What is the recommended tapering strategy for a patient on oxy (oxycodone) 5mg every 5 hours as needed, Journavx (not a standard medication, possibly a typo, assuming it's a non-steroidal anti-inflammatory drug) every 12 hours, and gabapentin 300mg three times a day, after an epidural steroid injection (ESI) for vertebral fracture pain management?

Opioid Tapering Strategy After Epidural Steroid Injection for Vertebral Fracture Pain

Begin by tapering the oxycodone first using a slow 10% per month reduction while maintaining the gabapentin at 300mg TID and continuing the NSAID (assuming "Journavx" is a long-acting NSAID), then reassess pain control monthly with the goal of discontinuing opioids within 6-12 months if the ESI provides sustained relief. 1

Prioritize Opioid Tapering First

The CDC 2022 guidelines explicitly recommend that when reducing multimodal pain regimens, opioids should be weaned first, followed by NSAIDs, and finally other adjuvants. 1 This approach is critical because:

• For patients on long-term opioids (≥1 year), tapers of 10% per month or slower are better tolerated than rapid tapers 1
• Your patient has been on oxycodone for approximately 6 months, which qualifies as intermediate-term use requiring gradual tapering 1
• The ESI performed recently should provide 6-12 weeks of pain relief, creating an optimal window for opioid reduction 1

Specific Opioid Tapering Protocol

Month 1-2: Initial Assessment and Preparation

• Calculate current total daily morphine milligram equivalents (MME): Oxycodone 5mg every 5 hours PRN = approximately 30mg/day maximum (assuming 6 doses), which equals 45 MME/day 1
• Establish baseline pain scores and functional goals with the patient before initiating taper 1
• Provide naloxone for overdose prevention, as tolerance decreases during tapering 1

Month 2-3: Begin 10% Monthly Reduction

• Reduce oxycodone by 10% of the original dose per month (reduce by 3mg/day monthly, or approximately 0.5mg per dose) 1
• Example: Month 2 = oxycodone 4.5mg every 5 hours PRN; Month 3 = oxycodone 4mg every 5 hours PRN 1
• Schedule monthly follow-up visits to monitor withdrawal symptoms and pain control 1

Month 4-8: Continue Gradual Reduction

• Continue 10% monthly reductions of the original dose 1
• Watch for withdrawal symptoms: anxiety, insomnia, abdominal pain, diaphoresis, tachycardia 1
• If withdrawal symptoms occur, pause the taper and slow the reduction rate to 5% per month 1

Month 9-12: Final Taper Phase

• As doses become very low (≤10mg/day), slow the taper further to 5% reductions or extend dosing intervals 1
• Extend intervals between doses rather than reducing dose amount (e.g., every 6 hours instead of every 5 hours) 1
• Discontinue when dosing frequency is less than once daily 1

Maintain Gabapentin Throughout Taper

Do not reduce gabapentin during opioid tapering—it should remain at 300mg TID to manage neuropathic pain components. 1 Here's why:

• Gabapentin at 900mg/day (300mg TID) is at the minimum effective dose for neuropathic pain 1, 2
• Vertebral fractures often have neuropathic pain components from nerve root compression 1
• Gabapentin requires 3-8 weeks for titration plus 2 weeks at maximum dose for adequate trial, meaning an adequate trial may require 2 months or more 1, 3
• The current dose of 900mg/day is well below the maximum of 3600mg/day, providing room for upward titration if needed during opioid taper 1, 2

Consider Gabapentin Optimization

• If pain increases during opioid taper, increase gabapentin by 300mg every 3-7 days up to 1800-3600mg/day in divided doses before increasing opioids 1, 2
• Slower titration is recommended for elderly or medically frail patients 1
• Assess renal function and adjust dosing if creatinine clearance is reduced 1, 3

NSAID Management

Continue the NSAID (Journavx) throughout the opioid taper to maintain baseline analgesia 1. The NSAID should be:

• Maintained at current dose during opioid tapering 1
• Discontinued only after opioids are successfully tapered 1
• Monitored for gastrointestinal and cardiovascular side effects, especially if long-term use continues 1

Critical Monitoring Parameters

Monthly Assessments Should Include:

• Pain intensity scores using numerical rating scale 1
• Functional status: ability to perform activities of daily living 1
• Withdrawal symptoms: anxiety, insomnia, GI symptoms, autonomic symptoms 1
• Signs of opioid use disorder: craving, loss of control, continued use despite harm 1
• Mental health screening: depression and anxiety often emerge during tapering 1

Warning Signs to Pause or Slow Taper:

• Clinically significant withdrawal symptoms signal need to slow taper rate 1
• Severe pain increase not responsive to gabapentin optimization 1
• Functional decline affecting quality of life 1
• Mental health crisis including suicidal ideation 1

Common Pitfalls to Avoid

Do not taper too rapidly—the 2016 CDC guidelines recommended tapers as fast as 10% per week, but the 2022 updated guidelines explicitly state that 10% per month or slower is better tolerated for patients on opioids ≥1 year 1

Do not abandon the patient—if the patient struggles with tapering, maximize nonopioid treatments and address behavioral distress rather than simply continuing high-dose opioids 1

Do not abruptly discontinue opioids—this increases overdose risk if the patient returns to previous doses due to loss of tolerance 1, 4

Do not assume gabapentin at 900mg/day is optimized—this is the minimum effective dose, and most patients require 1800-3600mg/day for adequate neuropathic pain control 1, 2, 5, 6

Do not taper gabapentin if considering discontinuation—gabapentin withdrawal can occur with chronic use and requires gradual tapering over weeks to months 7

Patient-Centered Approach

Collaborate with the patient on the tapering plan—patient agreement and interest in tapering is a key component of successful tapers 1. This includes:

• Discussing realistic goals: some patients may achieve complete discontinuation while others may reach a reduced stable dose 1
• Allowing patient input on taper speed and when to pause 1
• Providing education about increased overdose risk with return to higher doses 1
• Maximizing nonpharmacologic treatments: physical therapy, cognitive behavioral therapy, interventional procedures 1

Expected Timeline

Realistic timeline for this patient: 6-12 months to discontinue opioids, assuming the ESI provides sustained benefit and gabapentin is optimized 1. If the patient cannot tolerate complete discontinuation, a reduced stable dose may be an acceptable endpoint 1.