What is the best tapering regimen for an opioid‑tolerant adult on 1.5 mg daily hydromorphone (Dilaudid) who is stable and not experiencing severe uncontrolled pain?

Tapering Off 1.5 mg Daily Hydromorphone

For a stable patient on 1.5 mg daily oral hydromorphone, reduce the dose by 25-50% every 2-4 days while monitoring for withdrawal symptoms, as recommended by the FDA label. 1

Recommended Tapering Protocol

Initial Dose Reduction Strategy

• Reduce the current dose by 25-50% every 2-4 days as the standard approach for patients who have been taking hydromorphone regularly and may be physically dependent 1
• Start conservatively with 25% reductions (approximately 0.4 mg decrease) every 2-4 days for patients who have been on this dose for extended periods, as slower tapers minimize withdrawal symptoms 1
• Monitor carefully for signs and symptoms of withdrawal including anxiety, restlessness, sweating, muscle aches, insomnia, dilated pupils, and gastrointestinal distress 1

Practical Tapering Schedule

For a patient on 1.5 mg daily hydromorphone:

• Week 1-2: Reduce to 1.0-1.1 mg daily (25-33% reduction) 1
• Week 3-4: Reduce to 0.5-0.75 mg daily (another 25-33% reduction) 1
• Week 5-6: Reduce to 0.25-0.4 mg daily 1
• Week 7-8: Discontinue completely 1

Critical Adjustment Principles

• If withdrawal symptoms develop, immediately 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, or both 1
• Never abruptly discontinue hydromorphone in a physically dependent patient, as this can precipitate severe withdrawal 1
• The slower the taper, the lower the risk of withdrawal symptoms—there is no medical urgency to complete the taper quickly in a stable patient 1

Alternative Slower Taper for Long-Term Users

• Consider 10-20% dose reductions every 2-4 days for patients who have been on hydromorphone for many months or years, as this ultra-conservative approach minimizes discomfort 1
• Extend the interval between reductions to weekly if the patient experiences any withdrawal symptoms with the standard 2-4 day interval 1

Common Pitfalls to Avoid

• Do not use a fixed schedule without clinical reassessment—the taper must be adjusted based on individual patient response to dose reductions 1
• Do not continue reducing the dose if withdrawal symptoms appear—this is a clear signal to slow down or temporarily pause the taper 1
• Do not switch to another opioid during the taper unless there is a specific clinical indication, as this complicates the discontinuation process 1
• Avoid the temptation to accelerate the taper even if the patient is tolerating reductions well, as withdrawal can emerge suddenly with larger or faster decreases 1

Monitoring Requirements

• Assess for withdrawal symptoms at each dose reduction, particularly within 24-48 hours after the decrease when symptoms are most likely to emerge 1
• Document the patient's pain level to ensure that the original indication for hydromorphone has truly resolved and that pain is not re-emerging during the taper 1
• Provide clear instructions to the patient about what withdrawal symptoms to watch for and when to contact you if they occur 1