What is the protocol for tapering morphine (opioid analgesic) during inpatient care?

From the Guidelines

To titrate down morphine during inpatient care, a gradual reduction of 10% per month or slower is recommended, with close monitoring for withdrawal symptoms and adjustment of the taper plan as needed, as suggested by the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1. When implementing a taper plan, it is essential to:

• Collaborate with the patient on the tapering plan, including decisions on the rate of tapering and when to pause or slow down the taper 1
• Monitor patients frequently, at least monthly, and use a standardized assessment tool, such as the Clinical Opiate Withdrawal Scale (COWS), to evaluate withdrawal severity 1
• Provide adjunctive medications to manage withdrawal symptoms, such as clonidine for autonomic symptoms, ondansetron for nausea, and loperamide for diarrhea 1
• Consider the patient's individual circumstances, including the duration of previous opioid therapy, and adjust the taper plan accordingly, with longer durations of therapy potentially requiring slower tapers 1 Some key considerations when tapering opioids include:
• The risk of opioid withdrawal symptoms, which can be minimized with a slow and gradual taper 1
• The importance of patient agreement and interest in tapering, which can increase the likelihood of a successful taper 1
• The need for close monitoring and follow-up, including regular assessments of pain scores, vital signs, and withdrawal symptoms 1
• The potential for tapering to reveal underlying comorbidities, such as anxiety or depression, which should be addressed and treated as needed 1 It is also important to note that:
• Tapering opioids during pregnancy requires special consideration and consultation with appropriate expertise due to the potential risks to the pregnant patient and the fetus 1
• Patients should be advised of the increased risk of overdose if they return to a previously prescribed higher dose after tapering, and should be provided with opioid overdose education and offered naloxone 1

From the FDA Drug Label

When a decision has been made to decrease the dose or discontinue therapy in an opioid-dependent patient taking morphine sulfate tablets, there are a variety of factors that should be considered, including the dose of morphine sulfate tablets the patient has been taking, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient For patients on morphine sulfate tablets who are physically opioid-dependent, initiate the taper by a small enough increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms, and proceed with dose-lowering at an interval of every 2 to 4 weeks.

To titrate down morphine during inpatient care, consider the following key points:

• Initiate the taper by a small enough increment (no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms.
• Proceed with dose-lowering at an interval of every 2 to 4 weeks.
• Reassess the patient frequently to manage pain and withdrawal symptoms.
• Monitor patients for any changes in mood, emergence of suicidal thoughts, or use of other substances.
• Consider a multimodal approach to pain management, including mental health support (if needed), prior to initiating an opioid analgesic taper 2.

From the Research

Titrating Down Morphine During Inpatient Care

• The process of titrating down morphine involves gradually reducing the dose of morphine to minimize side effects while still providing adequate pain relief 3, 4.
• Studies have shown that intravenous morphine titration is an effective method for managing postoperative pain, with over 90% of patients achieving pain relief using this approach 4.
• The essential principle of morphine titration is to adapt the dose to the patient's pain level, with the goal of achieving pain relief while minimizing the risk of overdose and other adverse effects 3, 4.
• In practice, morphine titration can be used with caution in various patient populations, including elderly patients, children, and obese patients 4.

Key Considerations for Morphine Titration

• The dose of morphine should be titrated based on the patient's individual needs, with frequent assessments of pain and sedation levels 3, 4.
• The use of small intravenous boluses of morphine allows for rapid titration of the dose needed for adequate pain relief 4.
• Sedation is a common side effect of morphine titration, and should be considered as a morphine-related adverse event rather than evidence of pain relief 4.
• The incidence of ventilatory depression is low when the criteria to limit the dose of intravenous morphine are enforced 4.

Pharmacokinetic Considerations

• Opioid analgesics, including morphine, can interact with other medications, which may affect their efficacy and safety 5.
• Certain medications, such as P2Y12 inhibitors, gabapentin, and rifampin, can interact with morphine and affect its pharmacokinetics 5.
• Healthcare providers should be aware of these potential interactions and take steps to minimize the risk of adverse effects when using morphine and other opioid analgesics 5.