Kennebec Region Health Alliance

1. When to Taper 1
   • Patient Request
   • No clinically meaningful improvement in function after 3 months
   • Risk of continued treatment outweighs benefit (comorbid illness such as OSA, severe COPD, concurrent benzodiazepine use, etc)
   • Patient has experienced a severe adverse outcome or overdose event
   • Patient has a substance use disorder
   • Use is not in compliance with PL c488 or chapter 21 prescribing rules
   • Patient exhibits aberrant behaviors
     
     
2. Considerations Prior to Taper 1,2
   1. Explore the patient’s fears and emphasize that the goal of tapering is to make the patient feel better: to reduce pain intensity, to improve mood and function, and to avoid the risks and harms of long-term opioid therapy. Reassure the patient that pain and function will continue to be addressed with alternative treatments as needed and that they will not be abandoned. Support the patient’s work and celebrate his or her success.
   2. Share details of the treatment plan and taper.
   3. Be prepared to provide frequent follow-up visits and supportive counselling.
   4. Seek specialty consultation as needed for complex medical situations such as pregnancy, high-dose opioid therapy, active mental health diagnoses, etc.
      
      
3. Initiating Taper 1,2,3
   1. If patient has concurrent prescriptions for opioids and benzodiazepines and the goal is to taper both, taper opioids first.
   2. Base the rate of taper on safety considerations:
      1. No safety concerns: 10% of total daily dose weekly
         1. Example: if a patient takes 100mg of morphine daily, decrease to 90mg of morphine daily for a week, then 80mg of morphine daily for a week, etc. A tapering plan can also be accessed online through Washington state’s Medicaid program:
            www.hca.wa.gov/medicaid/pharmacy/documents/taperschedule.xls
         2. Prescriptions for varying strengths of the opioid may be needed during the taper process; be aware that co-pays may be affected.
         3. If patient is prescribed multiple opioids: start by tapering short-acting opioids then address long-acting opioids OR convert dose to one long-acting opioid as taper is started
         4. Use scheduled dosing to taper instead of “as needed” dosing
         5. Increase the taper rate as lower levels of opioids are reached (ie, < 15 MME daily) as risks of withdrawal symptoms are reduced and formulations of opioids may not be available in low doses
      2. Concern for Substance Use Disorder or severe adverse event: taper over 2-3 weeks while identifying treatment options in the case of Substance Use Disorder
      3. Diversion: immediate cessation of prescription
4. Considerations during Taper 1,2
   1. Tapers are unidirectional. Adjust the rate or intensity of the taper based on the patient’s response but do not go backwards.
   2. At each visit, ask about pain status, withdrawal symptoms and possible benefits of the taper such as reduced pain, improved mood, energy level and alertness.
   3. Monitor closely for evidence of Opioid Use Disorder or mental health disorders and treat appropriately.
      1. Screen for anxiety, depression, and Opioid Use Disorder at follow up visits. Refer patients with Opioid Use Disorder for treatment and ask for psychiatry input if mental health symptoms do not respond to routine therapies. Avoid benzodiazepines.
      2. There are 11 DSM V criteria for Opioid Use Disorder; however, the most pertinent criteria for patients who have been prescribed opioids as part of a medically supervised treatment plan are4:
         1. Persistent desire or unsuccessful efforts to cut down on opioid use
         2. Craving the opioid
         3. Opioid use resulting in failure to fulfill roles at home, work, school
         4. Persistent opioid use despite recurrent social or interpersonal problems caused by their effects
         5. Giving up or reducing social, interpersonal, or recreational activities due to opioid use
         6. Recurrent opioid use in situations in which it is physically hazardous
         7. Continued opioid use despite the knowledge of having a persistent or recurrent physical or psychological problem caused by or exacerbated by the opioid
   4. Treat opioid withdrawal symptoms as needed 1:
      • Restlessness, sweating, tremors: clonidine 0.1mg to 0.2mg PO every 6 hours as needed; watch for hypotension, dizziness
      • Nausea: antiemetics such as prochlorperazine, promethazine, ondansetron, etc
      • Diarrhea: antidiarrheals such as loperamide
      • Muscle pain/cramping: NSAIDs, muscle relaxants such as cyclobenzaprine or methocarbamol
      • Insomnia: melatonin, sedating antidepressants such as trazodone or amitriptyline. Avoid benzodiazepines or sedative-hypnotics.
5. Once taper is complete:
   1. Continue to assess and treat patient’s pain with the goal of functional improvement
   2. Continue to monitor for emergence of OUD or mental health disorders
   3. Do not restart opioid pain medication once a patient has successfully tapered from the medication 1.

References:
1) Interagency Guideline on Prescribing Opioids for Pain. Agency Medical Directors’ Group. Washington State. 2015.
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

2) Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Appendix B-12 Opioid Tapering. 2016. McMaster University.
http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b12.html

3) http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf

4) http://pcssmat.org/wp-content/uploads/2014/02/5B-DSM-5-Opioid-Use-Disorder-Diagnostic-Criteria.pdf