Background     Fast Fact #413 discussed decision-making regarding whether to taper opioids in a patient with a serious illness. This Fast Fact discusses practical aspects of helping patients successfully taper. This Fast Fact does not address tapering in seriously ill patients with opioid use disorders (OUD). Of note, despite how common opioid tapering is, there are virtually no clinical data to guide clinicians and the following recommendations are largely expert opinion. 

Collaborate with the patient on a tapering plan    Tapering is more likely to be successful when patients and clinicians collaborate in the plan (1,2). Therefore, commit to working with the patient to improve function and decrease pain, and not abandon them. Discuss whether the current opioid therapy is helping the patient meet treatment goals, exposing the patient to harms (e.g., development of OUD), or whether benefits outweigh the risks. Ideally a predetermined plan that includes the end goal for tapering (decrease dose vs complete cessation vs rotation to another opioid such as buprenorphine), rate of taper, and treatment of withdrawal symptoms is discussed and mutually agreed upon prior to initiating the taper. Educate patients that tapering is sometimes painful, but that many patients find that after a period of adjustment (which can be many months) pain returns to baseline or is even improved. 

Maximize pain and mood support     Ensure necessary consultants are involved, i.e. social workers, physical therapists, pain specialists, etc. It may take weeks to months to adopt new behavioral techniques so optimization may require time. Carefully review medications and maximize nonopioid adjuvants. Assess and treat psychiatric conditions with behavioral health clinicians and/or medications (3).

Decide a rate to taper     The taper should be slow enough to minimize symptoms of withdrawal. Typically, the longer the duration of opioid therapy, the slower the taper should be. For patients on chronic opioid therapy (COT) for over a year, a ~10% reduction (of the original dose) per month taper is often appropriate (2). The exact reduction amount will often depend on available pill/patch formulations, but typically is not more than 20%. For example, a patient is on 90 mg of morphine extended release 3x daily; one could initiate the taper by reducing each dose by 15 mg (a ~15% reduction) each month. That is, reduce to 75 mg 3x daily for a month, then 60 mg 3x daily for a month, and so on. For patients who have been on COT for less than a year, or when a more rapid taper is indicated, a faster taper can be used of approximately a 10% dose reduction (of the original dose) per week. If a patient demonstrates significant withdrawal symptoms along the way, you can switch to ~10% reductions of the remaining dose. Once the smallest available dose is reached, the interval between doses may be extended.  For a rapid taper example, consider a patient taking 30 mg of oxycodone 5 times a day, or 150 mg daily. Decrease the daily dose by 15 mg (10%) each week until the patient reaches 45 mg daily (approximately 30% of the original daily dose). Then decrease by 5 mg (approximately 10% of remaining daily dose) until the patient is taking 5 mg daily. It is reasonable to stop opioid therapy completely when the patient is taking opioids less than once a day, meaning they are having occasional days without requiring opioids. 

Be willing to adjust the rate     At times the taper may need to be paused and restarted when the patient is ready. A pause may allow the patient time to develop new skills for managing pain and emotional distress, initiate other treatments, and allow for physical adjustment to a new dosage. As long as the patient is making progress, the taper is considered successful. In some cases, it may take years (2).  

Treat withdrawal symptoms    Using the above parameters, severe abdominal cramping, diarrhea, and restlessness are rare. However, some patients may have prolonged, uncomfortable, withdrawal symptoms which are mild to moderate in severity.  Consider using a simple reporting tool like COWS to assess and monitor withdrawal symptoms (4).  Withdrawal symptom onset depends upon the duration of action of the opioid medication used by the patient and may be as early as a few hours after the last dose or a few days.  Most symptoms (anxiety, restlessness, sweating, yawning, muscle aches, diarrhea, cramping) resolve 5-10 days after the latest dose reduction.  Other symptoms (dysphoria, insomnia, irritability) can take weeks to months to resolve. Educating and providing encouragement that dysphoria and irritability will improve with time are essential skills in helping patients taper successfully. Alpha-2 agonists (e.g. clonidine) can be given for autonomic signs and symptoms (sweating, tachycardia).  Other medications for diarrhea, muscle aches, insomnia, nausea, and abdominal cramping may be appropriate (2). Regular follow-up is critical. 

Troubleshooting ‘unsuccessful’ tapers     If, despite all the above, the patient cannot taper successfully there are several considerations. Reconsidering the tapering goal is one – sometimes a modest dose reduction can be a clinical success for a patient. For some patients, poorly controlled psychiatric disorders such as severe anxiety interfere with the taper. Pausing the taper and refocusing on helping the patient improve their psychiatric condition is indicated here. Carefully assessing the patient for previously unrecognized OUD or complex persistent opioid dependence (CPD) is also important in these scenarios. “CPD” is a novel term used to describe patients with severe pain and poor function despite COT who cannot successfully taper, but who do not meet diagnostic criteria for OUD (5). There is no clear standard for how to help patients with CPD, although interdisciplinary pain care which addresses mood, coping, and physical function is recommended by experts. Buprenorphine-based therapies, which are, if nothing else, significantly safer for patients than full-opioid agonist COT, have also been proposed (5).  

References:

1. Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017;167(3):181–191. doi:10.7326/M17-0598
2. U.S. Department of Health and Human Services. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. U.S. Department of Health and Human Services. Available at: https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf. Published October 2019. Accessed Dec 1, 2020.
3. Goodlev ER, Discala S, Darnall BD, Hanson M, Petok A, Silverman M. Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship. J Palliat Med. 2019;22(11):1308‐1317. doi:10.1089/jpm.2019.0171.
4. “Clinical Opiate Withdrawal Scale.” National Institute on Drug Abuse. Available at: https://www.drugabuse.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf. Accessed Dec 1, 2020.
5. Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Subst Abus. 2018;39(2):152-161.

Authors’ Affiliations: University of Utah, Salt Lake City, UA (WJ, SJ); University of Minnesota Medical School, Minneapolis, MN (DR).

Conflicts of Interest: None to report

Version History:  first electronically published in January 2021; originally edited by Sean Marks MD