts on LTOT for chronic pain | 1. Common: reduce dose 5–20% every 4 weeks. 2. Gradual: reduce dose 10% per month or slower. 3. Rapid: reduce dose 10% per week up to 30% of the original dose and then 10% per week. |
Sunshine Health [45] | Y | Y | Y | Y | Y | Y |
| Mendoza, 2019 [46] | Pts with CNCP | 1. Rapid: reduce dose 20% per week or abrupt discontinuation. 2. Slow: reduce dose 5–20% every 2–4 weeks. |
Y | Y | Y | Y | Y | Y | |
| Lumish, 2018 [47] | Pts ≥65 years with CNCP | Reduce dose 5–20% every 4 weeks. | Y | Y | Y | Y | Y | Y | |
| Murphy, 2018 [48] | Pts with CNCP | Reduce dose 5–10% every 2–4 weeks. | Y | Y | Y | Y | Y | Y | |
| Nebraska Department of Health and Human Services, 2017 [35] | Pts on OPIs | 1. Long-acting OPIs: reduce dose 5–10% per week. 2. Short-acting OPIs: reduce dose 5–15% per week. 3. After reaching 1/4–1/2 of the initial dose, may slow dose reduction rate for pts cooperative with therapy. 4. Taper opioid first to reduce risk of overdose in pts on both OPI and BZD. |
Y | Y | Y | Y | Y | Y | |
| VA PBM, 2016 [49] | Pts on OPIs | 1. Slowest: reduce dose 2–10% every 4–8 weeks with pauses in taper as needed (e.g., pts taking high doses of long-acting opioids for many years). 2. Slower: reduce dose 5–20% every 4 weeks. 3. Faster: reduce dose 10–20% per week. 4. Rapid: reduce dose 20–50% of first dose, then 10–20% every day. |
United Healthcare [43] | Y | Y | Y | Y | Y | Y |
| AMDG, 2015 [36] | Pts with CNCP | 1. Taper off opioid first and then benzodiazepine with a deprescribing rate based on safety profile. 2. Slow: reduce dose by ≤10% per week for pts with no acute safety concerns from a mental/physical health perspective. 3. Rapid: discontinue over 2–3 weeks if pts having severe adverse outcomes (e.g., overdose or SUD). 4. Immediate: discontinuation if diversion/nonmedical use. |
Sunshine Health [45] | Y | Y | Y | Y | Y | Y |
| Berna, 2015 [50] | Pts with CNCP | Reduce dose 10% every 5–7 days until reaching 30% of the initial dose, then reduce 10% per week. | United Healthcare [43] | N | Y | Y | Y | Y | Y |
| Oregon Pain Guidance, 2014 [34] | Pts with CNCP | 1. Long-acting OPIs: reduce dose 5–10% per week. 2. Short-acting OPIs: reduce dose 5–15% per week. 3. Slow down rate toward the end of taper. Once reaching 25–50% of initial dose, slow to 5% per week. 4. Taper BZD followed by OPI if both drugs involved. |
Sunshine Health [45] | Y | Y | Y | Y | Y | Y |
| Benzodiazepines (N = 11) | |||||||||
| Kaiser Permanente, 2022 [51] | Pts on chronic BZD therapy | Individualized taper based on indication: 1. Slow (reduce dose 10% every 2–4 weeks): function not improved or tolerance developed with long-term Rx. 2. Moderate (reduce dose 10% per week): risks greater than benefit or increased risk with comorbidities. 3. Rapid (reduce dose 25% per week): substance abuse, significant risk due to unstable clinical condition or recent overdose or misuse or diversion of medication. |
Y | Y | Y | Y | Y | Y | |
| FDA, 2020 [17] | Pts on BZDs | 1. Gradual and individualized taper. 2. When experiencing withdrawal symptoms, may pause the taper or raise BZD to previous dose. Once stable, proceed with more gradual taper. |
Y | Y | Y | Y | Y | N | |
| Payne, 2019 [52] | Pts on BZDs | 1. Reduce dose 10–12.5% every 1–2 weeks over 2–12 months. 2. Reduce dose 10–25% every 2 weeks over 4–8 weeks. |
N | Y | Y | Y | Y | N | |
| Presbyterian Healthcare Services, 2019 [53] | Pts ≥18 years on BZD or Z-drug therapy | Taper duration (considering prior use duration) 1. Prior use < 3 months: over 1 week 2. Prior use 3 months–1 year: over 1 month 3. Prior use > 1 year: over 3 months Taper dosage 1. Typical 3-month duration, reduce from 100% to 50% of initial dose during the first 4 weeks, then reduce from 50% to 0% during remaining 2 months. 2. More rapid (25% per week) may be appropriate for pts having increased risk of respiratory depression or misusing/diverting Rx. |
Y | Y | Y | Y | Y | Y | |
| Pottie, 2018 [54] | Pts ≥65 years on BZRAs Pts 18–64 years on BZRAs > 4 weeks |
Reduce dose 25% every 2 weeks, then 12.5% near end with duration of taper dependent upon patient tolerance, dependence, and potential for withdrawal effects. | Choosing Wisely Canada [55,56] deprescribing.org [57] CalOptima [58] |
N | Y | Y | Y | Y | Y |
| Pruskowski, 2018 [59] | “Older” pts in palliative care on BZD | Reduce over 8–12 weeks total, reduce baseline dose 10–25% every 2–3 weeks based on BZD terminal half-life. | Y | Y | Y | Y | Y | Y | |
| Ogbonna, 2017 [60] | Pts on BZDs daily > 1 month | Reduce initial dose 5–25%, then 5–25% every 1–4 weeks as tolerated; reduce supratherapeutic dose 25–30% as tolerated, followed by 5–10% daily, weekly, or monthly as appropriate. Complex cases may require stabilization at 50% dose reduction for several months prior to resuming taper. | CalOptima [58] | Y | Y | Y | Y | Y | Y |
| VA PTSD, 2015 [61] | Pts with PTSD | Reduce dose 50% the first 2–4 weeks then maintain dose for 1–2 months. Further reduce dose 25% every 2 weeks. | Y | Y | Y | Y | Y | Y | |
| Oregon Pain Guidance, 2014 [34] | Pts on BZDs | 1. Slow: Reduce initial dose 25–50%, then 5–10% per week with follow up; total dose reduction of long-acting drug 5–10% per week in divided doses. When 25–50% of starting dose is reached, slowly taper further to 5% or less per week. 2. Rapid: Pre-medicate for 2 weeks prior with carbamazepine 200 mg every morning and 400 mg every bedtime or valproate 500 mg twice daily. Continue these medications 4 weeks after BZD is discontinued. Discontinue the current BZD and switch to diazepam 2 mg twice daily × 2 days, followed by 2 mg daily × 2 days, then stop. For high doses, may begin with 5 mg twice daily × 2 days and then continue as described. 3. Taper BZD followed by OPI if both drugs involved. |
Sunshine Health [45] | Y | Y | Y | Y | Y | Y |
| Belanger, 2009 [62] | Pts with chronic insomnia | 1. Reduce dose by 25% every 1–2 weeks to smallest minimal dose. 2. Switch short-acting BZD to longer-acting BZD. Reduce initial dose 25% by 2nd week, 50% by 4th week, 100% by 10th week. |
Y | Y | Y | Y | Y | Y | |
| Woodward, 2003 [63] | Pts ≥ 65 years | 1. Short-acting: cease or wean if not needed. 2. Long-acting: reduce dose 10–15% per week. 3. Both 1 and 2: combine with sleep hygiene/psychotherapy. |
Y | Y | Y | Y | Y | Y | |
Abbreviations: BZD: benzodiazepine; BZRA: benzodiazepine receptor agonist; CNCP: chronic noncancer pain; LTOT: long-term opioid therapy; MME: morphine milligram equivalents; OPI: opioid; Pts: patients; Rx: prescription. * United Healthcare [43] and Sunshine Health [45] cite the 2016 version of the CDC guideline.