INTRODUCTION — Chronic pain is among the most frequent reasons for seeking medical attention in the United States, and opioids have been commonly prescribed to treat chronic pain. In the context of the ongoing opioid epidemic, with heightened awareness of the risks of long-term opioid therapy (LOT), and the 2016 publication of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids in primary care [1], opioid prescribing has declined [2]. However, prescription opioids continue to contribute substantially to morbidity and mortality in the United States, and there is strong societal interest in further reducing prescription opioid use [3]. Retrospective data suggest that tapering among patients on stable higher-dose opioid therapy (≥50 milligram morphine equivalents [MME]) steadily increased from 12.7 percent in 2008 to 52.6 percent between 2017 and 2019 [4,5].
The decision to taper or discontinue opioids should be made collaboratively with each individual patient. Opioid tapering is difficult for patients, who are often fearful of increased pain and opioid withdrawal symptoms during the taper. Moreover, neurobiologic changes in the chronic pain state are complex and opioids may have effects different from their expected analgesic properties (eg, upregulation of opioid receptors, mood alterations) that may increase the difficulty with tapering [6]. In most cases, opioid tapering should proceed at a rate slow enough to minimize the likelihood that opioid withdrawal symptoms will occur, along with use of supportive measures that reduce risks and maximize chances of success. In many cases, opioid tapering will lead to stable perceived pain and in some cases decreased pain along with improved function [7].
This topic will discuss the indications for community-based opioid tapering (ie, a dose reduction or full withdrawal of opioids), preparatory counseling prior to opioid tapering, pragmatic tapering schedules, as well as risk-management strategies during opioid tapering.
Management of chronic opioid therapy in specific populations of patients with chronic pain is discussed separately in several topic reviews.
●(See "Overview of management of opioid use disorder during pregnancy".)
●(See "Acute vaso-occlusive pain management in sickle cell disease".)
●(See "Cancer pain management: General principles and risk management for patients receiving opioids".)
Opioid discontinuation in patients with opioid use disorder (OUD) is also discussed separately. (See "Medically supervised opioid withdrawal during treatment for addiction".)
INDICATIONS FOR OPIOID TAPER OR DISCONTINUATION — We consider opioid tapering for all patients with chronic non-cancer pain who take more than 90 milligram morphine equivalents (MME) of opioid per day, as well as any patient for whom the benefits of opioid therapy no longer outweigh the risks of continued use (table 1). This includes patients for whom the functional goals of opioid therapy are not met, those who develop intolerable side effects, and patients with signs of opioid use disorder (OUD). Tapering and discontinuation should also proceed in patients whose painful condition resolves.
Daily opioid dose >90 MME per day — Consistent with the Center for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain, opioid tapering should be considered for all patients with non-cancer pain who take more than 90 morphine milligram equivalents (MME) of opioids per day, since higher doses of opioids are associated with increased risk of mortality [1,8,9]. The risk of mortality for patients with chronic pain on total daily doses over 100 MME is approximately seven times higher than that of patients on doses of 1 to 20 MME daily [8].
We communicate these very real concerns to our patients in a compassionate and nonthreatening way as a component of motivational interviewing. However, we agree with expert opinion that the 90 MME dose should not be viewed as a strict limit, and we avoid abrupt discontinuation or rapid forced taper unless the patient (ie, due to risk of overdose) or community (ie, due to diversion) is at risk.
Benefits of opioids at higher doses may in specific circumstances outweigh risks for selected patients with persistent severe chronic non-cancer pain despite adherence to nondrug and nonopioid therapies (including compliance with primary disease modifying therapies). However, there is debate among pain management experts about how to best approach and risk stratify patients who are on opioid doses >90 MME. Given the mortality risk associated with opioid doses above 90 MME, and the lack of current evidence for benefits from such regimens over the long term, the decision to exceed 90 MME should be more the exception than a rule. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Opioids'.)
Approximate dose conversion for commonly used opioids are shown in a table (table 2). (See "Prescription of opioids for acute pain in opioid naïve patients", section on 'Morphine equivalents'.) (Related Pathway(s): Morphine milligram equivalent calculator for adults with chronic non-cancer pain.)
Lack or loss of therapeutic effect on pain and function — Patients using long-term opioid treatment (LOT) should be routinely monitored not only for pain control, but also for progress toward functional goals and endpoints [10]. These functional goals (ie, goals meaningful to the individual patient) should be explicitly stated in the treatment agreement signed at the beginning of therapy. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid agreement/consent form'.)
Available data suggest that pain is usually improved or unchanged after opioid tapering. (See 'Outcome of attempted opioid taper' below.)
Intolerable side effects — The utility of LOT may be limited by sedation, drowsiness, mood disturbances, constipation, hormonal changes with or without sexual dysfunction, or reduced cognitive function with limited concentration or memory [3,11]. These side effects may be encountered when increasing doses of opioids or with ongoing therapy, even when the dose is stable. Patients may be unaware or deny some of the side effects, and having a family member or friend who can report their observations can be very helpful.
Nonadherence to the opioid treatment agreement — All patients should sign a treatment agreement prior to starting opioid therapy. This agreement is a key component of the decision to prescribe LOT. Setting patient expectations and monitoring for compliance during treatment are discussed separately. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Setting patient responsibilities, expectations, and treatment goals' and "Urine drug testing for patients with chronic pain".)
We typically treat nonadherence to the opioid treatment agreement (eg, opioid misuse, use of illicit substances, diversion, or obtaining opioids from multiple providers) as an indication for opioid tapering and possibly discontinuation, or referral for treatment if OUD is suspected [12]. Diversion represents a special situation in which abrupt discontinuation of prescribing may be considered. If it is determined that the patient has not been taking opioids, and instead has been diverting the entire prescription, tapering is not required prior to discontinuation of prescriptions. Objective evidence of diversion is often difficult to obtain, particularly for patients who divert only part of their opioids. Diversion may be suspected if urine testing shows lack of appropriate metabolites of the prescribed opioid, but interpretation of urine results may be complicated. (See "Urine drug testing for patients with chronic pain", section on 'Unexpected results'.)
Prescribing clinicians should carefully document all plans and details for tapering. If there is evidence that the larger community may be harmed and there is clear evidence of diversion, institutional risk management and legal authorities should be alerted.
Substance use disorder — Patients who are diagnosed with OUD or substance use disorder (SUD) during opioid therapy require specialty consultation for tapering, discontinuation, or alternative therapy. (See "Medically supervised opioid withdrawal during treatment for addiction" and "Use of opioids in the management of chronic non-cancer pain", section on 'Monitoring and risk management strategies during trial'.)
Patient request — Not infrequently, patients themselves will initiate the discussion and request opioid tapering. In a survey of approximately 1200 patients taking high dose opioids (≥50 MME per day) for chronic non-cancer pain, half agreed or strongly agreed that they would like to taper or stop taking opioids [13]. Many patients request an opioid taper after concerns raised by family, friends, or clinicians, as well as knowledge or experience of adverse effects, or media coverage related to opioids. In a small study involving focus groups of patients in different stages of opioid tapering, patients reported a number of motivations, including a desire to take fewer medicines, the recognition that their lives revolved around opioids, known adverse effects of opioids, side effects, and the stigma associated with taking these medications [14].
PREPARING FOR OPIOID TAPERING
Screen for complicating conditions — Before initiating an opioid taper, the patient should be assessed for conditions that can reduce the likelihood of successful taper, including opioid use disorder (OUD), mental health disorders (eg, anxiety, depression), psychological inflexibility, high pain scores, and use of opioids for functional self-medication. Treatment for these conditions should be optimized before attempting a taper. (See "Evaluation of chronic non-cancer pain in adults", section on 'Patient evaluation' and "Approach to the management of chronic non-cancer pain in adults".)
●Depression – Depression is a significant risk factor both for dropout from taper and relapse of opioid use [15]. Depression may be a stronger risk factor for resumption of opioid use after chronic pain rehabilitation than substance use disorder (SUD) [16]. Opioids are frequently used by patients with chronic pain as a means of managing anxiety, depressive symptoms, or sleep issues [17]. For patients with pre-existing psychiatric comorbidities, supportive psychological treatment in a comprehensive multidisciplinary program may be indicated. (See 'Pain rehabilitation programs' below.)
●Opioid use disorder (OUD) – Patients who have SUD or OUD are unlikely to be able to taper or discontinue opioids without involvement of addiction medicine specialists. OUD should be considered in patients who report craving for opioids, compulsive use, continued use despite adverse consequences, and use that is out of control (eg, overuse or misuse). Collateral information from family members may be helpful in this regard. Patients should be screened for OUD prior to opioid taper, and this should be considered as a complicating comorbidity in patients who are unable to taper successfully. (See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis", section on 'Assessment'.)
Shared decision making and motivation — Opioid tapering is more likely to be successful when patients are motivated and adhere to the tapering plan [7]. Initiating taper is often the most difficult aspect of the tapering process and is the subject of substantial debate among pain management experts. Our approach is consistent with the recommendations from international experts [18] and stakeholders that the decision to taper must be part of a compassionate, collaborative plan that avoids rapid, forced tapers or rigid tapering schedules.
●Collaboration – We agree with the Centers for Disease Control and Prevention (CDC) opioid guideline recommendation that whenever possible, the patient should be engaged in the opioid tapering process, and the decision to taper should be made collaboratively [1]. Importantly, the threshold doses of opioid for considering taper that appear in the CDC opioid guidelines (ie, ≥90 milligram morphine equivalents [MME]) should not be viewed as a mandatory target used as justification to discontinue opioid prescription abruptly, or to taper rapidly without providing adequate and compassionate support to the patient. We make efforts to avoid rapid forced tapering of outpatients to a lower dose or off of opioids unless patient safety (eg, patients who have overdosed or those with OUD) or community safety (ie, evidence of diversion) is at risk.
Rapid forced tapering can lead to increased distress, drop out from treatment, patients seeking other sources of opioids, and can be a threat to the doctor patient relationship [19]. Rapid forced tapering has not been studied in community-based outpatients and can also lead to psychological harm and suicide. (See 'Suicide' below.)
We recognize that taper initiation often requires significant motivation on the part of the clinician. Although any taper may feel, "forced," to the patient, it may be initiated appropriately so long as it is employed in the context of a longitudinal provider-patient relationship with adequate patient support, a patient-centered approach, close follow up, and periodic review of progress toward functional and risk management (eg, risk for overdose of adverse outcome) goals.
There will continue to be tension between proponents of high-dose long-term opioid therapy (LOT) for so-called, "legacy patients," and supporters of opioid tapering. Our approach has been to carefully consider the mortality risks of LOT at doses ≥90 MME. We weight these risks heavily (beneficence and non-maleficence) against patient wishes to remain on high-dose LOT (patient autonomy).
●Establish tapering goals – Prior to initiating an opioid taper, the clinician and patient should agree on the goals of the taper (eg, dose reduction or discontinuation) and the markers of success. In collaboration with the patient, we plan to taper all patients who take >90 MME per day, with a further goal to reach ≤50 MME per day, but individualize the dosing as tapering proceeds. These goals are based on the relationship between long-term opioid dose and mortality risk. The risk of death in patients who take ≥90 MME of opioids per day is ≥7 times as high as patients who take no opioids, and is 2 to 6 times as high for patients who take 50 to 90 MME per day [8,9]. (See 'Daily opioid dose >90 MME per day' above.)
Determining the therapeutic endpoint for patients undergoing opioid tapering may be challenging. Ideally, patients would be tapered off opioids entirely and managed with a combination of nonopioid medications and adjunctive therapies, but this is often difficult, and in some cases, not possible.
The following are examples of some considerations when establishing tapering goals:
•For patients in whom side effects are the primary complaint, dose reduction with or without rotation to a different opioid may be the therapeutic endpoint.
•If ineffective analgesia is the reason for tapering, analgesia may improve with a decrease in dose, opioid rotation, or discontinuation. Inadequate analgesia may be the result of opioid-induced hyperalgesia. (See 'Outcome of attempted opioid taper' below.)
•For patients in whom safety is a significant concern due to harmful misuse, diversion, or concomitant use of illicit substances, rapid and complete discontinuation may be indicated along with consideration of referral for OUD and medication-assisted treatment (MAT).
•In some cases, the discussion and agreement with the patient can include the option to continue opioids at a lower dose, in a different or potentially safer formulation such as buprenorphine or on an as needed basis. The worry that opioids will never be prescribed again is frequent, and patients should be reassured that if they experience pain associated with acute illness or injury in the future, they will be treated and receive opioids if needed.
Tapering goals can be documented in a revised opioid agreement. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid agreement/consent form'.)
●Communication strategies – Conversations about opioid tapering with patients can be difficult. Importantly, communication strategies that foster a sense of collaboration between the clinician and the patient and enhance the patient-provider relationship can improve the chance of success.
We use motivational interviewing principles during patient visits. Motivational interviewing aims to help patients establish personal plans for change by understanding discrepancies between their own behaviors and values. It involves exploring the pros and cons of opioid use, eliciting the gap between the patient's desired and existing quality of life, and assessment of readiness for change, in a non-judgmental, supportive manner. (See "Motivational interviewing for substance use disorders".)
The strategies we use when discussing opioid tapering are shown in a table (table 3) [14,20,21].
The Stanford Center for Continuing Medical Education provides a free of charge, approximately 90 minute online course for clinicians on opioid tapering. It provides specific guidance on opioid-related conversations with patients with role-played examples.
●Education and support groups – We direct patients to free of charge online educational resources, such as the one available on the Oregon Pain website. Self-help books can also be suggested. Such reading material can also be used by primary care clinicians to be better equipped to support their patients.
Where available, structured support groups may be helpful for patients who are tapering opioids. In a randomized controlled trial of support groups for patients tapering opioids including weekly meetings with a physician assistant to explore motivation for tapering, at 22 weeks follow-up, the intervention group had less reported pain interference, improved pain self-efficacy, and fewer adverse effects attributed to opioids [22].
Maximize nonopioid pain therapies — Patients with chronic pain should use nonpharmacologic therapies and nonopioid analgesics to reduce or eliminate the need for opioids. An opioid taper provides an opportunity to review and optimize such strategies. Providing additional options may help engage the patient in the tapering process and improve success. (See "Approach to the management of chronic non-cancer pain in adults".)
Complementary and integrative therapies (eg, acupuncture, massage therapy) may be used as part of an opioid-sparing strategy for chronic pain, and may be helpful during opioid tapering. A 2019 meta-analysis of 60 randomized trials that evaluated the use of mind-body therapies for chronic pain found that mind-body therapies resulted in moderate improvements in pain and small reductions in opioid doses [23]. While it is beyond the usual skill set of the primary care clinician to guide the patient through comprehensive mind body interventions, some of these tools can be used in consultation with patients who use opioids (eg, to help patients reappraise their experiences and pain). A manual for specific mindfulness therapies for patients with chronic pain and opioid dependence has been published [24]. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Complementary and integrative health therapies' and "Approach to the management of chronic non-cancer pain in adults", section on 'Acupuncture'.)
However, there is limited, inconclusive literature on the efficacy or safety of such therapies as specific adjuncts during opioid tapering. A 2017 systematic review of the literature on this issue found five small randomized trials that involved acupuncture, mindfulness therapy, or cognitive behavioral therapy, with mixed results regarding reduction in opioid use [25].
Offer naloxone — We offer naloxone to all patients and their families during opioid taper, and educate them about the increased risk of overdose related to the rapid decrease in opioid tolerance during taper [26]. (See 'Opioid overdose' below.)
OPIOID TAPERING STRATEGY — Our strategy for opioid tapering is shown in an algorithm (algorithm 1).
Minimize opioid withdrawal — A primary goal for the opioid tapering strategy is to avoid or minimize symptoms of opioid withdrawal, primarily by reducing the opioid dose slowly. All patients who chronically take daily opioids become physically opioid-dependent and are at risk for withdrawal if the opioids are discontinued too quickly.
Taper slowly to minimize opioid withdrawal — A primary goal for the opioid tapering strategy is to avoid or minimize symptoms of opioid withdrawal. For avoiding withdrawal, the most important aspect of the taper is to reduce the opioid dose slowly. All patients who chronically take daily opioids become physically opioid dependent and are at risk for withdrawal if the opioids are discontinued too quickly.
We typically base the initial rate of taper on the duration of the patient's opioid use, planning slower taper for patients who have been using opioids for longer periods of time, modified for individual patient preferences and clinical circumstances. This approach is consistent with Centers for Disease Control and Prevention (CDC) and Department of Health and Human Services (HHS) guidelines [1,26], and with the 2019 US Food and Drug Administration (FDA) safety alert on avoidance of rapid discontinuation of long-term opioids [27]. Opioid tapering may take months to years depending on the patient's opioid dose. We avoid going backwards (ie, increasing opioid doses) during a taper as this creates unclear messaging to the patient and it is rare that increasing the opioid dose can be done without encountering the same issues that prompted the taper initially.
●For patients who have been on long-term opioid treatment (LOT) for more than one year, we aim to taper by 10 percent of the starting dose every month. An example of a tapering schedule is shown in a table (table 4).
●For patients who have been on LOT for less than one year, we aim to decrease by 10 percent of the starting dose each week.
●For patients who take opioids less frequently than daily, we do not formally prescribe a tapering schedule. In these patients, we discuss the target discontinuation date with the patient and typically prescribe approximately 50 percent fewer pills than the existing prescription, with the plan for the patient to self-taper by taking fewer pills for each dose over time [28].
During the taper, the rate of opioid dose reduction may need to be modified based on patient response. In some cases, the rate of taper must be slowed to adapt to patient tolerance, primarily related to opioid withdrawal symptoms. A retrospective review of data from 2017 to 2019 found that many opioid tapers may exceed the CDC/HHS recommended maximum rate of 10 percent per week [5]. While the majority of patients (62 percent) on greater than 50 MME were tapered at a maximum rate of up to 40 percent per month, a substantial minority (36 percent) were tapered at a rate greater than 40 percent per month [5].
●Withdrawal symptoms – Withdrawal symptoms are typically minimal at the taper rates described above. If tapering by 10 percent of total morphine milligram equivalents (MME) per month results in intolerable withdrawal symptoms, we slow the taper to 10 percent every second month, and add symptomatic treatment as necessary.
●Increased pain or distress – Patients may report increased pain during LOT taper. This may be related to stress, anxiety, or depression that are increased or unmasked by the taper, or may be unrelated to the taper and instead a fluctuation in intensity that often occurs with chronic pain.
For patients who complain of increased pain, the exact nature of the symptom should be discussed. Patients may experience new pain (eg, due to muscle tension) for which opioids are not the appropriate therapy. Thus a new nonopioid therapy may be helpful, and the process may break the conditioned belief that pain should be treated with opioids. In our experience, and based on the literature [7], pain usually improves after the dose reduction is achieved and stabilized. We continue to provide adjunctive pain management and supportive care.
A number of tapering strategies have been published, including on line resources. Examples include the Veterans Administration Support Tool for Opioid Tapering, and the Oregon Pain Guidance tapering approach.
The CDC opioid guidelines recommended reducing the daily dose by 10 percent per week as a starting point, and state that a slower taper of 10 percent per month might be better tolerated, particularly for patients who had taken opioids for years [1]. However, a retrospective national United States insurance database study including approximately 100,000 patients on LOT found that faster tapering rates have often been employed, particularly during 2016 and 2017 [4]. Among patients who tapered opioids, 26.5 percent tapered at a rate faster than 40 percent per month, and 5 percent tapered at a rate faster than 95 percent per month.
Opioid formulation during taper — We typically continue the patient's existing opioid during a taper, rather than changing to another opioid formulation for the purpose of tapering. We therefore employ an empiric regimen of reducing doses, as follows:
●During the taper, we reduce the patient's opioid dose to the smallest increment pill, followed by a gradual reduction in dosing frequency.
●For a patient who takes a combination of both long-acting and short-acting opioids, we will typically allow the patient to choose which medication to taper first. If there is no preference, we typically taper the long-acting medication first until it is discontinued, followed by the short-acting medication.
An example of a tapering schedule using these principles is shown in a table (table 4).
There are no data available to support changing a patient from one type of full agonist opioid formulation to another full agonist for the purposes of tapering. For patients who, due to dependence, are unable to continue the taper to the point where benefits outweigh risks, we consider using buprenorphine, and if there is concern for OUD, will plan a consultation with an addiction medicine specialist [29,30].
Management of opioid withdrawal symptoms — Patients should be monitored for symptoms of opioid withdrawal during a taper (eg, sweating, diarrhea, intestinal cramps, nausea, anxiety, myalgia, and irritability). Acute withdrawal typically occurs at two to three half-lives of the medication after each dose reduction (ie, about 5 to 10 hours for immediate-release formulations, and 10 to 15 hours for extended-release formulations). Withdrawal symptoms tend to resolve over 5 to 10 days, but may take longer for opioids with longer half-lives. There is also a secondary abstinence syndrome that may persist for several months following acute withdrawal and can include severe mood disturbance [31].
The authors do not prophylactically administer medication to prevent opioid withdrawal, since the slow taper we use does not usually produce symptoms.
●For patients who do develop withdrawal symptoms, we typically start by slowing or pausing the taper in order to allow physiologic adjustment to the new dose. If the taper is paused, once withdrawal symptoms subside we restart the taper at a slower rate than was initially used.
●For patients who desire treatment for bothersome withdrawal symptoms, we administer tizanidine as the first line agent, as it may help with both myalgias and sympathetic symptoms. We start at a low dose of 2 to 4 mg every six to eight hours as needed, typically starting with bedtime dosing, and titrate according to severity of symptoms. Tizanidine can usually be discontinued after approximately a week. We typically provide symptomatic medication to be taken as needed should withdrawal symptoms recur.
Opioid withdrawal may also be accompanied by transient withdrawal hyperalgesia (increased pain sensation). Patients should be reassured that withdrawal hyperalgesia and increased pain are usually transitory. Moreover, in the long term, tapering of opioids often results in reduced pain. (See 'Outcome of attempted opioid taper' below.)
For patients who are unable to tolerate opioid tapering despite slowing the taper and use of adjunctive medications, we would recommend referral to a pain medicine or addiction specialist. (See 'Inability to taper' below.)
Treatment of opioid withdrawal symptoms is discussed in detail separately. (See "Medically supervised opioid withdrawal during treatment for addiction".)
MONITORING DURING AN OPIOID TAPER — We follow patients during opioid taper with monthly clinic visits or more frequently, if needed. At each visit, we solicit the patient's overall impression of their progress with the taper, document physical function, inquire about withdrawal symptoms, and monitor for conditions that may require further supportive measures (eg, depression, anxiety, suicidal ideation). Similar to any chronic pain follow-up visit, we assess pain severity and impact, and efficacy of nonopioid pain management strategies. The Pain Tracker is a useful tool for systematically following patients with validated measures. (See "Evaluation of chronic non-cancer pain in adults".)
We encourage any new techniques that appear to be helpful for pain management. At each visit, we re-emphasize the overarching goal of the taper which includes reduced risk of mortality and morbidity, as well as the indication for which the taper was initiated. We empathetically communicate that opioid tapering takes strength, skills, and courage, and that this is a time of intense change.
Maintaining the patient-provider relationship, providing encouragement and support, offering nonopioid options as well as treatments for associated symptoms (sleep, mood, etc), and encouraging self-care are all key elements for the success of the taper.
We do not routinely use a scoring system for withdrawal, though some clinicians do. Validated scales such as the Clinical Opioid Withdrawal Scale (COWS) may be used during opioid taper, and can help distinguish anxiety from opioid withdrawal [32]. (See "Medically supervised opioid withdrawal during treatment for addiction", section on 'Monitoring'.)
PATIENTS WHO REQUIRE A MODIFIED STRATEGY — Some categories of patients are likely to require either a slower opioid taper or supportive strategies in order to tolerate the taper and increase the likelihood of success. Patient characteristics that may increase the risks of drop out of a tapering program, unsuccessful taper, or relapse after opioid discontinuation, include a long history of opioid use, high pain scores prior to taper, female sex, older age, anxiety over possible withdrawal, and psychiatric disorders [15-17,33]. (See 'Screen for complicating conditions' above.)
Opioids are frequently used by patients with chronic pain as a means of managing anxiety, depressive symptoms, or sleep issues [17], or to avoid depression during opioid taper. For patients with psychiatric comorbidities prior to or during tapering, supportive psychological treatment in a comprehensive multidisciplinary program may be indicated. (See 'Pain rehabilitation programs' below.)
PAIN REHABILITATION PROGRAMS — For patients who require additional support, we consider referral to a comprehensive interdisciplinary rehabilitation program. Such programs typically include pain management, psychological approaches, occupational therapy, and physical therapy, with the goal of providing functional restoration while also addressing pain generators as opioids are tapered [34]. However, access to these programs and insurer coverage are highly variable. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Comprehensive pain rehabilitation program'.)
RISKS ASSOCIATED WITH TAPERING — The primary risk of opioid tapering is opioid withdrawal, usually with too rapid tapering (see 'Minimize opioid withdrawal' above). Other serious risks of opioid tapering include opioid overdose and suicide. Such adverse outcomes further underline the importance of providing support and alternative pain management strategies to patients who taper, who are at high risk of hopelessness and helplessness.
A number of studies have found an association between stopping long-term opioid use and increased risks of overdose, suicide, and self-harm, though these are retrospective studies and other factors may have contributed to the outcomes [35-39]. In one example, a database study of approximately 1,400,000 patients in the Veterans Administration health system who chronically used opioids, the risks of death by overdose and suicide were higher in patients who stopped opioid treatment, with the risk increasing the longer the patient had used opioids [35]. A retrospective study of administrative claims data from 2008 to 2017 in commercially insured and Medicare Advantage populations found an increased relative risk for emergency department visits or hospital admission for both drug overdose or withdrawal and mental health crisis among patients with dose tapers greater than 15 percent over two months [40]. Conclusions are limited by lack of data on the reason for tapering (eg, aberrant behavior or monitoring data) and the high prevalence of potentially complicating risk factors (eg, drug use disorder [14 percent], concurrent benzodiazepine prescription [30 percent] and baseline diagnosis of either depression or anxiety [54 percent]).
Opioid overdose — Patients on long-term opioid treatment (LOT) commonly develop tolerance to these medications. During opioid taper, tolerance can be lost very rapidly (ie, in as little as seven days [26]), and there is a risk of overdose if patients return quickly to the higher dose or take additional illicit opioids during the taper. We counsel patients about tolerance and the possibility of increased sensitivity to opioids as these medications are tapered, including potential overdose even if they go back to their previously normal dose of opioid. We offer naloxone to all patients during opioid taper, and strongly recommend it for patients with increased risk of overdose (eg, history of overdose, substance use disorder [SUD], >50 morphine milligram equivalents [MME] daily opioid dose, concurrent use of sedatives). We educate family members on the use of naloxone and signs of overdose.
In one case control study of patients on LOT in a large integrated health plan, a high degree of dose variability was associated with increased risk of overdose, independent of absolute opioid dose; opioid tapering was one of several possible causes of dose variability [41].
Suicide — We closely monitor patients and ask about thoughts of self-harm during opioid taper. Following publication of the Centers for Disease Control and Prevention (CDC) opioid guidelines in 2016, there have been reports of suicidal ideation and harm presumptively related to rapid forced opioid taper [19]. These risks appear to be particularly high in patients with a history of SUD, and may be more likely after a rapid forced opioid taper. (See 'Shared decision making and motivation' above.)
The link between chronic pain, LOT and risk for suicide is complex and involves alterations in the reward pathway neurobiology [42]. Discussion of these issues is beyond the scope of this topic.
Illicit opioid use — There has been concern that tapering and discontinuation of opioids may lead patients to seek illicitly obtained prescription opioids or engage in use of illicit intravenous opioids such as heroin. Data on this phenomenon is difficult by its very nature to collect and is still emerging, but in general the risk appears to be low in patients who are not otherwise at high risk for opioid misuse or opioid use disorder, and who are tapered appropriately slowly. Nonetheless, expert opinion still warns that patients who are tapered too quickly from opioids may turn to illicit opioids to treat withdrawal. This is a complex topic; the risk of illicit opioid use is multifactorial and related to multiple patient characteristics and risk factors (eg, underlying, undiagnosed OUD) as well as opioid dose.
Patients at high risk of misuse require early identification via routine screening prior to prescribing opioids. We refer high risk patients to addiction medicine specialists for management of opioid tapering and consideration for medication assisted therapy. (See 'Screen for complicating conditions' above.)
Examples of studies on the risk of illicit opioid use after taper include the following:
●In a large retrospective, case-control study of more than 22,000 undifferentiated patients prescribed opioid therapy within an integrated health delivery system, new heroin use was associated with increased odds of having had opioids discontinued [43]. Of patients therapy whose opioids were discontinued, 74 (0.3 percent) patients used heroin after starting opioid therapy, and 28 (38 percent) of those patients started heroin use after opioid discontinuation. The odds of having had opioids discontinued was approximately twice as high in patients who used heroin than in control patients who did not use heroin (OR 2.19; 95% CI 1.27-3.78). It is unclear to what extent this association was causative due to the retrospective nature of the study, other patient risk factors for opioid misuse, and the long interval (mean 12.9 months) between opioid discontinuation and onset of heroin use.
●In a retrospective cohort study of 598 patients who were prescribed opioids for chronic pain, patients discontinued from prescribed opioids subsequently used heroin (OR 1.57, 95% CI 1.25–1.97) and non-prescribed opioids (AOR 1.75, 95% CI 1.45–2.11) more frequently than participants who had no change in their prescribed opioid dose [44]. A total of 38 participants (6 percent) initiated illicit opioid use for the first time during follow-up (9 [2 percent] heroin and 31 [5 percent] non-prescribed opioid pain relievers). This was a complex, retrospective modeling study that estimated the subsequent rate of heroin and non-prescribed opioid use in each group. Conclusions from this study are limited by the small number of patients in important groups and the indirect modeling technique used.
OUTCOME OF ATTEMPTED OPIOID TAPER
●Successful taper – The definition of successful opioid tapering depends on the indications for tapering, and the goals that were set at the beginning of the process. We define ongoing success as continued progress toward those goals. For patients who experience difficulty with tapering, the measures of success may include addition of therapies that will facilitate opioid tapering at a future time. In patients who are unable to taper, we reassess for opioid use disorder (OUD) and consider referral to addiction psychiatry whenever screening identifies significant risk [29]. A retrospective study of commercially insured and Medicare Advantage patients reported that 70 percent of patients who had initiated tapers had a relative dose decrease of >15 percent and only 14 percent of these patients had discontinued opioids completely at 16 months follow up [45].
We make every effort to maintain a constructive patient-provider relationship. A number of studies have reported high rates of patient dropout or termination of care during opioid tapering. As an example, a retrospective cohort study of over 1600 patients on long-term opioid therapy (LOT), opioid taper was associated with increased risk of termination of care (adjusted odds ratio 4.3 [95% CI 2.2-8.5]) [46].
●Effect on pain and function – Patients should be aware that distress may increase temporarily at the start of opioid taper. However, the limited available data suggest that that pain is often improved or unchanged after opioid taper is complete.
•In a 2017 systematic review of studies that assessed patient outcomes after opioid tapering, among 16 fair to good quality studies, opioid tapering was associated with improved pain, pain-related function, and quality of life [7].
•Similarly, in a small single institution observational study of patients who tapered LOT in a community pain clinic program, both pain intensity and pain interference were unchanged following opioid reduction by approximately 50 percent, from a median morphine equivalent (MME) daily dose of 288 to 150 mg. Conclusions from this study may be limited by a high rate of patient drop out (38 percent) [47].
•In a retrospective study of US veterans on chronic opioid therapy, opioid taper or discontinuation was associated with decreased numeric rating scale (NRS) pain scores, compared with patients who did not taper [48]. Of note, this study was limited to patients with pain diagnoses of arthritis, back pain, neck pain, neuropathic pain, or headache/migraine.
Opioid-induced hyperalgesia may be an indication for opioid taper but may also be unmasked at the start of opioid tapering. In a study of patients with chronic low back pain on LOT who underwent opioid tapering, quantitative sensory testing demonstrated hyperalgesia and decreased pain thresholds as early as three weeks after a rapid taper. However, at six month follow-up testing, hyperalgesia was found to have resolved, with patients tapered off opioids having similar pain thresholds as opioid-naive controls [49].
INABILITY TO TAPER — Inability to taper opioids may be a marker for opioid use disorder (OUD). For patients who are unable to make progress on tapering despite what seems to be an appropriately slow taper and adjunctive therapies, we reassess for OUD, and if necessary, refer the patient for addiction medicine evaluation and management. (See 'Screen for complicating conditions' above.)
For patients who continue opioid therapy, buprenorphine may be a reasonable option for treatment of chronic pain [50]. Use of buprenorphine for management of chronic pain is discussed separately. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Buprenorphine for chronic pain'.)
OPIOID TAPERING RESOURCES — Several guidelines are available for opioid tapering, including federal health system guidelines.
Specific tapering resources have been published by the following organizations:
●Department of Defense and Veterans Health Affairs Administration
●US Health and Human Services (HHS)
●Centers for Disease Control and Prevention
●Stanford Center for Continuing Medical Education
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic pain management".)
SUMMARY AND RECOMMENDATIONS
●Indications – We consider tapering to a lower dose or discontinuing opioid therapy for patients who take >90 milligram morphine equivalents (MME) of opioid per day, since higher doses of opioids are associated with increased risk of mortality. We also consider opioid tapering for any patient for whom the benefits of opioid therapy no longer outweigh the risks of continued use (table 1 and algorithm 1). (See 'Indications for opioid taper or discontinuation' above.)
●Preparation for taper – In preparation for opioid tapering, we screen for conditions that may reduce the likelihood of a successful taper and optimize those conditions before attempting to taper. Such conditions include mental health disorders, central sensitization pain, sleep disorders, and substance use disorders (SUDs). (See 'Screen for complicating conditions' above.)
Whenever possible, the patient should be engaged in the opioid tapering process, and the decision to taper should be made collaboratively. We avoid forced or mandatory tapering unless safety is an issue, establish individualized goals for tapering, and use motivational interviewing principles when communicating with patients (table 3). We make conscious effort to maintain the patient-provider relationship throughout the tapering process. (See 'Shared decision making and motivation' above.)
In collaboration with the patient, we consider tapering all patients who take >90 MME per day, with the goal of tapering to ≤50 MME per day, but individualize the dosing as tapering proceeds. (See 'Shared decision making and motivation' above.)
●Taper slowly – A primary goal for the opioid tapering strategy is to avoid or minimize symptoms of opioid withdrawal, primarily by reducing the opioid dose slowly. For most patients we base the initial rate of taper on the duration of the patient's opioid use, planning slower taper for patients who have been using opioids for longer periods of time, as follows, modified as necessary based on the patient response to tapering: (See 'Taper slowly to minimize opioid withdrawal' above.)
•For patients on long-term opioid therapy (LOT) for >1 year, we aim to taper by 10 percent of the starting dose per month (table 4).
•For patients who have been on LOT <1 year, we aim to decrease by 10 percent of the starting dose each week.
•For patients who take opioids less frequently than daily, we do not formally prescribe a tapering schedule. We discuss the target discontinuation date, prescribe approximately 50 percent less pills than the existing prescription, and plan for the patient to self-taper.
●Opioid formulation during taper – We typically continue the patient's existing opioid during a taper. We reduce the patient's opioid dose to the smallest increment pill, followed by a gradual reduction in dosing frequency. For patients who take both long-acting and short-acting opioids we typically taper the long-acting medication first until it is discontinued, followed by the short-acting medication, unless the patient prefers the reverse (table 4). (See 'Opioid formulation during taper' above.)
●Managing opioid withdrawal symptoms – We do not prophylactically administer medication to prevent opioid withdrawal symptoms. If necessary, our first line treatment of opioid withdrawal symptoms is tizanidine. (See 'Management of opioid withdrawal symptoms' above.)
●Monitoring during tapering – We follow patients with monthly clinic visits during opioid taper, or more frequently if needed, to assess taper progress and withdrawal symptoms, pain severity and impact, and efficacy of nonopioid pain management. (See 'Monitoring during an opioid taper' above.)
A primary risk of opioid tapering is opioid withdrawal. Other serious risks include opioid overdose, suicide, and use of illicit opioids. (See 'Risks associated with tapering' above.)
Pain may increase temporarily at the start of an opioid taper, but pain is often improved or unchanged after taper is complete. (See 'Outcome of attempted opioid taper' above.)
●Inability to taper – For patients who are unable to make progress on tapering despite what seems to be an appropriately slow taper and adjunctive therapies, we reassess for OUD, and if necessary, refer the patient for addiction medicine evaluation and management. For patients who continue opioid therapy, buprenorphine may be a reasonable option for treatment of chronic pain. (See 'Inability to taper' above.)
