Opioid Tapering Template

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This tool is to support primary care providers in discussing the value of opioid tapering with all adult patients currently prescribed an opioid and to support their patients in reducing opioid dosages in a safe and effective way.

Important considerations for opioid tapering

  • Clinicians should engage patients in shared decision-making, including consideration of the patient’s values, goals, concerns and preferences prior to tapering.1,2
  • When possible, an interdisciplinary team approach should be used during the tapering process to support complementary non-pharmacological and pharmacological management.1,2
  • For patients starting or continuing an opioid trial, discuss and document patients’ goals on a regular basis. (SMART goals: Specific, Measurable, Agreed-upon, Realistic, Time-based).
  • Consider the potential opioid harms and safety concerns.
CAUTION
  • Pregnancy – spontaneous abortion and premature labour have been associated with opioid withdrawal during pregnancy.
  • When you have concerns about tapers destabilizing mental illnesses, destabilizing or unmasking substance use disorders including opioid use disorders or medically unstable conditions (e.g. severe hypertension, unstable CAD) consider seeking out additional consultation or supports.
Naloxone
  • Naloxone is a medication that can reverse the effects of an opioid overdose. It is recommended to keep naloxone on hand in case of an accidental overdose. This is particularly important for patients on doses of >50 morphine equivalent dose (MED)/day, those with a history of overdose or concurrent benzodiazepine use
  • Ontarians with a health card are eligible for a free take-home naloxone kit. You can receive these kits and training on their use from pharmacies, community organizations and provincial correctional facilities.
Reasons to consider opioid tapering, reduction or discontinuation
  • Patient requests dosage reduction
  • Problematic opioid behaviour (e.g. diversion, altering the route of delivery, accessing opioids from other sources)
  • Clear evidence of opioid use disorder (OUD)
    Tapering alone is not likely an effective treatment for OUD. It may require further assessment and possible consultation to identify the optimal therapeutic options.
  • Adverse effects:
    • Experiences overdose or early warning signs for overdose risk (e.g. confusion, sedation, slurred speech)
    • Medical complications (e.g. sleep apnea, hyperalgesia and withdrawal mediated pain)
    • Adverse effects impair functioning below baseline level
    • Patient does not tolerate adverse effects
  • Opioid dosages >90 MED1
  • Opioid dosages >50 MED without benefit in improving pain and/or function
  • Opioid is combined with benzodiazepines3

If pain and function are not improving despite opioid therapy, one should consider the potential harms relative to the lack of benefits, reduce opioid use and focus on other approaches.

Opioid use disorder criteria
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Opioid use disorder criteria

  • Opioids are often taken in larger amounts or over a longer period than was intended
  • Persistent desire or unsuccessful efforts to cut down or control opioid use
  • Spending a lot of time obtaining the opioid, using the opioid, or recovering from its effects
  • Craving or a strong desire to use opioids
  • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use
  • Stopping or reducing important social, occupational, or recreational activities due to opioid use
  • Recurrent use of opioids in physically hazardous situations
  • Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids
  • Tolerance* as defined by:
    • Need for markedly increased amounts to achieve intoxication or desired effect
    • Markedly diminished effect with continued use of the same amount
  • Withdrawal* manifesting as either:
    • Characteristic opioid withdrawal syndrome (see Withdrawal symptoms & management)
    • Same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

 

Presence of 2 to 3 criteria indicates Mild OUD

Presence of 4 to 5 criteria indicates Moderate OUD

Presence of 6 or more criteria indicates Severe OUD

Talking points
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Talking points

Provide information about why a taper might be needed:

  • “Chronic pain is a complex disease and opioids alone cannot adequately address all of your pain-related needs.”
  • “I think it is time to consider the opioid dose you are on and its risk of harm. The risk of overdose and the risk of dying from overdose go up as the dose goes up.”
  • “Did you know that most of the evidence showing benefits from opioid use for chronic non-cancer pain supports relatively low doses (less than 100 MED)?”1,2
  • “In some people, opioids can make their pain worse rather than better. Hyperalgesia resulting from an opioid is when the opioid makes one more sensitive to pain instead of less.”

Ensure patients have clear expectations of tapering:

  • “Some patients suffering with pain do better if they reduce their use of opioids.”
  • “Dose reduction or discontinuation of opioids frequently improves function, quality of life and pain control. This may take some time, and your pain may briefly get worse at first.”

Address discrepancies between the patient’s goals and their current pain management:

  • “I want to make sure your pain management is as safe as possible and I want to get you back to your regular activities.”

Adjust to any resistance to opioid reduction by reframing the conversation:

  • “Opioids can have an effect on your central nervous system – they may be causing fatigue or lessening your ability to do daily activities. It is common to see one’s alertness and function level go down when the opioid dose goes up.”
  • “Sounds like your pain has not improved even with the high dose you have been trying. It may be time to consider a lower dose.”

 

Conversations about tapering require empathy and patient self-efficacy and should ideally be a joint decision. They may need to be revisited periodically depending on the patient’s readiness. As this process unfolds, continue to work with your patients to provide care that is safe.

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How to taper, reduce, or discontinue

For those on a higher dose and/or longer term opioids there is an increased potential for more challenges to tapering, including withdrawal symptoms.

General approach

  • 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 in adhering to the withdrawal plan1
  • Establish the dosing interval
    • Scheduled doses are preferred over PRN doses (to help with better pain control and withdrawal)
    • Keep the dosing interval constant (e.g. bid)
  • Establish the rate of taper based on patient health, preference and other circumstances
    • Individualize tapering schedule – there is insufficient evidence to recommend for or against specific tapering strategies and schedules1,2
    • Slow taper should be followed unless otherwise indicated (e.g. patient preference)
    • Rapid taper over 2–3 weeks
CAUTION

Reducing the dose immediately or rapidly over a few days/weeks, may result in severe withdrawal symptoms and is best carried out in a medically-supervised withdrawal centre.1

  • 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 potentially abandoned in patients who experience distressing or intolerable pain, withdrawal symptoms or a decrease in function that persists for more than 1 month after a small dose reduction.1
  • Treat pain and function with non-opioids (see Management of Chronic Non Cancer Pain tool)
  • Treat withdrawal symptoms PRN (see Withdrawal symptoms & management)
  • Taper to the lowest effective dose

How long a taper should take is difficult to predict and needs to be individualized to each patient, for some a very gradual taper is required that can take months and at times years.

Legend PRN = when necessary; ER = extended release; bid = twice a day; qam = in the morning; SR = slow release; qhs = at bedtime; IR = immediate release

Example of slow taper
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Example of slow taper

Current opioid: Morphine SR 120mg bid

  • Calculate total opioid dose: Total Daily Morphine Dose = 240mg/d
  • Calculate daily opioid dose – typically 5–10%
    • 5% = 12mg
    • 10% = 24mg
  • Reduce the dose every 2 to 4 weeks depending on how the patient is tolerating the taper and their desire to taper

Example:
Decrease Morphine SR by 15 mg

  • Weeks 1 & 2 Morphine SR 105mg qam and 120mg qhs
  • Weeks 3 & 4 Morphine SR 105mg bid
  • Weeks 5 & 6 Morphine SR 90mg qam and 105mg qhs
  • Weeks 7 & 8 Morphine SR 90mg bid
  • Weeks 9 &10 Morphine SR 75mg qam and 90mg qhs
  • Weeks 11 & 12 Morphine SR 75mg bid
  • Weeks 13 & 14 Morphine SR 60mg qam and 75mg qhs
  • Weeks 15 & 16 Morphine SR 60mg bid
  • Weeks 17 & 18 Morphine SR 45mg qam and 60mg qhs
  • Weeks 19 & 20 Morphine SR 45mg bid
  • Continue until the lowest effective dose is found for the patient.

NOTE: Lowest available Morphine SR formulation is 15mg tablet or Morphine ER 10mg capsule

Slow taper tips

  • Tapering reductions can be lower than 5% if gentler reductions are needed. For q24h formulation a gentler taper option is to reduce the dose by 10mg increments every 2 weeks.
  • For patients with no acute safety concerns (e.g. 5–10% of MED every 2–4 weeks),1 tapers might need to be slowed once low dosages have been reached. Once the smallest available dose is reached, the interval between doses can be extended. Opioids may be stopped when taken less frequently than once a day.3
Example of rapid taper
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Example of rapid taper

Current opioid: Morphine SR 120mg bid

Decrease Morphine SR 120mg bid to

  • 90mg bid x 3 days,
  • then 60mg bid x3 days,
  • then 30mg bid x 3 days,
  • then 15mg bid x 3 days,
  • then 15mg qhs x 3days,
  • then stop
Other methods used
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Other methods used to reduce dose, taper or discontinue

  • Switch current opioid to another opioid and reduce MED by 25% to 50% – see Opioid Manager Appendix C – Switching Opioids
  • Switch to opioid agonist therapy such as buprenorphine-naloxone or methadone. If unfamiliar with protocol, clinicians should consult with someone knowledgeable with buprenorphine-naloxone use.1
  • In Canada, all physicians prescribing methadone require a federal exemption for pain or addictions.

Withdrawal symptoms & management

Opioid withdrawal can be very uncomfortable and difficult for the patient and can feel like a very bad flu. Opioid withdrawal is not usually life-threatening.

Onset and duration of withdrawal symptoms

Short-acting opioids

  • Onset: ~6–24 hours after last use
  • Duration: ~3–10 days

Long-acting opioids

  • Onset: ~12–72 hours after last use
  • Duration: ~10–20 days

Some symptoms may last for weeks or months (e.g. cravings, insomnia, dysphoria).

Talking points
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Talking points

Ensure patients have clear expectations of tapering:

  • “Dose reduction or discontinuation of opioids could lead to withdrawal symptoms. During this time, your pain may get worse for a brief period of time, but your pain will decrease as your withdrawal symptoms lessen.”

 

Symptoms and management5,6

Muscle pain

Slower taper may be required to address these symptoms

Neuropathic pain

Slower taper may be required to address these symptoms

Physical symptoms of withdrawal

(e.g. sweating, diarrhea, vomiting, abdominal cramps, chills, anxiety, insomnia and tremor)

  • If BP >90/50 mmHg, may give clonidine 0.1mg. Check BP & HR 1 hour later. If BP <90/50, HR <50 or dizziness, do not prescribe further. May titrate up to qid prn, then taper.
  • Do not give clonidine if BP < 90/50 mmHg or HR < 50 bpm
Diarrhea
  • Stop stool softeners and/or laxatives (e.g. sennosides, docusate sodium, lactulose) if applicable
  • Loperamide (if necessary) 4mg STAT, then 2mg after each unformed stool up to a maximum of 16mg per day
Insomnia
  • Cognitive Behaviour Therapy for Insomnia (CBT–I) (see Management of Chronic Insomnia tool)
  • Do not prescribe benzodiazepines, zopiclone or zolpidem
  • For patients already on benzodiazepine, zopiclone or zolpidem discuss the increased risk of harm and consider tapering once the patients are tapered off opioids.
Nausea/vomiting
  • Dimenhydrinate 25–100mg q4h prn
  • Prochlorperazine 5–10mg q6h prn
  • Haloperidol 0.5–1mg q12h prn
  • Metoclopramide 10mg q4–6h prn
Abdominal cramps
  • Hyoscine butylbromide 20mg tid-qid prn for 2–3 days
Muscle cramps
  • Quinine sulfate 300mg bid prn
Sweating
  • Oxybutynin 2.5–5mg bid prn (short-term use)
  • Ensure patient is well-hydrated
Overdose prevention

Tolerance of previous dose of opioids is lost after 1–2 weeks. Patients may inadvertently take the original dose to help with withdrawal symptoms or pain resulting in possible overdose and mortality risk.

  • Naloxone kit

Tapering plan and follow-up visits

Tapering plan

This form is designed to help primary care providers document the tapering plan agreed upon by both the patient and the primary care provider. Ensuring the patient has been part of the planning process is important for buy-in and adherence to the agreed upon plan. Have the patient repeat the plan back to you to ensure that they understand it. When undertaking an opioid taper plan, please keep in mind that although there may be a taper schedule in place there may be a need to deviate from the plan (e.g. pausing) or adjust the rate, intensity or duration of the taper depending on how the patient is responding with regards to their pain, function, withdrawal symptoms and other life events.

Follow-up visits

This form is designed to help primary care providers document the patient’s tolerance to tapering. If the patient is experiencing a high degree of withdrawal symptoms, consider adjusting the rate of taper, pausing the taper, treating withdrawal symptoms or monitoring if the patient is tolerating symptoms and is motivated to continue.

After you have assessed how well the patient is tolerating tapering, determine if they are ready to continue with the taper as planned at this time or decide if you will need to deviate from the plan or pause the taper.

If the patient is NOT tolerating the taper please consider:

  • Pausing taper
  • Changing taper’s
    • Rate
    • Duration
    • Next planned visit

If the patient is tolerating the taper, please consider:

  • Current opioid dose
  • Week of taper
  • Next planned opioid dose
  • Planned next visit

Supporting material

*These supporting materials are hosted by external organizations and as such, the accuracy and accessibility of their links are not guaranteed. The CEP will make every effort to keep these links up to date.

References

  • [1]

    Michael G. DeGroote National Pain Centre, McMaster University. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. 2017; [cited Jan 4, 2018].

  • [2]

    Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guideline for opioid therapy for chronic pain. 2017 ; [cited Jan 4, 2018].

  • [3]

    Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain. 2016 ; [cited Jan 4, 2018].

  • [4]

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington: American Psychiatric Association; c2013.

  • [5]

    Michael G. DeGroote National Pain Centre, McMaster University. Opioid tapering – information for patients. [cited Jan 4, 2018].

  • [6]

    World Health Organization. Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. Geneva: 2009 ; [cited Jan 4 2018].