Safe Opioid Tapering and Discontinuation

Introduction to Opioid Tapering

The Centers for Disease Control and Prevention recommends that unless there is a life-threatening issue, the benefits of rapidly tapering or abruptly discontinuing opioids are unlikely to outweigh the substantial risks of these practices, which include mental health crisis, overdose events, withdrawal symptoms, and death 1, 2

Abrupt discontinuation has been directly associated with overdose death, suicide, mental health crisis, emergency department utilization, and patients self-medicating with illicit substances, according to the Centers for Disease Control and Prevention 3, 4, 5, 6
Discontinuation of long-term, high-dosage opioid therapy was associated with increased risk for suicide and paradoxically increased overdose risk in some studies, as reported by the Centers for Disease Control and Prevention 3

For patients on long-term opioids, tapers of 10% per month or slower are likely to be better tolerated than more rapid tapers, as recommended by the Centers for Disease Control and Prevention 3
Each new dose should be 90% of the previous dose, not a straight-line reduction from the starting dose, according to clinical guidelines 7
Longer duration of previous opioid therapy requires a longer taper—tapers can be completed over several months to years depending on opioid dosage, as stated by the Centers for Disease Control and Prevention 3

Maximize nonopioid treatments for pain and address behavioral distress before and during the taper, as recommended by the Centers for Disease Control and Prevention 3
Clinically significant opioid withdrawal symptoms signal the need to further slow the taper rate, according to the Centers for Disease Control and Prevention 3

Withdrawal distress should be preempted and managed with adjuvant medications for specific symptoms such as anxiety and insomnia, as recommended by the Mayo Clinic 4, 5
Pain itself may be a withdrawal symptom and not simply an exacerbation of original chronic pain, as reported by the Mayo Clinic 4, 5

Do not insist on opioid tapering or discontinuation when opioid use might be warranted, as recommended by the Centers for Disease Control and Prevention 1, 2
Tapering is essential only if patients are in serious danger because of medical complications, overdose, or hazardous behaviors, according to the Mayo Clinic 4, 5

Consider switching to buprenorphine, especially if the patient has aberrant behaviors or opioid use disorder, as recommended by the Mayo Clinic 4
Buprenorphine initiation requires discontinuing all opioids the night before, waiting for mild withdrawal, then initiating 2-4 mg repeated at 2-hour intervals until resolution of withdrawal symptoms, according to the Mayo Clinic 4, 5

Advise patients of increased risk for overdose on abrupt return to a previously prescribed higher dose because of loss of opioid tolerance, as recommended by the Centers for Disease Control and Prevention 3
Provide opioid overdose education and offer naloxone, according to the Centers for Disease Control and Prevention 3

Never use "cold referrals" to other clinicians who have not agreed to accept the patient during taper, as stated by clinical guidelines 7
Do not use straight-line tapers that subject patients to increasingly large absolute dose reductions as they approach zero, according to clinical guidelines 7
Do not mandate zero as the target dose for all patients—some may require long-term low-dose maintenance, as recommended by clinical guidelines 7
Do not taper faster than 10% per month for long-term users, as this increases risk of withdrawal and relapse, according to clinical guidelines 7
Before reversing a taper, carefully assess and discuss with the patient the benefits and risks of increasing opioid dosage, as recommended by the Centers for Disease Control and Prevention and clinical guidelines 3, 7

The American College of Physicians recommends that opioid withdrawal symptoms be understood as a predictable physiological pattern, making alternate-day dosing particularly problematic, with withdrawal onset occurring 2-3 half-lives after the last opioid dose 8
The American Medical Association suggests that physical dependence develops with repeated opioid exposure and manifests as withdrawal symptoms upon discontinuation, including piloerection, chills, insomnia, cramps, diarrhea, nausea, vomiting, aches, dysphoria, anxiety, and irritability 9

The Mayo Clinic Proceedings indicate that withdrawal symptoms follow a predictable physiological pattern, with symptoms peaking at approximately 48-72 hours and resolving within 7-14 days with complete discontinuation 8
The Annual Review of Medicine states that the severity of withdrawal symptoms varies with opioid potency and duration of treatment, with stronger withdrawal occurring with more potent, shorter-acting drugs and longer treatment durations 9

The JAMA recommends scheduled, continuous dosing as the appropriate approach for patients requiring long-term opioid therapy, maintaining stable opioid levels and preventing withdrawal cycles 10, 11
The Centers for Disease Control and Prevention suggest that if dose reduction is needed, slow tapers of 10% per month (or slower) are recommended, not intermittent dosing patterns 12, 13

The Mayo Clinic Proceedings note that patients with substance use disorder or mental health conditions face amplified risks, with anxiety symptoms enhancing subjective withdrawal symptoms or anxiety itself being interpreted as withdrawal 8
The Annual Review of Medicine describes a secondary abstinence syndrome including general malaise, fatigue, decreased well-being, poor stress tolerance, and opioid craving in patients with substance use disorder, lasting up to 6 months 9