McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Appendix B-12: Opioid Tapering

  1. 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: 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.
  2. 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.
    • 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.