You may use this guidance when an opioid misuse algorithm recommends tapering. The algorithms recommend tapering when a patient’s opioid misuse behaviors increase their risk, and these risks likely outweigh the benefits of continuing the current opioid regimen.
Tapering means reducing an opioid from a higher to a lower dose. It does not necessarily mean to reduce by a large amount or to stop.
We recommend following these principles when implementing a taper:
- Patient-centeredness1: Tapers should be patient-centered as much as is possible. For example, in most cases, the patient can decide whether to begin the taper by reducing their long acting or short-acting medication and should be a part of a decision about how rapidly to taper.
- Pace of taper: There is no agreed upon universal tapering protocol. Use your best judgment in terms of how quickly to taper. Do not reduce the amount of opioid by more than 25% to avoid withdrawal, but withdrawal may also occur with much slower tapers. We find that starting with a 10% dose reduction is often reasonable.
- Flexibility: if a patient’s opioid misuse behaviors subside during a taper, or you now believe the benefits of opioids outweigh the risks, the taper may be paused or even reversed. It is not necessary to "commit" to a particular course, or "finish" a taper simply because you started one. If you change course, continue to re-evaluate the risks and benefits of the patient’s opioids at regular intervals.
- Encountering challenges2: Be alert to common challenges encountered during tapering. These include unmasking of mood symptoms (e.g., depressive symptoms, anxiety, insomnia) and opioid use disorder. Be prepared to treat the patient for these as needed. If a patient is otherwise struggling with a taper (e.g., significantly increased pain or worsened function as the dose is reduced), consider switching the patient to buprenorphine as a safer opioid and a potentially easier opioid from which to taper. If the patient improves on buprenorphine, they may have had an undiagnosed opioid use disorder. In these situations, buprenorphine may be continued indefinitely.
- Acknowledging one’s implicit biases3: The Joint Commission defines implicit bias as "attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner." They go on to say that "these biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control." In addition to systemic measures (e.g., changing norms, evaluating monitoring systems), individual clinicians can address their own implicit biases by understanding and respecting the magnitude of implicit bias, recognizing situations (including opioid tapering)4,5,6 that may magnify stereotyping and bias, and assiduously practicing evidence-based medicine. Also implicit bias based upon race and gender have been shown to influence tapering habits over objective clinical data. This has disproportionately affected Black women. Clinicians should be aware of these strategies to mitigate bias during tapering. This is a vulnerable moment in long term opioid treatment.
U.S. Department of Health and Human Services Opioid Tapering Flowchart:
The full summary below includes DHHS guidance. There is also an e-consult for microinduction if needed.
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics (PDF)
Please note there are many formulations of buprenorphine. Consult the DHHS summary for more guidance.
References
1. Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. Patient Educ Couns. 2018;101(9):1669-1675. doi:10.1016/j.pec.2018.05.016
2. Madden EF, Qeadan F. Racial inequities in U.S. naloxone prescriptions. Subst Abus. 2020;41(2):232-244. doi: 10.1080/08897077.2019.1686721. Epub 2019 Nov 13. PMID: 31718487.
3. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/implicit-bias-in-health-care/#.YstPeuzMLlw
4. Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy. Pain Med. 2019 Aug 1;20(8):1519-1527. doi: 10.1093/pm/pny137. PMID: 30032197; PMCID: PMC6686117.
5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. Pain. 2013 Jan;154(1):46-52. doi: 10.1016/j.pain.2012.07.034. PMID: 23273103.
6. Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376. doi:10.1016/j.drugalcdep.2018.05.033