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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

What’s the safest, effective way to taper a patient off of opioid therapy?

In this Ask the Expert, learn why patients undergoing opioid taper should receive overdose education and an offer for at-home naloxone.

There has been considerable attention placed on the role of opioid medication in the treatment of chronic pain with limited direction on how and when to taper opioids. This article provides insights and strategies to conduct the process effectively and safely.

General Approaches

Adverse effects, lack of benefit, comorbidities, concomitant medications, non-adherence with the treatment plan, improvement in pain, or patient preference are all possible reasons to consider opioid tapering. Essentially, any time the risks of opioid therapy outweigh the benefits to the patient, a change to the treatment plan should occur.1-4

When tapering opioid therapy, an individualized approach should be used.2,3 At the outset of the taper, it is important to determine the ultimate goal – dose reduction versus discontinuation – as this will guide the process. Throughout the taper, it is vital to revisit the original goal to determine whether the plan is still appropriate for the patient.


One of the first things to consider is the setting in which to taper the patient. The setting of taper should correspond to the patient’s level of risk. Higher-risk patients (eg, those with substance use disorder, a history of recent overdose, or a respiratory condition) should receive higher levels of care and more specialized providers depending on availability. Most often, opioid tapers occur in the outpatient setting, particularly if they are slow tapers that occur over months to years. An inpatient setting may be more appropriate for those that fail outpatient tapering and those at highest risk. As always, it is also important to consider patient preference in developing an opioid taper.2,4

Medication Selection

When tapering from opioids, ironically, an opioid medication is still involved. Most often, the patient’s current opioid medication is used for the taper. Even fentanyl patches can be tapered in 12-mcg increments.1 On the other hand, there may be times when the patient’s current opioid needs to be switched to another. The route of administration, renal/hepatic function, drug-drug interactions, availability, and formulary considerations contribute to the optimal opioid medication to use.2

Patients may present on both extended-release/long-acting (ER/LA) and short-acting opioids. When patients are on ER/LA and short-acting opioids, beginning the taper with the ER/LA opioid may be wise because of their association with increased risk for overdose compared to short-acting opioids.2 Overall, the selection of tapering the ER/LA or short-acting opioid first should be individualized to the patient and reflect patient risk and comorbidities.2

Furthermore, in patients at high risk, tapering both the ER/LA and short-acting formulation simultaneously may be appropriate.2 Patient preference should also be considered; allowing the patient to choose which opioid to taper first is a way to include them in the decision-making process.


There is no evidence to demonstrate that one opioid taper strategy over another is better.3 The objective with tapering is to reduce the dose at a rate that does not produce withdrawal symptoms.1-3 From the addiction literature, 25% of the previous day’s dose is needed to prevent overt withdrawal.1 The speed varies depending on the reason for the taper and the patient’s level of risk. Other factors to consider when determining the speed of taper include opioid dose, duration of opioid therapy, opioid medication, and comorbidities.1-3 Depending on patient safety, slower tapers are typically preferred and implemented for those on high doses of opioids, longer duration of opioid therapy, and at lower risk.2

The Centers for Disease Control and Prevention (CDC) guideline and the Washington State Agency Medical Directors’ Group (AMDG) interagency guideline on this topic both recommend a reduction of total daily opioid dose by 10% per week for most patients.3,4 Another guideline recommends decreases of the total daily opioid dose by 5 to 20% occurring as frequently as every month in a lower-risk patient.2 Reductions may occur less frequently with dose changes every few months.2 A faster taper, days to weeks, of 5 to 20% per week may be necessary in patients at significant risk.2 Throughout the taper, the speed may need to be adjusted; pauses in the taper may be needed with avoidance of reversing the taper, particularly if the aim is to discontinue opioid therapy.2-4 Providing the patient with clear written instructions for each step of the opioid taper is crucial.2

Other Considerations

Substitute and Complementary Therapies

Nonpharmacological and non-opioid pharmacological options are typically trialed or put in place as first-line treatment in patients with chronic pain conditions. However, even after moving to opioid therapy, there may be other alternatives that the patient has not used or that have not been maximized. Therefore, the time immediately before and during opioid tapering may be optimal to try other treatment strategies that target pain from a biopsychosocial perspective. Incorporating other specialties from mental health, pain management, and rehabilitation to physical therapy, occupational therapy, pharmacy, and others for a team-based approach may be useful for optimizing care, although these approaches may not always be feasible.2,4 Regardless, patients should be reassured they will continue to receive pain management in one or more modalities.2

Withdrawal Symptoms

Patients may exhibit symptoms of opioid withdrawal during the tapering process. While not typically life-threatening, withdrawal can be uncomfortable.4 There are several proposed theories that explain opioid withdrawal symptoms, including changes in levels of norepinephrine and metabolites, alpha and beta-adrenergic receptors, or the mesolimbic dopaminergic pathways. Primarily, symptoms reflect an overly active autonomic nervous system.5

Symptom presentation tends to vary on the volume of distribution and the half-life of the opioid but typically begin 8 to 10 hours after the last dose. Early symptoms of withdrawal may include lacrimation, rhinorrhea, yawning, and sweating—these early symptoms may persist for a week. Other symptoms that may present slightly later in the initial withdrawal phase include difficulty sleeping, chills, nausea, vomiting, myalgia, weakness, and involuntary movements. A secondary phase may occur as well, lasting up to 26 weeks or more, and includes hypotension, bradycardia, hypothermia, mydriasis, and changes in the responsiveness to carbon monoxide levels.5

There are several medications that may be used to mitigate opioid withdrawal. These include alpha-1 antagonists (prazosin, trazodone), alpha-2 agonists (clonidine, tizanidine), beta-blockers (propranolol, atenolol), N-methyl-D-aspartate (NMDA) receptor antagonists (dextromethorphan, memantine), serotonin norepinephrine reuptake inhibitors (venlafaxine), selective serotonin reuptake inhibitors (fluvoxamine, sertraline), or other antidepressants (mirtazapine, bupropion).5 Additionally, medications may be used to target specific symptoms, such as loperamide or anti-spasmodics for diarrhea and anti-emetics for nausea.4

Unexpected Outcomes

Tapering does not always go as planned. During the tapering process, untreated mental health conditions (including opioid use disorder, or OUD) may appear or established mental health disorders may worsen. In these cases, it is essential to work alongside mental health specialists to provide appropriate treatment. For patients exhibiting OUD symptoms, referral may be made for mental health services to assess and provide medication-assisted therapy (MAT), which may involve buprenorphine/naloxone, methadone, or long-acting injectable naltrexone. A plan should be in place if a patient expresses suicidal ideation to connect the patient with emergent psychiatric treatment.2-4

Keep in mind that there are situations in which a taper may not be needed. If a patient is exhibiting dangerous or illegal behavior (diversion), for instance, opioids may be discontinued completely. In these cases, the discontinuation should be coupled with the continued provision of care or referral to a MAT program to best manage the patient’s withdrawal symptoms and/or OUD.2,4

Risk Mitigation Strategies

Risk mitigation strategies are standard during opioid therapy and should continue to be used throughout the taper. Urine drug monitoring (UDM) may be helpful to ensure the patient continues with the medications prescribed and is not using alternative opioids or substances. Prescription drug monitoring program (PDMP) queries should be continued throughout the taper. Follow-up is key as well, with recommended intervals of every 1 to 4 weeks coordinating with the speed of taper and patient level of risk.2

Most importantly, patients undergoing opioid taper should receive opioid overdose education and an offer for at-home naloxone. Despite lowering opioid doses during an opioid taper, there is still a role for naloxone because a change in tolerance may occur in as little as a week at a lower opioid dose, so an abrupt return to higher doses of opioids may be deadly.2 The use of these risk mitigation strategies may provide additional information that ultimately alters the taper plan.


An imbalance of the risks and benefits of opioid therapy should trigger evaluation and consideration of an opioid taper. The setting, medications used, and speed of the taper need to align with the patient’s level of risk. Slower tapers may be used for low-risk patients who have a longer duration of opioid-use history and have been on higher doses of opioids, while a faster taper may be used in high-risk patients.

Non-opioid and nonpharmacological options for pain management as well as risk mitigation strategies should be utilized throughout the taper process. Medications are available that may mitigate opioid withdrawal symptoms. A team approach incorporating providers from multiple disciplines is recommended.

Continue Reading:
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