Opioid therapy in a chronic pain patient may be done for a variety of reasons. Sometimes it is done because the pain is resolved or a more effective therapy is available, but more often it is done to address a problem.
NOTE: Switching opioid therapy is handled separately.
Discontinuation may be done:
(1) immediately
(2) rapid taper
(3) slow taper
|
Discontinuation
|
Indications
|
|
immediate
|
drug diversion; prescription forgery/fraud; immediate danger to the patient; incarceration; threats against practice; suicide attempt
|
|
rapid taper
|
non-adherence with opioid agreement; medication misuse; red flags for misuse
|
|
slow taper
|
lack of benefit; opioid-induced toxicity; opioid-induced hyperalgesia; excessive dose (MMED > 90)
|
Immediate discontinuation:
(1) no further prescriptions for opioids
(2) at risk for withdrawal and inpatient detoxification may be necessary
(3) refer to substance abuse specialist
Rapid taper:
(1) convert opioids to MME per day (if on methadone, then convert to methadone equivalents)
(2) switch opioid to an equivalent amount of morphine sulfate, preferrable extended release
(3) taper by 25% every 3 days (if taking short acting-opioid) to 7 days (for intermediate-acting). This would take about 2 weeks for a short-acting agent or 4 weeks for intermediate-acting.
(4) severe withdrawal can be avoided with as little as 25% of the preceding dose
Slow taper:
(1) convert opioids to MME per day (if on methadone, then convert to methadone equivalents)
(2) switch opioid to an equivalent morphine sulfate, preferrable extended release
(3) taper by 10% every week until 20% remains (over 7 weeks)
(4) taper the final 20% by reducing 5% of the original baseline dose each week (over 4 weeks)
Explain the reasons for discontinuing the opioid medication to the patient.
Explain the tapering process.
If problems arise, then consider referral to a specialist in addiction medicine.
