From the Guidelines
To taper a patient off morphine MSIR 15mg BID, I recommend a gradual reduction of 10% per month or slower, as suggested by the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1. This approach allows for a slow and individualized taper, taking into account the patient's goals and concerns. The patient's current dose of morphine MSIR 15mg BID is 30mg per day, so a 10% reduction would be 3mg per day, resulting in a new dose of 27mg per day, which can be achieved by decreasing to morphine 13.5mg BID. The taper can be continued with monthly reductions of 10% or slower, with frequent follow-up and monitoring for withdrawal symptoms. It is essential to collaborate with the patient on the tapering plan, including decisions on the taper rate and when pauses in the taper might be warranted 1. During the taper, it is crucial to monitor the patient closely for withdrawal symptoms, such as anxiety, insomnia, muscle aches, nausea, or increased pain, and consider adjunctive medications to manage specific withdrawal symptoms if they occur. The CDC guideline also recommends maximizing nonopioid treatments for pain and addressing behavioral distress for patients struggling to tolerate a taper 1. For patients with severe withdrawal despite this approach, the taper can be slowed further with smaller decrements or longer intervals between dose reductions. It is also important to advise patients of an increased risk for overdose on abrupt return to a previously prescribed higher dose because of loss of opioid tolerance and provide opioid overdose education and offer naloxone 1. Another study published in Mayo Clinic Proceedings in 2020 also suggests individualized tapering plans, but the CDC guideline is more recent and provides a more comprehensive approach to tapering opioids 1. Therefore, the CDC guideline should be followed for tapering opioids, prioritizing a gradual and individualized approach to minimize withdrawal symptoms and ensure patient safety. Key points to consider during the taper include:
- Frequent follow-up with the patient, at least monthly, to monitor for withdrawal symptoms and adjust the taper plan as needed 1
- Collaboration with the patient on the tapering plan, including decisions on the taper rate and when pauses in the taper might be warranted 1
- Maximizing nonopioid treatments for pain and addressing behavioral distress for patients struggling to tolerate a taper 1
- Advising patients of an increased risk for overdose on abrupt return to a previously prescribed higher dose because of loss of opioid tolerance and providing opioid overdose education and offering 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 taper a patient off morphine MSIR 15mg BID, a patient-specific plan should be developed to gradually reduce the dose.
- The taper should be initiated by reducing the dose by no greater than 10% to 25% of the total daily dose (in this case, 30mg) to avoid withdrawal symptoms.
- The dose should be lowered at an interval of every 2 to 4 weeks.
- It may be necessary to provide the patient with lower dosage strengths to accomplish a successful taper.
- The patient should be frequently reassessed to manage pain and withdrawal symptoms, should they emerge 2.
From the Research
Tapering Morphine MSIR 15mg BID
To taper a patient off morphine MSIR 15mg BID, the following steps can be considered:
- Gradually reducing the dose of morphine to minimize withdrawal symptoms
- Using medications such as buprenorphine, clonidine, or lofexidine to manage withdrawal symptoms 3, 4, 5
- Considering the use of gabapentin as an adjunctive treatment to reduce withdrawal symptoms 6
Medications for Managing Withdrawal Symptoms
Some medications that can be used to manage withdrawal symptoms include:
- Buprenorphine: shown to be effective in reducing withdrawal symptoms and improving treatment outcomes 3, 5
- Clonidine: can be effective in suppressing autonomic signs of withdrawal, but may not be as effective in reducing subject-reported symptoms 4
- Lofexidine: similar to clonidine, can be effective in managing withdrawal symptoms 3
- Gabapentin: may be effective in reducing some withdrawal symptoms, particularly at higher doses 6
Considerations for Tapering
When tapering a patient off morphine, it is essential to consider the following:
- The rate of tapering: a gradual taper is often recommended to minimize withdrawal symptoms, but the optimal rate of tapering is not well established 3
- The use of adjunctive medications: medications such as buprenorphine, clonidine, or gabapentin may be used to manage withdrawal symptoms and improve treatment outcomes 3, 4, 5, 6
- Individual patient factors: patient characteristics, such as sex and medical history, may influence the response to tapering and the use of adjunctive medications 3