Indications for opioid tapering
Severe pain despite an adequate trial of several different opioids Opioid-related complications (eg, sleep apnea, falls) As a component of “structured opioid therapy” for addicted patients with a pain condition who do not access opioids from other sources or alter the route of delivery
1.1. Precautions for outpatient opioid tapering
Pregnancy: acute withdrawal can cause premature labour and spontaneous abortion Unstable medical and psychiatric conditions: while opioid withdrawal does not have serious medical consequences, it can cause considerable anxiety and insomnia that might exacerbate severe, acute medical or psychiatric conditions Opioid addiction: outpatient tapering is unlikely to be successful if the patient regularly accesses opioids from other doctors or the street; methadone or buprenorphine treatment is advised Concurrent medications: avoid sedative-hypnotic drugs, especially benzodiazepines, during the taper
Opioid tapering protocol
2.1. Before initiation
Emphasize that the goal of tapering is to make the patient feel better: to reduce pain intensity and to improve mood and function Have a detailed treatment agreement Be prepared to provide frequent follow-up visits and supportive counseling
2.2. Type of opioid, schedule, dispensing interval
Use controlled-release morphine if feasible (see 2.3 below) Prescribe scheduled doses (not as needed) Prescribe at frequent dispensing intervals (daily, alternate days, or weekly, depending on patient’s control over opioid use); do not refill the prescription if the patient runs out Keep daily schedule the same for as long as possible (eg, 3 times daily)
2.3. Rate of taper
Can vary from 10% of the total daily dose every day to 5% every 1 to 4 weeks Slower tapers are recommended for patients who are anxious about tapering, those who might be psychologically dependent on opioids, and those who have cardiorespiratory conditions Once a third of the original dose is reached, slow the taper to half of the previous rate Hold or increase the dose if the patient experiences severe withdrawal symptoms or worsening of pain or mood
2.4. Switching to morphine
Consider switching patients to morphine if the patient is addicted to oxycodone or hydromorphone Calculate equivalent dose of morphine Start patient on half this dose (tolerance to one opioid is not fully transferred to another opioid) Adjust dose up or down as necessary to relieve withdrawal symptoms without inducing sedation
2.5. Monitoring during taper
See patient frequently; at each visit, ask about benefits of taper (eg, improved pain, mood, alertness) Use urine drug screening to ensure compliance
2.6. Completion of taper
Taper can usually be completed in between 2 to 3 weeks and 3 to 4 months Patients who are unable to complete the taper may be maintained at a lower opioid dose if they are compliant with the treatment agreement
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