Can a primary care physician taper a patient off Tussionex (hydrocodone and chlorpheniramine) or is a specialist consultation required?

Can a Primary Care Physician Taper Tussionex?

Yes, a primary care physician can and should manage the tapering of Tussionex (hydrocodone/chlorpheniramine) without requiring specialist consultation in most cases. 1

Primary Care Capability and Responsibility

Primary care physicians are explicitly identified as the appropriate clinicians to manage opioid tapering, including hydrocodone-containing products like Tussionex. 1 The consensus panel recommendations specifically emphasize that opioid reduction should occur in primary care settings with patient-centered, integrated treatment models. 1

The FDA label for hydrocodone products explicitly provides tapering guidance for prescribers, indicating this is within the scope of general practice. 2

When Specialist Referral IS Required

Refer to a pain specialist or addiction medicine specialist only in these specific situations:

• Co-occurring opioid use disorder (OUD) requiring medication-assisted treatment 1
• Concurrent benzodiazepine or alcohol abuse/dependence 1
• Uncontrolled or unstable psychiatric disorder (severe depression, active suicidal ideation, bipolar disorder) 1
• Comorbid chronic pain requiring ongoing opioid therapy 1
• Previous failed tapering attempts in primary care 1
• Patient requires dosages ≥90 MME/day and experiences escalating requirements 1

Recommended Tapering Protocol

Initial Assessment Before Starting Taper

• Determine total daily morphine milligram equivalents (MME) - Tussionex contains 10mg hydrocodone per 5mL, with hydrocodone having a conversion factor of 1:1 with morphine 1
• Assess duration of use - patients on opioids >1 year require slower tapers 1
• Evaluate for physical dependence - expect withdrawal symptoms if used daily for weeks or longer 2
• Screen for substance use disorders and psychiatric comorbidities 1

Tapering Schedule

For patients on Tussionex <1 year:

• Reduce by 10-25% of the current dose every 2-4 weeks 1, 2
• Example: If taking 10mL daily (20mg hydrocodone), reduce to 7.5-9mL for 2-4 weeks, then reduce the new dose by 10-25% 1

For patients on Tussionex ≥1 year:

• Reduce by 10% of the current dose per month or slower 1
• This slower approach minimizes withdrawal symptoms and improves completion rates 1
• Each reduction should be 10% of the most recent dose, NOT the original dose 1

Critical principle: Never abruptly discontinue. Rapid discontinuation has resulted in serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. 1, 2

Managing Withdrawal Symptoms

Monitor for these withdrawal symptoms at each visit:

• Autonomic symptoms: restlessness, perspiration, chills, lacrimation, rhinorrhea, mydriasis 2
• Gastrointestinal symptoms: nausea, vomiting, diarrhea, abdominal cramps, anorexia 2
• Musculoskeletal symptoms: myalgia, backache, joint pain, weakness 2
• Psychological symptoms: anxiety, irritability, insomnia 2
• Cardiovascular symptoms: increased blood pressure, respiratory rate, heart rate 2

If withdrawal symptoms emerge, pause the taper or slow the reduction rate. 1, 2 It may be necessary to temporarily increase back to the previous dose and then proceed more slowly. 2

Follow-Up Requirements

• Schedule visits at least monthly during the taper 1
• More frequent contact (every 1-2 weeks) during difficult phases 1
• Utilize team members including nurses, pharmacists, or behavioral health professionals for telephone contact or telehealth visits between physician appointments 1
• Monitor for emergence of depression, suicidal thoughts, or substance use 1, 2

Concurrent Non-Opioid Therapies

Optimize nonopioid pain management before and during the taper:

• Non-pharmacologic approaches (physical therapy, cognitive behavioral therapy, exercise) 1
• Nonopioid medications (NSAIDs, acetaminophen, gabapentin, SNRIs) 1
• Ensure mental health support is in place prior to initiating taper 2

This multimodal approach optimizes chronic pain treatment and assists with successful opioid tapering. 2

Realistic Timeline

Expect the taper to require 6-12 months minimum for most patients. 1 Patients on long-term therapy (>1 year) may require several months to years depending on the dose and individual tolerance. 1

The goal is durability of the taper, not speed. 1 Patient agreement and interest in tapering is a key component of success. 1

Common Pitfalls to Avoid

• Never use a straight-line taper - each reduction must be a percentage of the current dose, not the original dose 1
• Never abandon the patient if tapering is unsuccessful - maintain the therapeutic relationship and consider maintenance at a lower dose 1
• Never taper too quickly to meet arbitrary timelines - withdrawal symptoms signal the need to slow down 1, 2
• Never mistake withdrawal symptoms for relapse of underlying condition - this leads to unnecessary reinitiation of opioids 1, 3

Documentation Requirements

Document the following at each visit:

• Current dose and any changes made 1
• Withdrawal symptoms and their severity 1
• Pain levels and functional status 1
• Patient's goals and concerns about the taper 1
• Assessment of mood, suicidal ideation, and substance use 1