Tapering recommendations for patients on high opioid doses

The Centers for Disease Control and Prevention (CDC) advise that the benefits and risks of opioid therapy change over time. Patients should be periodically reevaluated to ensure that opioids are helping meet their treatment goals and providing functional benefit.

It is critical to recognize when risks of chronic opioid therapy outweigh benefits, and to effectively communicate this information to patients. Clinicians are encouraged to collaborate with patients receiving opioids at a dose above 90 MME and, if appropriate, taper/discontinue opioids to improve the safety of their drug regimen.

Planning taper conversations

• Consider scheduling a separate patient visit or extending the length of an existing appointment to discuss a taper.
• Use motivational interviewing techniques to discuss ongoing opioid therapy in a collaborative manner, and to assess the patient’s readiness for change.
• Talk to your patient about their understanding of the perceived risks and benefits of continued opioid therapy.
• Focus on the patient’s safety when initiating conversations about opioid therapy.
• Assure patients that the clinical relationship will not be harmed if they are not ready to taper.

Patient education

• Discuss different approaches around timing and dosage. Providing options may reduce a patient’s fear and anxiety by giving them control over elements of the process.
• Educate patients about expected withdrawal symptoms and pain outcomes.
• Discuss the differences between opioid dependence and addiction.
• Educate patients on the increased risk of overdose as tolerance is reduced when tapering.
• Supply a naloxone prescription and encourage the patient to ask family and friends to become educated about rescue use.

Taper plan

• The taper approach should incorporate patient preferences and be individualized based on the patient’s risk profile, goals and concerns.
• Engage the patient in shared decision making to establish a patient-centered plan.
• The success of the initial dose reduction is more important than achieving a specific dose decrease.
• Flexible, slow taper plans focused on sustained, gradual reductions are often more successful than a predetermined reduction rate.
• Provide patients with the option to pause the taper and restart again when ready. Pauses give patients time to acquire new skills for managing pain and emotional distress, introduction of other medications or initiation of other treatments, while allowing for physical adjustment to a new dosage.
• Increase the frequency of clinic visits or remote visits during dose reductions. Encourage the patient to contact the clinic if problems arise during dose reductions.
• Support the patient throughout the taper, especially during dose reductions.
• Identify the signs and symptoms of opioid use disorder (addiction) and intervene with compassion.
• Optimize non-opioid and non-pharmacologic treatment modalities for pain.

Addressing withdrawal symptoms

Tapering should not result in withdrawal. However, if withdrawal symptoms occur, the following adjunctive medications may be prescribed:

Various health organizations have published suggested taper plans. For example, the CDC recommends a slow taper of 10% opioid taper per month.

However, there is no one approach to tapering, and it is essential that each taper plan is individualized and based on the patient’s history, goals and an objective assessment. Please refer to the following resources as references only:

• CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022
• Opioids and Chronic Pain: A Guide for Primary Care Providers (PDF) — California Department of Public Health