Tapering

Opioid Taper/Discontinuation

Opioid therapy should be tapered down or discontinued if any of the following situations occur:

• The medication fails to show significant analgesia despite incremental dose increases.
• The medication fails to show functional improvement over time.
• MED is in excess of 90 mg/d or methadone dose is in excess of 30mg/d.
• Significant physical risk factors are present (sleep apnea, prolonged QT, pulmonary disease, etc.).
• Side effects of medication are interfering with quality of life.
• Patient request.
• Evidence of misuse, abuse, diversion, or other behavioral/psychological dysfunction.
• Other violations of opioid agreement.

Opioids should be weaned, rather than abruptly stopped, after chronic use (30 days or greater). When opioids are being sold, injected, used in a dangerous or clearly illegal fashion, immediate discontinuation should be undertaken for patient safety and compliance with the law. Referral to a medication-assisted treatment program (methadone or buprenorphine) may be a safer and more appropriate treatment consideration under these circumstances.

Some providers have found the following dialogue useful when explaining the process to patients:

“Medical knowledge changes over time, and just as we have discovered that some of our recommendations today concerning the treatment of cancer or heart disease are different from 10 years ago, the same is true of the treatment of chronic pain. We now know that it can be dangerous to take large amounts of opioids every day. We have also learned that pain relief with high doses may not be any better than with lower doses
of painkillers.”

General considerations

• Some short-term increase in pain is to be expected during the tapering process. This is usually transient, and after achieving a reduced baseline dose, the patient is likely to experience decreased medication-related side effects and a reduced risk of unintentional overdose, without an increase in pain. Many times, opioids may be completely discontinued with no increase in pain, and with improved function and quality of life.
• The slower the taper, the less the short-term discomfort. Educating the patient about the risks of their current regimen and what to expect as they taper off the medications is often helpful.
• Some highly motivated patients prefer a rapid taper (weeks versus months). Patient preference needs to be considered in designing a tapering schedule.
• Psychosocial support is an essential component of successful medication withdrawal for patients who have been on long-term opioid therapy. Discussions about weaning are often associated with fear and anxiety about the recurrence or worsening of pain and/or the development of other withdrawal symptoms. Reassure the patient that supportive adjunctive treatment of withdrawal will be provided as needed, and may be quite helpful, but set expectations that this will not include replacement medications such as other opioids or benzodiazepines. Certain medications that treat autonomic responses, medications such as clonidine, loperamide, or hydroxyzine may be useful short-term adjuncts.
• Patient empowerment is key to success. Involve patients in the planning from the beginning. Elicit suggestions from them for healthful activities that can replace reliance on medications.
• Certain therapies, CBT and Living Well With Chronic Illness workshops, for example, can be quite helpful to support patients through the tapering process and beyond.
• The last part of the dosage reduction is the most difficult for the patient. This is a phenomenon that is true for many psychoactive drugs. You and your patient should anticipate this, and engage supports that are meaningful to the patient. Even in motivated patients, a slow-down of the tapering process may be necessary toward the end. Liquid forms of medication can be helpful for more precise dosing and can be obtained from a compounding pharmacy.
• We tend to associate “ceiling dose” with the concept that there is a dose at which the risks of the medication outweigh the benefits. However, medication dependence, side effects, and other physical and behavioral changes experienced with chronic opioid use, are related to dose also; for many individuals, quality of life improves as the dose approaches or reaches zero.

Symptoms of Opioid Withdrawal

Initial steps

1. Calculate the current daily MED, review the ORT (or other risk-screening assessments), and assess patient progress in treatment, including UDS, PDMP, and any signs of aberrant behavior. Use that review to inform the patient concerning the appropriateness of tapering. Involve the patient in the creation of his or her new care plan.
2. Sometimes, giving the patient some time to assimilate this new information may be appropriate. Starting the taper at the follow-up visit may help build trust.
3. Patients at risk for aberrant behaviors during the tapering process (suicidality, illicit drug use, loss of impulse control) will need referral to a behavioral health specialist prior to the initiation of the taper. It is helpful to work in parallel with such behavioral specialists during the tapering process for these patients.
4. Document your plan and the reasons for the taper in the chart note, and provide appropriate information to your patient.
5. Medication tapering may be a very stressful experience for patients. Close monitoring for aberrant behaviors is critical during this period to assure patient compliance and safety. Misuse of medications, use of illicit drugs, and “doctor shopping” may necessitate a change in approach, requiring a switch from a tapering strategy to substance-abuse treatment (residential care or medication-assisted treatment such as buprenorphine).

Slow-taper protocol

1. Long-acting opioids: Decrease total daily dose by 5–10% of initial dose per week.
2. Short-acting opioids: Decrease total daily dose by 5–15% per week.
3. These regimens may need to be slowed toward the end of the tapering process (see General Considerations above). Often, once 25–50% of the total dose is reached, the rate of taper can be slowed to 5% per week.
4. You and your patient should know the signs and symptoms of opioid withdrawal. Some of those symptoms may be present during this process, and can be controlled by support medication, psychosocial supports, or slowing the tapering process.
5. Remain engaged with the patient through the taper and provide psychosocial support as needed. Peer-to-peer groups, Living Well With Chronic Pain workshops, CBT, and other counseling/therapy modalities may be quite helpful.
6. Consider the following adjuvants as needed:

• Antidepressants to manage irritability, sleep disturbance (e.g., trazodone)
• Hydroxyzine for insomnia and anxiety
• Anti-epileptics for neuropathic pain
• Clonidine for autonomic withdrawal symptoms such as rhinorrhea, diarrhea, sweating, tachycardia, hypertension
• NSAIDS for myalgia (e.g., ibuprofen)
• Anti-diarrheal agents for diarrhea
• Opioid Withdrawal Attenuation Cocktail (Appendix F)

Special considerations for methadone

Methadone withdrawal symptoms take longer to manifest because of the long and unpredictable metabolism of the drug. Patients may be overconfident early in the tapering process only to experience severe withdrawal over time. The same principles of opioid tapering are true for methadone; although, a more drawn-out taper may be necessary. Understanding the unique metabolic characteristics of methadone will be helpful for you and the patient to achieve a successful dosage reduction.

Benzodiazepine Taper/Discontinuation

Benzodiazepines are potentially addictive drugs that may produce physical dependence, amnesia, emotional blunting, psychomotor retardation, and synergistic respiratory depression when combined with opioids. Anxiety, although initially ameliorated by benzodiazepines taken short term, often returns to near baseline levels with chronic use. Patients may be reluctant to taper off of these medications fearing the exacerbation of anxiety that usually accompanies the dose-reduction process.

Unlike opioids, abrupt withdrawal from high doses of benzodiazepines can result in seizures and death. The detoxification resembles alcohol withdrawal in terms of symptomatology and risk. Some patients will need medically supervised residential treatment to successfully discontinue benzodiazepines.

Withdrawal: The longer the treatment, the higher the dosage, the shorter the half-life, or the faster the taper, then the more likely the patient will have withdrawal symptoms. Even small doses of benzodiazepines taken chronically may produce uncomfortable symptoms if discontinued abruptly.

Common Benzodiazepine Withdrawal Symptoms

General considerations

• Some short-term increase in anxiety is to be expected during the tapering process. This is usually transient, and after achieving a reduced baseline dose, the patient is likely to experience decreased medication-related side effects without an increase in anxiety. Many times, benzodiazepines may be completely discontinued with no increase in symptoms but with improved function and quality of life.
• The slower the taper, the less the short-term discomfort. Educating the patient about the risks of their current regimen and what to expect as they taper off the medications is often/can be helpful.
• Some highly motivated patients prefer a rapid taper (weeks versus months). Patient preference needs to be considered in designing a tapering schedule.
• Psychosocial support is an essential component of successful medication withdrawal for patients who have been on long-term benzodiazepine therapy. Discussions about weaning are often associated with fear and anxiety about the recurrence or worsening of anxiety and/or the development of other withdrawal symptoms. Reassure each patient that supportive adjunctive treatment of withdrawal will be provided as needed, and may be quite helpful, but set expectations that this will not include dangerous replacement medications. Certain non-habit forming medications that treat insomnia specifically (such as trazodone or hydroxyzine) might be useful.
• Patient empowerment is key to success. Involve patients in the planning from the beginning. Elicit suggestions for healthful activities that can replace reliance on medications.
• Certain therapies, CBT and trauma-focused care, for example, can be quite helpful in supporting patients through the tapering process and beyond.
• The last part of the dosage reduction is the most difficult for patients. This is a phenomenon that is true for many psychoactive drugs. You and your patients should anticipate this and use supports that are meaningful to your patients. Even in motivated patients, a slow-down of the tapering process may be necessary toward the end. Liquid forms of medication can be helpful for more precise dosing and can be obtained from a compounding pharmacy.

Discontinuation strategies

Here are two strategies that can be used to taper off of benzodiazepines:

1. Switching to a long-acting benzodiazepine (or to phenobarbital) and then start slower taper.
2. Simultaneous treatment with an anti-epileptic drug during taper (allows for a more rapid taper).

Special circumstances

Consider inpatient/medical residential treatment in patients with significant substance abuse history, history of benzodiazepine overdose, seizure disorder, or illicit benzodiazepine use. Modified CIWA-b evaluation or MSSA (withdrawal scoring systems) can be used in such circumstances to determine the total 24-hour dose needed to begin the taper and provide safe medical monitoring of the taper process.

Slow-taper method

1. Calculate the dose equivalence of the current benzodiazepine into clonazepam, diazepam, or phenobarbital long-acting drug: (Benzodiazepine Equivalence Table). Provide behavioral support to the patient during the tapering process above (see General Considerations concerning opioid tapering).
2. Switch the patient from the short-acting drug to the longer-acting drug. Be conservative in estimating the long-acting dose since variation in metabolism may create safety issues. Consider a reduction of 25–50% of the calculated dose for initiation of tapering.
3. See the patient for a return visit a few days after initiating the taper to be sure your dose equivalency is appropriate.
4. Reduce the total dose of the long-acting agent by 5–10% per week in divided doses.
5. Consider slowing the taper to 5% or less per week when the dose has been reduced to 25–50% of the starting dose.
6. Consider adjunctive agents to help with symptoms: trazodone, buspirone, antidepressants, hydroxyzine, clonidine, neuroleptics, and alpha-blocking agents have all been useful.

Benzodiazepine Equivalency Chart

Onset of Action

Rapid = within 15 min.

Intermediate = 15–30 min.

Slow = 30–60 min.