A practical guide to tapering opioids

Abstract

Tapering opioids is one of the most daunting dilemmas in clinical practice today. The decision to taper opioids is based on many factors, including a lack of efficacy, unacceptable risk, perioperative management, noncompliance, or patient preference. Tapering in the perioperative setting is quite common, though more complex in patients previously taking chronic opioid therapy. Outside of a medical emergency, opioid tapers are best managed in an outpatient setting, allowing for adjustments and more long-term nonopioid pain management, if necessary. No single strategy can be applied to all patients, and very few published guidelines are available for reference. Dose reductions and schedules are highly variable across available guidelines and literature. Dose reductions range from 10% to 50%, with a frequency ranging from daily reductions to every 2 weeks. Most guidelines address the concern of preventing physical withdrawal symptoms; however, few address the psychological ramifications of tapering. Individualized regimens and a willingness to adjust schedules and doses allows for improved patient comfort. The goal is to complete tapering without any symptoms of withdrawal; however, this is not always possible. Several available agents may help ameliorate these symptoms, including antihypertensives, antihistamines, antiemetics, antidepressants, anticonvulsants, and antipsychotics. Opioid tapering is rarely easy but should be a manageable process.

Case report: Comprehensive management of painful diabetic neuropathy—Addressing opioid-induced hyperalgesia through multimodal approaches

“…[ 14 ] The rate of opioid dose de-escalation should be around 10% to 20% of the initial dose every 4 weeks (slow taper) or weekly (fast taper). [ 15 ] The gradual reduction of oxycodone dosage and the inclusion of pregabalin and duloxetine in the pain management strategy led to a reduction in pain and facilitated the gradual discontinuation of opioids in our patients.…”

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

“…Whilst many guidelines do not provide clear recommendations on the use of SA vs LA opioids, rationalising all medications to a single LA opioid when tapering is one commonly recommended approach, which was inconsistent with our findings. 30 , 37 , 50 Some guidelines discussed that LA opioids may enable less frequent dosing which could reduce psychological focus on opioids and patient's pill intake and help to maintain stable blood plasma levels around the clock. 4 , 37 , 42 However, our study suggests that empirical evidence is needed to support such a recommendation in light of our findings.…”

Care of the Patient with Chronic Pain

“…Anxiety, lacrimation, and dysphoria may be managed with hydroxyzine (25-50 mg TID PRN) or diphenhydramine (25 mg q6h PRN). Myalgia is often managed with NSAIDs or acetaminophen [14]. For patients who are abusing the medication or noncompliant with the taper schedule, referral for inpatient detoxification is encouraged [12].…”