Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain
Appendix B-12: Opioid Tapering
- Precautions for Outpatient Opioid Tapering
Opioid Tapering Protocol
- 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: While opioid withdrawal does not have serious medical consequences, 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; such 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.
- 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.
- Type of Opioid, Schedule, Dispensing Interval
- Use controlled-release morphine if feasible (see 2.3 below).
- Prescribe scheduled doses (not p.r.n.).
- Prescribe at frequent dispensing intervals (daily, alternate days, weekly, depending on patient’s degree of control over opioid use). Do not refill if patient runs out.
- Keep daily schedule the same for as long as possible (e.g., t.i.d.).
- Rate of the Taper
- The rate of the taper can vary from 10% of the total daily dose every day, to 10% of the total daily dose every 1–2 weeks.
- Slower tapers are recommended for patients who are anxious about tapering, may be psychologically dependent on opioids, have co-morbid 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 patients to morphine if the patient might be dependent on oxycodone or hydromorphone.
- Calculate equivalent dose of morphine (see Appendix B-8: Oral Opioid Analgesic Conversion Table).
- Start patient on one-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.
- 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: reduced pain and improved mood, energy level and alertness.
- Use urine drug screening to assess compliance.
- Completing the Taper
- Tapers can usually be completed between 2–3 weeks and 3–4 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.