Module 4: Therapeutics
The following steps from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain outline the actions for each phase of opioid tapering (NOUGG, 2017, Appendix 12).
- Emphasize that the goal of tapering is to make the patient feel better: to reduce pain intensity and to improve mood and function.
- Develop a detailed treatment agreement.
- Prepare to provide frequent follow-up visits and supportive counselling.
Type of opioid, schedule, dispensing interval
- Use controlled-release morphine if feasible (see 2.3 below).
- Prescribe scheduled doses (not PRN).
- Prescribe at frequent dispensing intervals (daily, alternate days, or weekly, depending on the patient’s degree of control over opioid use).
- Do not refill if the patient runs out.
- Keep daily schedule the same for as long as possible (e.g., TID).
Rate of the taper
The rate of the taper can vary from 10% of the total daily dose every day to 10% of the total daily dose every 1–2 weeks. Slower tapers are recommended for patients who are anxious about tapering, may be psychologically dependent on opioids, have co-morbid cardio-respiratory conditions, or express a preference for a slow taper.
- Slow the taper to one-half or less of the previous rate once one-third of the original dose is reached.
- Hold the dose when appropriate. The dose should be held or increased if the patient experiences severe withdrawal symptoms, a significant worsening of pain or mood, or reduced function during the taper.
Switching to morphine
- Consider switching to morphine if the patient may be dependent on oxycodone or hydromorphone.
- Calculate equivalent dose of morphine.
- Start the patient on one-half of this dose. Note that tolerance to one opioid is not fully transferred to another opioid.
- Adjust the dose up or down as necessary to relieve withdrawal symptoms without inducing sedation.
Monitoring during the taper
- Schedule frequent visits during the taper (e.g., weekly).
- At each visit, ask about pain status, withdrawal symptoms and possible benefits of the taper: reduced pain and improved mood, energy level, and alertness.
- Use urine drug screening to assess compliance.
Completing the taper
- Tapers can usually be completed between 2–3 weeks and 3–4 months.
- Patients who are unable to complete the taper may be maintained at a lower dose if their mood and functioning improve and they follow the treatment agreement.
- NOUGG. (2017). Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Retrieved from http://nationalpaincentre.mcmaster.ca/opioid/