Tapering and stopping

It is important to taper or stop the opioid regimen if: 

  • the medication is not providing useful pain relief. The dose above which harms outweigh benefits is 120mg oral morphine equivalent/24hours. Increasing opioid load above this dose is unlikely to yield further benefits but exposes the patient to increased harm
  • the underlying painful condition resolves
  • the patient receives a definitive pain relieving intervention (eg, joint replacement)
  • the patient develops intolerable side effects
  • there is strong evidence that the patient is diverting his/her medications to others 

Preparation for dose reduction includes:

  • explanation of the rationale for stopping opioids including the potential benefits of opioid reduction (avoidance of long term harms and improvement in ability to engage in self management strategies)
  • agreeing outcomes of opioid tapering
  • deciding which patients may need admission for opioid taper/cessation informed by existing opioid dose
  • physical co-morbidities
  • mental health co-morbidities including significant emotional trauma
  • monitoring during taper of pain
  • symptoms and signs of opioid withdrawal
  • choice of opioid reduction scheme
  • incremental taper of existing drug
  • conversion to methadone or buprenorphine
  • defining the role of drug and alcohol services to support dose reduction
  • close collaboration between the patient, his or her carers and all members of the patient's health care team
  • arrangements for follow-up including agreed prescribing responsibilities

The dose of drug can be tapered by 10% weekly or two weekly.

 

Stopping opioids in primary care

The decision to taper/stop an established opioid regimen needs to be discussed carefully with the patient including: 

  • explanation of the rationale for stopping opioids including the potential benefits of opioid reduction (avoidance of long term harms and improvement in ability to engage in self management strategies)
  • agreeing outcomes of opioid tapering
  • arrangements for monitoring and support during opioid taper
  • documented agreement of tapering schedule

 

Stopping opioids in collaboration with specialist services

Patients who are failing to derive benefit from large doses of opioids (greater than oral morphine equivalent of around 300mg/day) may need support from specialist services in order to reduce medication.

This must include detailed exploration of emotional and mental health history (including addiction). Opioid tapering/cessation when patients are taking high doses is more likely to succeed if patients’ emotional and mental health needs are identified and an appropriate plan for support established.
 

Points to discuss with patients when de-prescribing:

  • Remain empathic and focus the discussion on medicines only
  • Take a full medicines history and ask the patient how well the medicines are working, and reflect that the patient is describing severe pain despite medicines
  • Share that the experience of many patients is that taking medicines results in no observable benefit for pain
  • Explain that we have much better ways of working out how helpful medicines really are and we know that a lot of things that we thought were helpful in the past have proved to be disappointing and...
  • ...take responsibility for contributing to where we are now!
  • Medicines for pain can be associated with significant harm
  • It matters a lot that the patient has confidence that all their medicines are working well
  • Usally stopping medicines makes no difference to the pain but can make people feel better
  • If a tapering trial doesn't work we can think again

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