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Tapering Opioids – Tips from the I-WOTCH team

The BMJ has published a paper on tapering opioids from the team responsible for the I-WOTCH study and their collaborators. The paper includes the following tips and suggestions:

Limit prescribing, which is unlikely to offer benefit—Avoid opioids for pain relief in people at high risk for opioid use disorder, such as those with an active or previous substance use disorder, or a psychiatric disorder.

Explain the harms of long term opioid use and enable access to non-pharmacological pain management interventions—Provide clear advice on the high potential for physical dependence and its consequences.

Monitor the benefits and harms—Once prescribed, monitor patients on opioids for pain relief. Ask about adverse effects such as overdose, motor vehicle accident, addiction, sleep apnoea, osteoporosis, drowsiness, constipation, dizziness/vertigo, hypogonadism/sexual dysfunction, vomiting/nausea, opioid induced hyperalgesia, and dry skin/pruritus.

Offer patients taking opioids for chronic pain a trial of supported opioid tapering, particularly if the following apply:

  • The patient requests dosage reduction
  • No clinically meaningful improvement in pain and function
  • Patient is on dosages ≥ 50 mg of morphine equivalent daily without benefit or opioids are combined with benzodiazepines
  • Signs of substance use disorder (eg, work or family problems related to opioid use, difficulty controlling use)
  • Patient experiences overdose or other serious adverse event, or shows early warning signs for overdose risk such as confusion, sedation, or slurred speech.

Stop Opioids

Abrupt opioid cessation can be associated with unpleasant physical and emotional symptoms (opioid withdrawal) lasting typically up to two weeks. Slow and monitored tapering can minimise these effects. Tapering is usually carried out by reducing a small percentage (10%-20%) of the total dose every week, and the duration of the tapering depends on the starting dose. A person starting on a dose of 100 mg of morphine per day may take up to 14 weeks to discontinue the drug. Opioid withdrawal is not life threatening; however, precautions are advised in high risk patients such as pregnant women, those with opioid use disorder, unstable coronary artery disease, or unstable psychiatric disease. Risks include over-stimulation of the sympathetic system, which may result in tachycardia, piloerection, nausea, vomiting, and agitation.

Taper Opioids

When starting to discuss tapering use reasons that are convincing and true to that person. For example, explain that the opioid the patient is using every day may be contributing to the worsening of their chronic pain (opioid induced hyperalgesia), loss of libido (hypogonadism), general fatigue, or sleep apnoea. This may make the patient more receptive to opioid tapering.