The patient’s degree of physical dependence dictates how to stop opioid therapy.
- Patients taking only short acting opioids 4 pills per day (any strength) should be able to stop without a taper
- Patients on long acting medication may need taper
- Patients on >50 mg Morphine equivalents per day may require taper, with higher doses more likely to require a taper (Click here for a morphine equivalence calculator).
Higher intensity of withdrawal symptoms is linked to:
- Higher steady-state levels
- Longer term exposure
- Faster rate of medication clearance (i.e. long vs. short half-life agents)
How to taper opioid medications:
- Taper 10-20% per week.
- Most people can be tapered fairly rapidly in the first 50% of their opioid dose. The last 25% of the tapering is the difficult part.
- When tapering off of extended-release/long-acting (ER/LA) opioids, a short-acting (immediate release) opioid may help with breakthrough symptoms.
- To taper ER/LA opioids, build up non-pharmaceutical pain management techniques.
- High dose short acting agents should not be changed into long acting for the taper as that may increase dependence potential.
When NOT to taper
- Evidence of illegal diversion or tampering
- Patient with suspected addiction not willing to engage in treatment
- Patients without evidence of taking medication (e.g. multiple, negative urine drug screens despite high dose or long acting medication).
- Patients on low dose short acting medications
- Patients with addiction
- If patients are willing to engage in addiction treatment, a short tapering dose is potentially useful to bridge the patient to a detoxification program, or medication assisted treatment (methadone, buprenorphine).
- Non-opioid pharmacotherapy may be helpful for some patients who experience physical discomfort from opioid withdrawal.
- Behavioral treatment
Katz N. Patient Level Opioid Risk Management: A Supplement to the PainEDU.org Manual. Newton, MA: Inflexxion, Inc.; 2007.
Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996 Apr;11(4):203-217.
Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guideline for Practitioners. 1st Edition. North Branch, MN: Sunrise Press; 2007.