What is the recommended tapering schedule for an adult chronic pain patient on oxycocet (oxycodone 5 mg/acetaminophen 325 mg) and pregabalin (150–300 mg daily)?

Tapering Oxycodone/Acetaminophen and Pregabalin in Chronic Pain

For a patient on oxycodone 5 mg/acetaminophen 325 mg (Oxycocet) and pregabalin 150–300 mg daily, taper the opioid first using a gradual 10–25% dose reduction every 1–4 weeks, then taper pregabalin by 25–50 mg weekly after opioid discontinuation is complete. 1

Opioid Tapering: First Priority

Why Taper Opioids Before Pregabalin

• The CDC explicitly recommends tapering opioids before benzodiazepines or other CNS depressants because opioid withdrawal is safer than withdrawal from other sedating medications, and because the anxiety associated with opioid tapering can complicate concurrent pregabalin withdrawal. 1
• Pregabalin potentiates CNS depression when combined with opioids, increasing overdose risk, making it safer to reduce the opioid burden first. 1, 2

Opioid Taper Protocol

• Reduce the oxycodone/acetaminophen dose by 10–25% every 1–4 weeks, adjusting the pace based on withdrawal symptoms and patient tolerance. 1
• For a patient taking oxycodone 5 mg three times daily (15 mg total daily), this translates to reducing by approximately 5 mg (one tablet) every 1–4 weeks initially. 1
• Slower tapers (reductions every 2–4 weeks rather than weekly) are associated with better completion rates and less severe withdrawal symptoms, though the evidence is limited (GRADE C). 1
• The Mayo Clinic reports taper completion rates above 90% using a structured 3-week inpatient protocol, but community-based tapers typically require longer timeframes of 8–12 weeks or more. 1

Monitoring During Opioid Taper

• Assess for opioid withdrawal symptoms at each dose reduction: anxiety, restlessness, muscle aches, lacrimation, rhinorrhea, diaphoresis, nausea, and insomnia. 1
• If withdrawal symptoms are intolerable, hold the current dose for an additional 1–2 weeks before attempting further reduction. 1
• Functionality is a better endpoint than numerical pain scores—if pain increases but function remains stable or improves, continue the taper. 1
• Consider that opioid-induced hyperalgesia may be present; paradoxically, pain may improve as opioids are reduced. 1

Transition Strategy

• Once the oxycodone dose reaches 5 mg daily (one tablet), consider switching to a pure opioid formulation without acetaminophen to allow more granular dose reductions, though this may not be necessary for such low doses. 1
• The final step is to increase the interval between doses (e.g., from three times daily to twice daily to once daily) before complete discontinuation. 1

Pregabalin Tapering: Second Priority

When to Begin Pregabalin Taper

• Do not begin tapering pregabalin until the opioid taper is complete or nearly complete (at least 75% reduced), as concurrent tapering increases the risk of severe withdrawal and treatment failure. 1
• Pregabalin withdrawal can include anxiety, insomnia, nausea, sweating, and in rare cases seizures, making it more dangerous than opioid withdrawal. 3, 4

Pregabalin Taper Protocol

• Reduce pregabalin by 25–50 mg per week for patients on 150–300 mg daily, which represents approximately a 25% reduction every 1–2 weeks. 1
• For a patient on pregabalin 300 mg daily (e.g., 150 mg twice daily), reduce to 250 mg daily for 1–2 weeks, then to 200 mg daily, continuing in 50 mg decrements. 1
• Slower tapers (25 mg reductions every 1–2 weeks) are safer for patients with a history of anxiety or those who have been on pregabalin for extended periods. 1, 3
• One case report documented an 18-month taper for severe gabapentin dependence (a closely related drug), highlighting that some patients may require extremely gradual reductions of 5–20 mg per month in the final stages. 4

Monitoring During Pregabalin Taper

• Assess for pregabalin withdrawal symptoms: anxiety, insomnia, nausea, headache, diarrhea, flu-like symptoms, and rarely seizures. 3, 4
• Withdrawal symptoms typically resolve within one week after each dose reduction if the taper is appropriately paced. 3
• If severe withdrawal occurs, return to the previous dose and slow the taper rate (e.g., reduce by 25 mg every 2 weeks instead of weekly). 3, 4

Alternative Strategies for Pregabalin

• Consider switching to gabapentin before tapering if pregabalin withdrawal proves difficult, as gabapentin has more flexible dosing increments (100 mg, 300 mg capsules) allowing finer titration, though this adds complexity. 5, 6
• Cognitive behavioral therapy (CBT) increases tapering success rates for CNS depressants and should be offered if available. 1

Critical Pitfalls to Avoid

• Never taper both medications simultaneously—this dramatically increases withdrawal severity and the risk of treatment failure. 1
• Do not rush the taper in response to patient anxiety about medication dependence—faster tapers have lower completion rates and higher relapse rates. 1
• Avoid abrupt discontinuation of either medication—opioid withdrawal is uncomfortable but not dangerous, whereas abrupt pregabalin cessation can rarely cause seizures. 1, 3
• Do not assume pain will worsen with tapering—many patients experience stable or improved pain and function after opioid reduction due to resolution of opioid-induced hyperalgesia. 1
• Ensure adequate non-opioid pain management is in place before and during tapering: physical therapy, NSAIDs (if not contraindicated), topical agents, and consideration of antidepressants (SNRIs or TCAs) for neuropathic pain. 1

Expected Timeline

• Total taper duration: 12–24 weeks minimum (8–16 weeks for opioid taper, followed by 4–8 weeks for pregabalin taper). 1
• Patients with longer duration of use, higher doses, or comorbid anxiety/depression may require 6–12 months for complete tapering. 1, 4
• Reevaluate the necessity and effectiveness of both medications regularly—if there has been no improvement in function, tapering is strongly indicated. 1