What is the best approach to taper a patient with a history of substance abuse or mental health conditions off opioid-based pain pills?

Tapering Opioids in Patients with Substance Abuse or Mental Health Conditions

For patients with a history of substance abuse or mental health conditions on chronic opioid therapy, taper at 10% per month or slower over several months to years, never abruptly discontinue, and maximize nonopioid treatments while closely monitoring for withdrawal symptoms, anxiety, depression, and signs of opioid use disorder. 1

Critical Safety Principles

Abrupt discontinuation is dangerous and contraindicated. Stopping long-term opioid therapy has been associated with mental health crises, overdose events, overdose death, and increased suicide risk. 1 Death rates for overdose or suicide increase immediately after stopping opioids, with incidence decreasing over approximately 3-12 months but potentially persisting over 2 years. 1

Patients face increased overdose risk after tapering due to loss of opioid tolerance if they return to previously prescribed higher doses or illicit opioids. 1 Prescribe naloxone and provide overdose education to all patients undergoing tapers. 1

Recommended Taper Protocol

Initial Taper Rate

• For patients on opioids ≥1 year: Start with 10% per month or slower. 1 This is better tolerated than rapid tapers and is the CDC's primary recommendation for long-duration users. 1
• For shorter duration use (weeks to months): Tapers can be completed over several months. 1
• Never use the 10% per week approach in high-risk patients with substance abuse or mental health conditions, as this is too rapid and increases adverse event risk. 1

Dose-Specific Guidance

• When tapering from high doses (>91 mg morphine equivalent daily): Slow the taper rate as patients reach lower dosages. 1 The final stages of tapering require extra caution. 1
• At the lowest available dose: Extend the interval between doses rather than further reducing the dose, then stop when taken less than once daily. 1

Managing Withdrawal Symptoms

Clinically significant withdrawal symptoms signal the need to slow the taper further or pause entirely. 1 Common withdrawal symptoms include:

• Anxiety, irritability, dysphoria 1
• Insomnia and restlessness 1
• Physical symptoms (sweating, muscle aches, gastrointestinal distress) 1

Pharmacological adjuvants for withdrawal management include: 1

• Clonidine 0.1-0.2 mg orally every 6 hours for autonomic symptoms (monitor for hypotension and sedation) 1
• Lofexidine 0.1 mg orally every 8-12 hours (not FDA-approved in US but available in UK) 1
• These medications address withdrawal symptoms but do not provide analgesia 1

Essential Concurrent Interventions

Maximize Nonopioid Pain Treatments

Before and during tapering, aggressively implement multimodal analgesia: 1

• Acetaminophen (up to 4 grams daily if no contraindications) 2
• NSAIDs (if not contraindicated) 2
• Physical therapy and graded exercise 1
• Cognitive behavioral therapy 1
• Mindfulness-based stress reduction 1

Screen and Treat Comorbidities

Remain alert to and actively screen for anxiety, depression, and opioid use disorder throughout the taper. 1 These conditions may be revealed or worsened by tapering and require concurrent treatment. 1

For patients who develop opioid use disorder during tapering: 1

• Consider transitioning to buprenorphine maintenance therapy rather than continuing taper to zero 1, 3
• Buprenorphine can stabilize patients on lower, safer doses while providing analgesia 3
• Refer to addiction specialists for formal evaluation and management 1

Communication and Therapeutic Alliance

Essential Patient Discussions

Stress empathy and commitment to continued care: 1

• "I believe your pain is real and severe" 1
• "We will continue working on your pain even without opioids" 1
• "You will not be abandoned" 1

Explain the rationale clearly: 1

• "The risks of continuing opioids now outweigh the benefits for your health" 1
• Discuss specific observed behaviors raising concern if substance use disorder is suspected 1

Set realistic expectations: 1

• Goals may vary—some patients achieve complete discontinuation, others reach a reduced dose where benefits outweigh risks 1
• Many patients actually experience improved function and pain control after opioid reduction 1

Documentation and Agreements

Provide detailed documentation including: 1

• Diagnosis, physical examination findings 1
• Substance abuse risk assessment 1
• Review of prescription monitoring program data 1
• Rationale for tapering decision 1

Use proper informed consent and taper agreements outlining the plan, timeline, and patient responsibilities. 1

When to Pause or Reverse a Taper

Pause the taper if: 1

• Patient develops severe withdrawal symptoms despite adjuvant medications 1
• Mental health crisis emerges (suicidal ideation, severe depression) 1
• Patient is unable to tolerate current rate despite maximized nonopioid treatments 1

Before reversing a taper (increasing dose): 1

• Carefully assess and discuss with the patient the benefits and risks of increasing opioid dosage 1
• Consider whether alternative pain management strategies have been adequately tried 1

Tapers can be restarted when the patient is ready, with potentially slower rates than initially attempted. 1

Special Considerations for High-Risk Populations

Pregnancy

Access appropriate expertise before tapering opioids during pregnancy due to risks to both the pregnant patient and fetus if withdrawal occurs. 1 Abrupt discontinuation can cause fetal distress and preterm labor. 1

Patients Unable to Taper

Closely monitor patients who cannot successfully taper and continue on high-dose or high-risk therapy. 1 These patients require:

• More frequent follow-up visits 1
• Continued urine drug testing 4
• Prescription monitoring program checks 4
• Consideration of interdisciplinary pain rehabilitation programs 1

Common Pitfalls to Avoid

Do not taper too rapidly (faster than 10% per month in long-term users), as this increases risk of adverse outcomes including overdose death and suicide. 1

Do not abandon patients who struggle with tapering. Termination of care has been associated with opioid tapering and worsens outcomes. 1

Do not ignore protracted withdrawal syndrome (dysphoria, irritability, insomnia, anhedonia persisting months after opioid elimination), which requires recognition and treatment. 1

Do not use methadone for outpatient tapering unless you have specific training in its risks and uses, due to complex pharmacokinetics and high lethality. 1

Do not prescribe mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) during or after tapering, as these can precipitate acute withdrawal. 2, 5