POCKET GUIDE: TAPERING OPIOIDS FOR CHRONIC PAIN

This guide provides recommendations based on the CDC Guideline for Prescribing Opioids for Chronic Pain. These recommendations focus on pain lasting longer than 3 months or past the time of normal tissue healing, outside of active cancer treatment, palliative care, and end-of-life care.

Follow up regularly with patients to determine whether opioids are meeting treatment goals and whether opioids can be reduced to a lower dosage or discontinued.

When to Taper

Consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy when your patient:

• Requests a dosage reduction.
• Does not have a clinically meaningful improvement in pain and function (e.g., at least 30% improvement on the 3-item PEG scale).
• Is on dosages ≥ 50 MME (morphine milligram equivalents)/day without benefit, or opioids are combined with benzodiazepines.
• Shows signs of substance use disorder (e.g., work or family problems related to opioid use, difficulty controlling use).
• Experiences an overdose or other serious adverse event.
• Shows early warning signs for overdose risk, such as confusion, sedation, or slurred speech.

How to Taper

Tapering plans should be individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with nonpharmacologic therapies and nonopioid medications.

Tapering Velocity

• Slow Taper: A decrease of 10% of the original dose per month is often appropriate for patients who have taken opioids for a long time (e.g., years).
• Faster Taper: A decrease of 10% of the original dose per week may be used for patients who have taken opioids for shorter periods (e.g., weeks or months).

Key Steps

1. Assess: Weigh the benefits and risks of opioids. Use clinical judgment to decide whether to continue, taper to a lower dose, or discontinue.
2. Avoid Abruptness: Avoid abrupt tapering or sudden discontinuation of opioids.
3. Monitor: Adjust the rate and duration of the taper according to the patient’s response.
4. Flexibility: Don’t reverse the taper; however, the rate may be slowed or paused while monitoring and managing withdrawal symptoms.
5. Final Steps: Once the lowest available dose is reached, the interval between doses can be extended. If discontinuing, opioids may be stopped when taken less than once a day.

Patient Support and Education

Patient commitment and buy-in are critical to successful tapering.

• Set Expectations: Tell patients that improved function and decreased pain after a taper can be expected, even though pain might initially get worse.
• Reassure: Use supportive language such as “I know you can do this” or “I’ll stick by you through this.”
• Collaborate: Work with the patient to develop a plan that includes non-opioid pain management strategies.

Resources

• CDC Guideline for Prescribing Opioids for Chronic Pain: www.cdc.gov/drugoverdose/prescribing/guideline.html
• CDC Opioid Prescribing Guideline Mobile App: www.cdc.gov/drugoverdose/prescribing/app.html
• Tapering Long-Term Opioid Therapy in Chronic Noncancer Pain: www.mayoclinicproceedings.org

U.S. Department of Health and Human Services | Centers for Disease Control and Prevention