What is the best way to taper off opioids?

Opioid Tapering: Evidence-Based Approach

The best way to taper opioids is through a slow, hyperbolic reduction of 10% of the current dose per month (not the original dose), with each new dose being 90% of the previous dose, combined with patient agreement, close monitoring, and adjunctive treatments for withdrawal symptoms—never abruptly discontinue opioids in physically-dependent patients as this constitutes unacceptable medical care and carries significant risks including overdose, psychological distress, and suicide. 1, 2

Critical Safety Principles

Never abruptly discontinue opioids in patients who have been taking them regularly and may be physically dependent, as this is considered unacceptable medical care and is associated with serious harms including withdrawal symptoms, psychological distress, self-medication with illicit substances, uncontrolled pain, and suicide. 1, 3

Mandatory Prerequisites Before Starting

• Obtain patient agreement and collaboration—involuntary tapering is associated with poor outcomes including treatment dropout, emergency department utilization, and suicidal ideation. 1
• Never abandon the patient if tapering becomes difficult; maintain the therapeutic relationship and consider pausing at a stable dose rather than pushing forward. 1
• Ensure the patient understands they can request slower tapering if withdrawal symptoms or pain become intolerable. 1

Recommended Tapering Protocol

Tapering Rate Based on Duration of Use

For long-term opioid users (years of use):

• Reduce by 10% of the current dose per month or slower, using a hyperbolic taper where each new dose is 90% of the previous dose (not the original dose). 2
• This prevents disproportionately large final reductions that occur with linear tapers. 2
• The entire taper will likely take 6-12 months minimum, possibly years. 2

For short-term users (weeks to months):

• The FDA label for oxycodone recommends tapering by 25-50% every 2-4 days for patients who may be physically dependent. 3
• However, if withdrawal symptoms develop, slow the taper immediately. 3

Practical Implementation Steps

1. Start with small initial reductions (even 5-10%) to address patient anxiety and build confidence in the tapering process. 2

2. Very slow tapers with pauses may be necessary to allow gradual accommodation to lower doses—pauses are acceptable and often necessary when withdrawal symptoms emerge. 2

3. Monitor at every dose reduction for withdrawal symptoms and adjust accordingly. 2

4. If withdrawal symptoms occur, raise the dose back to the previous level and taper more slowly by either:

   • Increasing the interval between decreases
   • Decreasing the amount of change in dose
   • Both 3

Managing Withdrawal Symptoms

Common Physical Withdrawal Symptoms to Monitor

• Tremor, diaphoresis, agitation, insomnia
• Myoclonus, diffuse pain/hyperalgesia
• Hypertension, hyperthermia
• Cramping/diarrhea, pupillary dilation
• Piloerection 1

Common Affective Withdrawal Symptoms

• Dysphoria, anhedonia, anxiety
• Depression, hopelessness/suicidal ideation 1

Critical distinction: Pain itself may be a withdrawal symptom and not simply an exacerbation of the original chronic pain, as descending pain facilitatory tracts show increased firing during early abstinence. 1

Adjunctive Medications for Symptom Management

Consider the following medications to manage specific withdrawal symptoms (this improves taper success rates): 2

• Clonidine or tizanidine: For general withdrawal symptoms
• Trazodone: For insomnia
• Gabapentin: For anxiety and irritability
• Loperamide: For gastrointestinal discomfort 2

Special Considerations

When Tapering May Not Be Appropriate

There is insufficient evidence to advise opioid reduction in patients who:

• Show clear benefit from treatment
• Lack evident adverse effects
• Show no aberrant behavior
• Have no major risks 1

The determination that a treatment should not have been initiated is not equivalent to a decision that it should be stopped. 1

When to Consider Buprenorphine Transition

If tapering fails or the patient cannot tolerate withdrawal symptoms, consider switching to buprenorphine/naloxone for a controlled transition off full opioid agonists. 2

Concurrent Benzodiazepine Use

If the patient is taking both opioids and benzodiazepines:

• Some older guidance suggested tapering opioids first 4
• However, more recent consensus recommends tapering benzodiazepines first due to the higher risks associated with benzodiazepine withdrawal (including seizures and death). 4
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and should always be conducted gradually. 4

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases. 2
• Screen for emerging psychiatric conditions including depression, anxiety, and substance use disorders that may emerge during tapering. 2
• Remain alert for unmasked conditions such as anxiety, depression, or opioid use disorder. 2
• Advise patients of increased overdose risk if they return to previous doses after tolerance is lost. 2

Common Pitfalls to Avoid

1. Using a fixed timeline—the taper must be adjusted based on the individual's response, not a predetermined schedule. 1

2. Making "cold referrals" to other clinicians during the taper without ensuring they have agreed to accept the patient's care. 1

3. Tapering solely based on dose thresholds—exceeding recommended opioid dose limitations is not in itself a sufficient reason to taper if the patient is benefiting without adverse effects. 1

4. Failing to address pain management—alternate pain control treatments must be made available to the patient early in the process. 5

5. Abandoning patients who struggle—maintain the therapeutic relationship even if tapering is unsuccessful; consider maintenance therapy rather than discontinuing care. 1

Alternative Pain Management During Taper

Integrate comprehensive pain management strategies including:

• Behavioral therapies (cognitive behavioral therapy significantly improves outcomes) 1
• Physical therapy and exercise
• Non-opioid analgesics
• Interventional pain procedures when appropriate 1

The patient should never feel abandoned by the healthcare team during this process. 5