What is a recommended tapering schedule for a patient on morphine 5 mg (four times a day)?

Morphine 5 mg QID Tapering Schedule

For a patient on morphine 5 mg four times daily (20 mg total daily dose), reduce by 10-25% of the current dose every 2-4 weeks, which translates to decreasing by 0.5-1 mg per dose (2-5 mg total daily) at each step, continuing this pattern until complete discontinuation over approximately 2-4 months. 1

Specific Tapering Protocol

Week-by-week schedule using 10% reductions every 2 weeks:

• Current dose: Morphine 5 mg QID (20 mg/day total) 1
• Week 0-2: Reduce to 4.5 mg QID (18 mg/day) - a 10% reduction 1
• Week 2-4: Reduce to 4 mg QID (16 mg/day) - another 10% of current dose 1
• Week 4-6: Reduce to 3.5 mg QID (14 mg/day) 1
• Week 6-8: Reduce to 3 mg QID (12 mg/day) 1
• Week 8-10: Reduce to 2.5 mg QID (10 mg/day) 1
• Week 10-12: Reduce to 2 mg QID (8 mg/day) 1
• Week 12-14: Reduce to 1.5 mg QID (6 mg/day) 1
• Week 14-16: Reduce to 1 mg QID (4 mg/day) 1
• Week 16-18: Reduce to 0.5 mg QID (2 mg/day) 1
• Week 18-20: Discontinue 1

The FDA label explicitly states to initiate tapers by "no greater than 10% to 25% of the total daily dose" at intervals of every 2-4 weeks for physically opioid-dependent patients. 1 The 10% reduction should be calculated from the current dose, not the original starting dose, to avoid disproportionately large reductions as the taper progresses. 2

Alternative Conservative Approach for High-Risk Patients

For elderly patients, those with prolonged opioid exposure, or patients who experience withdrawal symptoms with the standard schedule, use a slower taper of 10% per month (every 4 weeks) instead of every 2 weeks. 2 This would extend the total tapering duration to approximately 8-10 months. 3

Some patients may require reductions as small as 5% of the current dose, which from a 20 mg/day starting dose would mean initial reductions of only 1 mg total daily dose (0.25 mg per dose). 3

Managing Withdrawal Symptoms

Pharmacological adjuvants to prevent and treat withdrawal:

• Alpha-2 agonists: Clonidine 0.1-0.2 mg twice daily or tizanidine 2-4 mg twice daily for autonomic symptoms (sweating, tachycardia, hypertension, restlessness). 3, 2 Start with small doses of clonidine due to orthostasis risk. 3
• For anxiety/irritability: Gabapentin 100-300 mg three times daily. 3
• For insomnia: Trazodone 25-50 mg at bedtime or mirtazapine 7.5-15 mg at bedtime. 3
• For GI symptoms: Loperamide 2-4 mg as needed for diarrhea (but avoid high doses due to abuse potential). 3
• For muscle aches: NSAIDs or acetaminophen. 2

Common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, mydriasis, irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, and diarrhea. 1

Critical Monitoring and Adjustment Rules

If withdrawal symptoms emerge at any reduction:

• Immediately return to the previous well-tolerated dose. 1
• Wait until symptoms fully resolve (typically 3-7 days). 1
• Resume tapering at a slower rate—either extend the interval between reductions (e.g., every 4 weeks instead of 2 weeks) or make smaller reductions (5% instead of 10%). 1

Never abruptly discontinue morphine. Rapid discontinuation in physically dependent patients has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. 1 The FDA specifically warns against this practice. 1

Reassess the patient frequently after each dose reduction to manage pain and withdrawal symptoms before proceeding to the next reduction. 1 Monitor for changes in mood, emergence of suicidal thoughts, or use of other substances. 1

Important Pitfalls to Avoid

Do not calculate reductions as a percentage of the original dose throughout the taper. This creates disproportionately large reductions at the end when the patient is most vulnerable. 2 Always calculate the reduction as a percentage of the current dose. 2

Do not set arbitrary deadlines for completing the taper. The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule. 2 If the patient experiences significant withdrawal or pain exacerbation, slow down or temporarily pause the taper. 2

Do not stop at a "minimum therapeutic dose" and then discontinue. The final doses before complete cessation may need to be very small (as low as 0.5 mg per dose or less) to prevent a large drop in opioid receptor occupancy when stopped. 2

Ensure multimodal pain management strategies are in place before and during the taper, including non-opioid analgesics, physical therapy, cognitive behavioral therapy, and other non-pharmacological approaches. 1

Expected Timeline

Using the standard 10% every 2-week schedule, complete discontinuation from morphine 20 mg/day will require approximately 4-5 months. 1 For more conservative tapers (10% per month), expect 8-10 months or longer. 2 Some patients may require up to several years for very slow tapers. 3