Tapering opioids in patients at high risk​

When to taper opioids

Opioid tapering is indicated in the following situations:

• The patient continues to report severe pain despite an adequate trial of two or three different opioids.
• The patient is experiencing complications of opioid therapy (e.g., depressed mood, sleep apnea, sedation).
• The patient is displaying persistent drug-related aberrant behaviours despite reasonable dose and dispensing interval adjustments.
• There is good evidence that tapering in these circumstances is associated with improved mood, reduced pain and increased function (Baron & McDonald, 2006; Crisostomo et al., 2008; Hooten et al., 2007).

How to taper opioids

Precautions for outpatient opioid tapering

• Pregnancy: Severe, acute opioid withdrawal has been associated with premature labour and spontaneous abortion.
• Unstable medical and psychiatric conditions that can be worsened by anxiety: Opioid withdrawal does not have serious medical consequences, but it can cause significant anxiety and insomnia.
• Addiction to opioids obtained from multiple doctors or "the street": Outpatient tapering is unlikely to be successful if the patient regularly accesses opioids from other sources. These patients are usually best managed in an opioid agonist treatment program (methadone or buprenorphine).
• Concurrent medications: Avoid sedative-hypnotic drugs, especially benzodiazepines, during the taper because the potential for misuse is higher during tapering.

Opioid tapering protocol

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 counselling.
• Indicate type of opioid, schedule, dispensing interval.
• Use controlled-release morphine if feasible.
• Prescribe scheduled doses (not prn).
• Prescribe at frequent dispensing intervals (daily, alternate days, weekly, depending on the patient's degree of control over opioid use). Do not refill if the patient runs out.
• Keep the daily schedule the same for as long as possible (e.g., tid).

Rate of the taper

• The rate of the taper can vary from 10 per cent of the total daily dose every day to 10 per cent of the total daily dose every one to two weeks.
• Slower tapers are recommended for patients who are anxious about tapering, may be psychologically dependent on opioids, have comorbid cardio-respiratory conditions or express a preference for a slow taper.
• Once one-third of the original dose is reached, slow the taper to one-half or less of the previous rate.
• Hold the dose when appropriate: The dose should be held or increased if the patient experiences severe withdrawal symptoms, a significant worsening of pain or mood, or reduced function during the taper.

Switching to morphine

• Consider switching to morphine if the patient might be dependent on oxycodone or hydromorphone.
• Calculate equivalent dose of morphine (see Oral opioid analgesic conversion and Equivalence between oral morphine and transdermal fentanyl).
• Start patient on one-half of this equivalent 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.

Monitoring during the taper

• Schedule frequent visits during the taper (e.g., weekly).
• At each visit, ask about pain status, withdrawal symptoms and possible benefits of the taper, such as reduced pain and improved mood, energy level and alertness.
• Use urine drug testing to assess compliance.

Completing the taper

• Tapers can usually be completed between two to three weeks and three to four months.
• Patients who are unable to complete the taper may be maintained at a lower dose if their mood and functioning improve and they follow the treatment agreement.

* Reproduced with permission from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain © 2010 National Opioid Use Guideline Group (NOUGG).

Table 1: Oral opioid analgesic conversion

Table 2: Equivalence between oral morphine and transdermal fentanyl