What is the recommended guideline for tapering opioids in patients on long-term opioid therapy?

From the Guidelines

The recommended guideline for tapering opioids in patients on long-term therapy is a gradual reduction of 10% or less of the original dose per month, with a slower taper of 5% or less every 2-4 weeks for patients who have been on opioids for years. This approach is supported by the CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 1, which emphasizes the importance of individualizing the taper plan based on the patient's specific circumstances, including duration of opioid use, total daily dose, and medical and psychiatric comorbidities. Some key points to consider when tapering opioids include:

• Collaborating with the patient on the tapering plan, including decisions on how quickly tapering will occur and when pauses in the taper might be warranted 1
• Monitoring patients frequently for withdrawal symptoms, such as anxiety, insomnia, nausea, abdominal pain, and increased pain, and managing these symptoms with supportive medications like clonidine, antiemetics, and non-opioid analgesics 1
• Providing psychological support during tapering, as anxiety about increased pain and withdrawal symptoms can complicate the process 1
• Being aware of the potential risks of rapid tapering or abrupt discontinuation, including severe withdrawal and increased risk of relapse 1
• Considering the use of nonpharmacologic and nonopioid pharmacologic treatments to maximize pain management during the taper 1 It's also important to note that the taper should be tailored to the individual patient's needs and circumstances, and that a slower taper may be necessary for patients who have been on opioids for an extended period or who have a history of substance use disorder 1.

From the FDA Drug Label

When discontinuing Morphine Sulfate Injection in a physically-dependent patient, gradually taper the dosage Do not abruptly discontinue Morphine Sulfate Injection in these patients

The recommended guideline for tapering opioids in patients on long-term opioid therapy is to gradually taper the dosage.

• Do not abruptly discontinue the opioid in physically-dependent patients.
• The goal is to minimize withdrawal symptoms and allow the patient to safely stop using the opioid.
• It is essential to work closely with a healthcare provider to develop a tapering schedule that is individualized to the patient's needs 2.
• Patients seeking to discontinue treatment with buprenorphine for opioid dependence should also work closely with their healthcare providers on a tapering schedule 3.

From the Research

Guideline for Opioid Taper

The recommended guideline for tapering opioids in patients on long-term opioid therapy involves a gradual and systematic approach. Key considerations include:

• Tapering should be planned in advance with the patient, with a shared decision-making model to ensure the patient understands the risks and benefits of opioid therapy and the tapering process 4.
• The tapering process should be gradual, with a slow decrease in opioid dose over time to minimize the risk of withdrawal symptoms and other adverse effects 4, 5.
• The use of a fixed starting dosage (FSD) or an individualized starting dosage (ISD) may be considered, with the FSD approach potentially resulting in a lower burden of withdrawal symptoms 5.
• Alternate pain control treatments should be made available to the patient early in the tapering process, and the patient should be closely monitored throughout the process 4.
• Patients who experience withdrawal symptoms during the tapering process may be managed with medications such as lofexidine, and those with opioid use disorder may benefit from addiction counseling 4.

Key Considerations for Opioid Tapering

Some key considerations for opioid tapering include:

• The patient's daily opioid dose and the rate of tapering, with slower tapers (over months) potentially being more comfortable for patients but not always appropriate 4.
• The use of adjuvant medications to manage withdrawal symptoms and other adverse effects during the tapering process 6.
• The importance of shared decision-making and patient engagement throughout the tapering process, with a focus on minimizing the risk of harm and maximizing patient safety 4, 6.
• The potential benefits and risks of switching to alternative medications, such as buprenorphine, for patients who are experiencing harms from long-term opioid therapy 6.