Opioid Tapering for Addiction: Recommended Rate
For patients with opioid use disorder (OUD), the recommended approach is a slow, hyperbolic taper of 10% of the current dose per month (not the original dose), where each new dose is 90% of the previous dose, typically requiring 6-12 months minimum and often extending to years. 1, 2
Critical Distinction: Addiction vs. Dependence
The management differs fundamentally based on whether the patient has OUD (addiction) versus simple physical dependence from chronic pain treatment:
For patients with diagnosed OUD, medication-assisted treatment (MAT) with buprenorphine/naloxone or methadone is the gold standard, not tapering. 1 Research demonstrates that tapering off buprenorphine results in significantly worse outcomes compared to maintenance therapy, with only 11% completing taper versus 66% remaining in treatment on maintenance. 3
Attempting to taper patients with OUD off all opioids has poor success rates: only 27.9% achieved abstinence in one study 4, and in another study of methadone patients, zero patients successfully completed tapering. 5
Recommended Tapering Protocol When Tapering Is Appropriate
Taper Speed and Calculation
Reduce by 10% of the CURRENT dose per month, not the original dose. 1, 2 This hyperbolic approach prevents disproportionately large final reductions that occur with linear tapers.
Example calculation: A patient on 100mg morphine equivalents would reduce to 90mg (month 1), then to 81mg (month 2), then to 73mg (month 3), continuing this pattern. 1
The taper rate must be determined by patient tolerance, not a rigid schedule. 1, 2 Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge.
Timeline Expectations
Minimum duration: 6-12 months for most patients. 2 For patients on opioids for years, the taper may take several years. 1
Very small initial dose decreases (even smaller than 10%) can address patient anxiety and build confidence. 1
Withdrawal Symptom Management
Physical withdrawal symptoms typically:
Monitor for withdrawal symptoms using validated scales: 1
- Clinical Opiate Withdrawal Scale (COWS): scores 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), >36 (severe)
- Subjective Opiate Withdrawal Scale (SOWS): patient self-rated
Adjunctive medications for symptom management: 1, 2
- Clonidine or tizanidine for general withdrawal symptoms (tremor, sweating, agitation)
- Trazodone for insomnia
- Gabapentin for anxiety and irritability
- Loperamide for gastrointestinal symptoms
When Tapering Fails or Is Inappropriate
Consider switching to buprenorphine/naloxone if: 1, 2
- The patient cannot tolerate the taper
- Withdrawal symptoms are unmanageable
- The patient has poor pain control and poor functioning despite slow taper
This is NOT abandonment—it is appropriate medical care. 1 Research shows that 61% of patients who taper off buprenorphine return to treatment within 2 years. 6
Absolute Contraindications to Rapid Tapering
Never abruptly discontinue opioids in physically-dependent patients. 1, 2 This constitutes unacceptable medical care equivalent to suddenly stopping antihypertensives or antihyperglycemics, and carries significant risks including:
- Overdose (if patient returns to previous doses after tolerance is lost) 1
- Psychological distress and suicidal ideation 2
- Protracted abstinence syndrome lasting up to 6 months 1
Monitoring Requirements
Follow-up frequency: 2
- At least monthly during the taper
- More frequent contact during difficult phases
- Screen for depression, anxiety, and substance use disorders that may emerge
At each visit, assess: 2
- Withdrawal symptom severity
- Pain levels and functional status
- Psychiatric stability
- Any aberrant behaviors or drug use
Special Considerations for Methadone
Methadone tapering requires extreme caution due to: 7
- Long and variable half-life (8-59 hours)
- Delayed peak respiratory depression
- Accumulation in tissues with repeated dosing
- Steady-state not reached until 3-5 days
For medically supervised withdrawal from methadone maintenance: 7
- Dose reductions should be less than 10% of the established maintenance dose
- Allow 10-14 day intervals between dose reductions
- Most patients achieve stability at 80-120mg/day maintenance doses
Common Pitfalls to Avoid
- Using a fixed timeline rather than patient-guided pace 2
- Calculating percentage reductions from the original dose instead of current dose 1
- Making "cold referrals" without ensuring another provider has agreed to accept the patient 1
- Failing to obtain patient agreement and collaboration 2
- Not addressing underlying pain management needs 2
Bottom Line for Clinical Practice
For true opioid addiction (OUD), maintenance therapy with buprenorphine or methadone is superior to tapering. 1, 3 If tapering is attempted despite this evidence, use the 10% per month hyperbolic reduction with close monitoring, adjunctive medications, and readiness to transition to MAT if the taper fails. The goal is durability and patient safety, not speed. 2