Opioid Tapering Template

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RxFiles Academic Detailing

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For use when a decision is made to reduce or discontinue an opioid in chronic non-cancer pain (CNCP).

General approach considerations:

1. In discussion with the patient, set a reasonable start date for the taper.

2. Gradual tapers can often be completed in the range of 1 to 6 months. However, some may benefit from a longer time

frame of 12-24 months. Initial daily dose reductions in the range of 5-10% every 2-4 weeks are reasonable.

Once a dose of

approximately 1/3 of the original dose is reached, smaller dose reductions (e.g. 5% every 4-8 weeks) may be more suitable

for some & more likely to result in a successful taper.

More rapid tapers are possible and sometimes desired. In such cases,

use of an opioid withdrawal scale (e.g. COWS) & corresponding withdrawal protocols may be recommended, allowing for

successful withdrawal within 1-2 weeks. (See links

2-4

)

3. Long-acting formulations that offer smaller dose increments are useful for more gradual tapers once in the lower end of

the dosage range. {Examples: morphine long-acting: M-ESLON 10mg cap

q12h

, KADIAN 10mg cap

q24h

4. Consider daily dispensing of opioids or blister packs for those at high risk of overdose or aberrancy use.

5. Determine if the goal of dose reduction is reasonable (e.g. opioids have offered some benefit) or if complete

discontinuation is more suitable (e.g. opioid trial has been highly problematic/non-helpful or there is a concern regarding

opioid induced hyperalgesia).

6. If goal is to reduce dose, option to taper further & more gradually may be entertained at a later point. Tapering plan

may be held/reassessed at any point if pain/function deteriorate or withdrawal symptoms persist for 1 month or more.

However, the “hold off on further taper & plan to reassess/restart taper” conversation should have a designated

endpoint & be one conversation, not two!

7. Encourage functional goal setting & efforts to enhance non-drug approaches in management plan.

8. Optimize other pain management (e.g. Is something needed for neuropathic pain such as nortriptyline, gabapentin or pregabalin).

9. Anticipate likely and possible withdrawal effects & have a management plan in place. (See Pg 2 & Withdrawal Rx)

10. Given the complexities in some cases, discussion with experienced colleagues and an interdisciplinary approach will

help optimize management. Continue to use “best practice” tools (e.g. Opioid Manager, UDS).

11. Strongly caution patients that a) they have lost their tolerance to opioids after as little as a week or two of abstinence, &

b) they are at risk for overdose if they relapse/resume their original dose. OTC:

Consider a Take Home Naloxone Kit  !

Timeline for discontinuation or reaching a taper “target dose”

Current dose ______________________________________________________

Proposed target dose _______________________________________________

Timeline (in weeks or months) __________________________ weeks months

 Allow for gradual q3 day, weekly, bi-weekly or monthly dose reductions. Reassess as necessary.

 In general, the longer the duration of previous opioid therapy, the more time should be allotted for tapering. Rate of

tapering should often be even more gradual as total daily dose reaches lower end of range (e.g. 120 mg Morphine/day)

See page 2 for customizable Tapering Template, or go online for customizable Opioid Withdrawal Prescription.

Name: __________________________________________ Date: ________________

Address: ___________________________________________________________________

(May switch/rotate to 50-75% equivalent morphine dose of an alternate opioid.)

A) Tapering Schedule*: Drug _____________________________

Reduced dose accounts for incomplete cross tolerance. See Opioid Manager Switching Tool.

Dates (# wks)

AM Dose**

PM Dose

Other

Total

Dose/Day

Quantities Needed

Current Regimen

Start Date!

x wk

10.

x wk

11.

x wk

*template may be adjusted based on patient’s progress; decisions on further tapering, etc. Last 20-30 mg may require more time.

**if once daily formulation (eg. morphine SR KADIAN) record dose in respective AM or PM column & “0” in other.

individualize duration! May begin by reducing dose q2-4 weeks and then q4-8 weeks once 1/3 of the dose is reached.

B) Opioid withdrawal symptoms:

- Many of these symptoms may not be seen with a gradual taper!

- Physical withdrawal symptoms generally resolve by 5-10 days following opioid dose reduction/cessation.

- Psychological withdrawal symptoms (dysphoria, insomnia), if seen, may take longer (months) to resolve.

Early symptoms may include:

Late symptoms may include:

Prolonged symptoms may include:

- anxiety and restlessness

- sweating

- rapid short respirations

- runny nose, tearing eyes (minor)

- dilated reactive pupils

- brief

 in pain (usually few

days)

- runny nose, tearing eyes

- rapid breathing, yawning

- tremor, diffuse muscle

spasms/aches

- pilo-erection (goose bumps)

- nausea and vomiting; diarrhea

- abdominal pain

- fever, chills

-  white blood cells (if sudden

withdrawal)

- irritability, fatigue; hormonal

related

- bradycardia (slower heart rate)

- decreased body temperature

 Some people with chronic pain will

find that symptoms such as fatigue

& general well-being are improved

over time with tapering of the

opioid. In such cases, gradual gains

in function will be possible &

should be explored.

Early = hours to days

Late = days to weeks

Prolonged = weeks to ~6 months

C) NSAID (e.g. naproxen

250-375mg twice daily

or ibuprofen

400-600mg four times daily

): useful for pain & withdrawal aches/pains.

D) Laxative: continue initially; with time, or if diarrhea emerges, reduce, hold & eventually stop laxative

(See Q&A)

E) Management of other side effects:

1. Clonidine 0.1mg twice daily PRN (up to 4 times daily) may be prescribed for general relief/prevention of physical

withdrawal sxs. (Caution if SBP <100, orthostasis, or HR <60); Some patients may not require if gradual taper. May use SOWS

(patient administered scale) for monitoring (e.g. score 10-20 take clonidine) see Pg 9. [Cochrane review documented use for

7-14 days up to 30 days,

but some may need longer]. If used regularly, taper, over ~7-10d, to stop.

2. Acetaminophen (650-1000mg every 6 hours as needed) may be used for aches, pains, flu-like symptoms.

3. Loperamide may be used as necessary for diarrhea; however, may not need with gradual taper.

4. Non-drug & “sleep hygiene” measures should be employed

(e.g. U of R pain course www.onlinetherapyuser.ca/pain; regular

bedtime/wake-time; sleep restriction)

7-9

If additional tx required, short-term trazodone 25-50-100mg HS is an option.

5. Dimenhydrinate 50-100mg every 6 hours as needed for nausea/vomiting

[Alternatives: prochlorperazine 5-10mg q6h, haloperidol 0.5-1mg q12h]

6. Other

7. Remember tolerance to previous dose of opioid is lost after 1-2 weeks!

Consider Naloxone Kit OTC  for risk of overdose!

Physician: ____________________________



Page 2 of 2

Opioid Tapering

Template

Extras, Links & References © www.RxFiles.ca

A) Sample Slow Tapering Schedule*: Drug _____Morphine long acting_(MS CONTIN)

Dates (# wks)

AM Dose**

PM Dose

Total

Dose/Day

Quantities Needed

Current

245mg

490 mg

X2 wk

230 mg

460 mg

(4x100mg) + (2x30mg) x14d

X2 wk

215 mg

430 mg

X2 wk

200 mg

400 mg

X2 wk

190 mg

380 mg

X4 wk

175 mg

350 mg

X4 wk

160 mg

320 mg

X4 wk

145 mg

290 mg

X4 wk

130 mg

260 mg

X4 wk

115 mg

230 mg

10.

X8 wk

100 mg

200 mg

11.

X8 wk

90 mg

180 mg

12.

X8 wk

80 mg

160 mg

Switch to M-ESLON, or

once daily KADIAN for smaller titrations

13.

X8 wk

140 mg

0 mg

140 mg

14.

X12 wk

120 mg

0 mg

120 mg

15.

16.

*this template may be adjusted based on patient’s progress; decisions on further tapering, etc.

**if once daily formulation (i.e. KADIAN) record dose in respective AM or PM column and “0” in other.

-----------------------------------

Additional information:

2017 C anadian Guideline for Opioids for Chronic Pain (May 2017) - Links

 Link to Guideline Site: http://nationalpaincentre.mcmaster.ca/guidelines.html

 Opioid Tapering- Information for Patients – English:

http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20Information%20(english).pdf

 Opioid Tapering- Information for Patients – French:

Sevrage des opioïdes : informations à l’intention des patients.

http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20information%20FRENCH.pdf

Other

 CAMH: Video discussion of issues around how to taper.

http://knowledgex.camh.net/videos/Pages/tapering_presopioids_selby2013.aspx

 RxFiles: Opioid Taper Template & related materials at: www.RxFiles.ca

o Pain/Opioid Resource Links: http://www.rxfiles.ca/rxfiles/uploads/documents/RxFiles-Pain-and-Opioid-Resource-Links.pdf

o RxFiles Pain/Opioid Newsletter Part 1 – Fall 2017: http://www.rxfiles.ca/rxfiles/uploads/documents/Opioids-Pain-2017-Newsletter.pdf

 TheWell (Centre for Effective Practice):

o Opioid Tapering Template (2018) at: https://thewellhealth.ca/opioidtaperingtool

o Opioid Manager tool to support the Canadian Opioids in CNCP guideline: https://thewellhealth.ca/pain

 CDC - POCKET GUIDE: Tapering Opioids For Chronic Pain: https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

Clinical Opiate Withdrawal Scale (COWS).

https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf

Subjective Opiate Withdrawal Scale (SOWS).

http://www.bccsu.ca/wp-content/uploads/2017/08/SOWS.pdf

Butt P, McLeod M. Opioid withdrawal protocol, Saskatchewan.

Opioid Induced Constipation Q&A: http://www.rxfiles.ca/rxfiles/uploads/documents/members/Opioid-Induced-Constipation-QandA.pdf

Gowing L, Farrell MF, Ali R, White JM. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2014 Mar

31;3:CD002024.

Merrigan JM, Buysse DJ, Bird JC, Livingston EH. JAMA patient page. Insomnia.JAMA. 2013 Feb 20;309(7):733. Accessed online 21 Oct, 2013 at

http://jama.jamanetwork.com/article.aspx?articleid=1653524 .

Sedative Patient Information Sheet (RxFiles) http://www.rxfiles.ca/rxfiles/uploads/documents/PSYC-Sedative-PtHdout.pdf

Chronic Insomnia in Older Adults (RxFiles Q&A) http://www.rxfiles.ca/rxfiles/uploads/documents/Insomnia-Older-Adults-QandA.pdf