What are the options for a 68-year-old male (YOM) on chronic opioids (e.g. morphine, oxycodone) for back pain who wants to wean down on opioids for pain control?

Options for Weaning Down Opioids for Chronic Back Pain

For a 68-year-old male wanting to wean down from chronic opioids for back pain, a gradual tapering approach combined with multimodal non-opioid pain management strategies is strongly recommended.

Tapering Protocol

• Begin with a small dose reduction of 10-25% of the total daily dose at intervals of 2-4 weeks to minimize withdrawal symptoms 1, 2
• For patients who have been on opioids for longer periods, a more extended tapering schedule beyond the standard 10-14 days is necessary 2, 1
• Monitor for withdrawal symptoms including restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis 1
• If withdrawal symptoms emerge, pause the taper temporarily or return to the previous dose before proceeding with a slower taper 1

Non-Opioid Pain Management Alternatives

• NSAIDs are effective for back pain and should be considered as a primary alternative (unless contraindicated) 2
• Acetaminophen can be used as an alternative or adjunct to NSAIDs 2
• Muscle relaxants may be considered, though evidence for long-term use is limited 2
• Anticonvulsants (particularly α-2-delta calcium-channel antagonists like pregabalin) can be effective for neuropathic components of back pain 2
• Antidepressants, particularly tricyclics and serotonin-norepinephrine reuptake inhibitors, may help with chronic pain 2

Risk Mitigation During Tapering

• Document the rationale for tapering and create a formal tapering plan with the patient 2
• Consider using a written opioid taper agreement outlining the schedule and expectations 2
• Monitor for changes in mood, emergence of suicidal thoughts, or use of other substances during the tapering process 1
• Review prescription drug monitoring program (PDMP) data periodically during the taper 2
• Consider urine drug testing to assess for prescribed medications and other substances 2

Special Considerations

• For patients with suspected opioid use disorder, consider referral for medication-assisted treatment with buprenorphine or methadone 2
• Buprenorphine may be particularly beneficial for patients with both chronic pain and opioid dependence 2
• Avoid concurrent use of benzodiazepines and opioids whenever possible 2
• Reassure the patient that their pain will continue to be treated and they will not be abandoned 2

Non-Pharmacological Approaches

• Physical therapy and exercise programs should be incorporated into the treatment plan 2
• Consider referral for cognitive behavioral therapy or other pain management programs 2, 3
• Interventional procedures may be appropriate for some patients (e.g., epidural injections for radicular pain) 2

Monitoring During Tapering

• Schedule frequent follow-up visits (every 2-4 weeks initially) to assess pain control, function, and withdrawal symptoms 2, 1
• Evaluate for improvement in function, not just pain scores 2
• Be prepared to adjust the tapering schedule based on individual response 2, 1
• Consider offering naloxone for patients at higher risk of overdose (≥50 MME/day, history of overdose, or concurrent benzodiazepine use) 2

Common Pitfalls to Avoid

• Tapering too rapidly can lead to withdrawal symptoms and treatment failure 2, 1
• Failing to address underlying anxiety or depression that may worsen during tapering 1
• Not providing adequate alternative pain management strategies before beginning the taper 2
• Overlooking the importance of functional improvement as a treatment goal rather than focusing solely on pain scores 2

The evidence for opioids in chronic low back pain is limited, with studies showing only modest short-term pain relief that may not be clinically significant at recommended doses 4, 5. A gradual, patient-centered approach to tapering combined with multimodal pain management offers the best chance for successful opioid reduction while maintaining adequate pain control and function.