Opioid Tapering for Chronic Pain Patients

• For those using high doses of opioids (90 mg of morphine or equivalent) the 2017 Canadian Opioid Guidelines recommend tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy.
• Improvements in pain severity, function, and quality of life have been reported after opioid dose reduction. (Frank et al. 2017 Annals of Internal Medicine).
• Opioid tapering is not without risk and may not always be appropriate (Fenton et al. 2022 JAMA)

• Treatment goals have not been met (inadequate analgesia, no clear functional improvement).
• Adverse events (sedation, constipation, falls in elderly, etc.).
• Long-term opioid complications (tolerance, hyperalgesia, sleep apnea, and hypogonadism, etc.).
• Patient request (negative social stigma, financial issues, etc.).
• Inability to adhere to the agreed upon plan.
  • Note: Tapering may not be appropriate in this instance if opioid use disorder is suspected as a primary cause. Instead, opioid agonist therapy may need to be considered.

• Those who are pre-contemplative or not ready for tapering should not be forced to do so.
• Tapering may not be appropriate for those living with opioid use disorder. Opioid agonist therapy or referral to an opioid dependency program may be more appropriate.
  • High risk of relapse and being forced to access an unsafe supply places this population at risk of opioid poisoning.
• Pregnant patients
  • Risk for premature labour and spontaneous abortion with severe, acute withdrawal is possible. This does not preclude this population from a carefully implemented taper.
• Significant comorbidities
  • Withdrawal can cause significant anxiety and insomnia, which can worsen unstable medical and psychiatric conditions

• Emphasize that the goal of tapering is to help the patient feel better (i.e. to reduce pain intensity, and to improve mood and function).
• Explore benefits and barriers of tapering in a non-judgmental manner.
• Provide supportive counseling to the patient and their family.
• We recommend strong social support for the patient during an opioid taper such as access to a nurse, psychiatrist, psychologist, physiotherapist, dietician, pharmacist, social worker and others.
• We recommend discussing a plan for:
  • Sleep, nutrition, movement, productivity, relationships, mindfulness, and mental health.
  • How to use self-management skills for chronic pain including: self-monitoring, relaxation, pacing, self-talk, and communication

• There is no single tapering strategy to fit all patients.
• Reducing total daily dose by 5-10% every 2-4 weeks is a reasonable place to start.
• Taper according to the patient’s physiologic and psychological status; be flexible in the rate of taper.
• Consider a slower taper for:
  • High levels of anxiety, those who have attempted tapering previously, comorbid cardiorespiratory conditions, elderly.
• The last stage of tapering can be very difficult. Consider tapering at one-half or less of previous rate when one-third of the total dose is remaining.
• Hold or plateau the dose if the patient is experiencing severe withdrawal, reduced function, or significant worsening of pain or mood. 
  • You may need to take a step back if too big a of a reduction is made. Be cautious if returning to a higher dose becuase opioid tolerance can change rapidly.
  • Consider extending the taper rate from every 2-4 weeks to every 4-6 weeks temporarily until symptoms settle, and then continue with the taper

• Use a controlled-release formulation and a fixed dosing schedule (not PRN). 
• Let the patient choose which dose of the day is decreased first (AM, PM or HS).
• Keep dosing interval the same for as long as possible (BID or TID). 
• Prescribe at frequent dispensing intervals (daily, alternate days, or weekly).
  • If the patient runs out early, increase the frequency of dispensing.
•  We suggest blister packing for better control

• Withdrawal can be quite uncomfortable but is unlikely to be life-threatening in patients without significant comorbidities.
• Signs/symptoms: Abdominal cramping, nausea, vomiting, diarrhea, myalgias, arthralgias, muscle spasms, tremors, headaches, yawning, lacrimation, rhinorrhea, piloerection, diaphoresis, chills, hypertension, tachycardia, insomnia, fatigue, anxiety, irritability, restlessness.
• If withdrawal symptoms cannot be managed or are prolonged, an apporpriate response is to make a smaller or less frequent dose reduction.
• If no contraindications, clonidine 0.05-0.1 mg BID-TID PRN may alleviate autonomic symptoms such as hypertension, diaphoresis, and tachycardia (monitor blood pressure).
• Consider avoiding treating withdrawal symptoms with opioids or benzodiazepines.

• Schedule frequent visits (e.g. weekly at first). •
• Assess pain status, withdrawal symptoms and possible benefits (reduced pain, improved mood, energy, alertness, etc.).
• Allow 3-6 months or longer for the taper, depending on the situation. Changes are unlikely to be achieved quickly.
• Some patients may not stop daily use of opioids, even small dose reductions may be beneficial.

• Patients should be strongly cautioned that they may lose their tolerance after as little as a week or two after a reduction, and they are at risk for poisoning if they return to a previous opioid dose. 
• All patients who are on high doses of opioids should be offered a take-home naloxone kit as a general precaution.

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