What is the suggested titration and duration of withdrawal symptoms for a patient taking 90 mg of Kadian (morphine sulfate) daily?

Tapering Kadian (Morphine Sulfate) 90 mg Daily: Recommendations for Withdrawal Management

For a patient on 90 mg daily of Kadian (morphine sulfate extended-release), a gradual taper of no more than 10% of the total daily dose every 2-4 weeks is recommended to minimize withdrawal symptoms, which may persist for weeks to months after discontinuation.

Recommended Tapering Schedule

Initial Phase (First Month)

• Begin with a 10% reduction (reduce by 9 mg to 81 mg daily)
• Maintain this dose for 2-4 weeks before next reduction
• Monitor for withdrawal symptoms during this period

Subsequent Reductions

• Continue with 10% reductions of the current dose every 2-4 weeks
• Example schedule:
  • Weeks 1-4: 81 mg daily
  • Weeks 5-8: 73 mg daily
  • Weeks 9-12: 66 mg daily
  • Weeks 13-16: 59 mg daily
  • Weeks 17-20: 53 mg daily
  • Continue this pattern until reaching very low doses

Final Phase

• When reaching approximately 30 mg daily, consider slowing to 5% reductions
• For doses below 15 mg daily, even smaller percentage reductions may be needed
• The entire taper process may take 4-6 months or longer depending on individual response

Expected Withdrawal Symptoms

Withdrawal symptoms from chronic Kadian use at 90 mg daily may include:

• Acute withdrawal symptoms (first 1-2 weeks after each dose reduction):

  • Anxiety, restlessness
  • Lacrimation, rhinorrhea, yawning
  • Perspiration, chills, myalgia
  • Mydriasis (pupil dilation)
  • Irritability, insomnia
  • Abdominal cramps, nausea, vomiting, diarrhea
  • Increased blood pressure, respiratory rate, or heart rate

• Protracted withdrawal symptoms (may persist for weeks to months):

  • Dysphoria, irritability
  • Insomnia
  • Anhedonia (inability to feel pleasure)
  • Vague sense of being unwell

Managing Withdrawal Symptoms

• Use adjuvant medications to manage specific symptoms:

  • Clonidine for autonomic symptoms (0.1-0.2 mg every 6 hours as needed)
  • Antiemetics for nausea/vomiting
  • Loperamide for diarrhea
  • Non-opioid analgesics for pain/discomfort

• If withdrawal symptoms become intolerable:

  • Pause the taper temporarily
  • Return to the previous dose that was well-tolerated
  • Resume tapering at a slower rate (5% reductions)

Special Considerations

• Pain management during taper: Implement multimodal pain management strategies including non-opioid medications and non-pharmacological approaches
• Psychological support: Consider referral for psychological support to address anxiety about tapering
• Monitoring: Schedule frequent follow-ups (at least monthly) during the tapering process 1

Common Pitfalls to Avoid

1. Tapering too quickly: The FDA warns against rapid discontinuation which can result in serious withdrawal symptoms, uncontrolled pain, and even suicide attempts 2

2. Rigid tapering schedules: Adjust based on individual response rather than adhering to a fixed schedule 1

3. Inadequate symptom management: Withdrawal distress should be preempted and treated with adjuvant medications 1

4. Misinterpreting withdrawal pain as underlying condition: Pain during withdrawal may be new or amplify preexisting pain due to increased firing of descending pain facilitatory tracts 1

5. Overlooking protracted withdrawal: Be aware that symptoms may persist for months after opioid elimination 1

If the patient struggles significantly with the taper despite these measures, consider consultation with a pain specialist or addiction medicine specialist for additional support and potentially alternative approaches.