What is the recommended taper plan for codeine (opioid analgesic) in a patient with chronic severe musculoskeletal (MSK) pain who is transitioning to Butrans (buprenorphine) patch?

Codeine Tapering Plan for Patient Transitioning to Butrans Patch

A gradual taper of codeine extended release 50mg BID over 2-3 weeks is recommended for this 84-year-old female with chronic severe MSK pain who has been started on Butrans patch 5mcg/hr. This approach minimizes withdrawal symptoms while allowing the buprenorphine patch to reach therapeutic levels.

Recommended Tapering Schedule

• Week 1: Reduce codeine extended release to 50mg in the morning and 25mg in the evening while continuing Butrans patch 5mcg/hr 1

• Week 2: Further reduce to codeine extended release 25mg BID while continuing Butrans patch 5mcg/hr 1

• Week 3: Reduce to codeine extended release 25mg once daily for 3-4 days, then discontinue completely 1

Rationale for This Approach

• Buprenorphine has a high binding affinity for μ-opioid receptors and slow dissociation, which provides long-term analgesia for chronic pain 1

• The Butrans patch (transdermal buprenorphine) bypasses first-pass hepatic metabolism, providing better bioavailability compared to oral formulations 1, 2

• Transdermal buprenorphine reaches therapeutic levels within 1-2 hours but may take up to 3-5 days to reach steady state, necessitating a gradual taper of the full opioid agonist 2, 3

• Gradual tapering (20-50% per week) is preferred over rapid tapering to minimize withdrawal symptoms, especially in elderly patients 1

Monitoring During Taper

• Assess for signs of withdrawal using the Clinical Opioid Withdrawal Scale (COWS); scores should remain below 5 4

• Monitor for adequate pain control throughout the tapering process 1

• Watch for potential side effects of buprenorphine including nausea, headache, and constipation 1, 3

Special Considerations for This Patient

• At 84 years old, this patient may be more sensitive to withdrawal symptoms and require a more gradual taper 1

• The patient has been on Butrans patch for 2 weeks already, so the buprenorphine should be providing some analgesic effect, facilitating the codeine taper 3

• If withdrawal symptoms occur despite the gradual taper, consider slowing the taper rate further 1

Potential Challenges and Solutions

• If pain control is inadequate during the taper, consider:

  • Using non-opioid adjuvant therapies (NSAIDs, acetaminophen) for breakthrough pain 1
  • Temporarily slowing the taper schedule 1

• If withdrawal symptoms become problematic:

  • Symptomatic treatment with clonidine or other α2-adrenergic agonists can help manage increased sympathetic activity 1
  • Consider splitting the daily codeine dose into more frequent, smaller doses 1

Documentation

• Document the rationale for tapering, the specific plan, and patient education in the medical record 1

• Consider using a formal taper agreement that outlines the schedule and expectations 1

• Schedule follow-up appointments to assess pain control and adjust the plan as needed 1