A taper is a reduction in daily opioid dosage done to improve a patient’s safety profile or quality of life. A successful taper reflects shared decision making and can result in either a lower daily dose, or discontinuation of opioid therapy, dependent on the patient’s goals and risk profile. A taper should only be undertaken when it improves the patient’s risk benefit profile, or when it is requested by the patient.
In order to determine whether a taper is indicated, providers must complete and document a thorough, thoughtful risk benefit analysis (RBA) of continuing opioid therapy at the current dose. A thorough RBA requires a depth of knowledge about the patient’s circumstances, which is why tapers should occur within a strong, therapeutic alliance. This may not be possible in every situation, e.g., a patient presenting to an Emergency Department with a life-threatening opioid related harm. But a thoughtful RBA provides the foundation for decision-making for most outpatient opioid therapy tapers. The general sequence of events that occur when considering a taper are:
Thoughtful risk benefit analysis » Patient engagement through shared decision making » Formulating a patient-centered taper plan based on reassessment of pain and function » Ongoing patient support
Concern about the safety and efficacy of opioid therapy for chronic pain has led to increased numbers of patients being considered for dose reductions. Clinicians should be aware that not every risk benefit analysis will indicate a taper is needed to improve the patient’s risk profile. In addition, for some patients long-term opioid therapy may be a useful component of multidisciplinary care, e.g., some cases of sickle cell disease, hospice, palliative care, and pain management for certain cancers. Non-voluntary tapers raise significant ethical and clinical issues, and are generally not recommended.
At its best, tapering opioids slowly to a most comfortable, most functional and safest dose possible is an opportunity to improve health, to improve patient engagement in one’s health, and to strengthen the patient-provider relationship. It is normal for patients to express apprehension, but over time, patients often experience a sense of empowerment as their opioids are tapered successfully and they become less reliant on the health care system. However, when done poorly, tapering opioids is unsafe, stigmatizing, and may estrange a patient from their providers. Tapering opioids should never increase stigma or be accompanied by negative judgement or impatience on the part of the provider. Tapering opioids well requires time, compassion, empathy, education and support for patients.
This guidance, as well as the US Health and Human Services’ guidance, the Veterans Affairs Taper Decision tool and various state-level recommendations on tapering recommend including behavioral health providers on the treatment team (HHS, 2019; VA Taper Decision Tool, BRAVO guidance). While anyone can develop long-term opioid use for chronic pain, those with anxiety, depression, or a history of trauma or substance use disorders are at higher risk (Halbert, 2016; Edlund, 2010; Sullivan, 2014, Hooten, 2015). Opioids can mask underlying, comorbid mental health condition, and a taper can reveal or exacerbate those conditions. Assessment and treatment of these conditions prior to and during a taper is necessary. The presence of these conditions should not be stigmatized; rather, it is reason to provide additional support and behavioral health care during a taper.
The following recommendations focus on opioid tapers that occur in an outpatient setting, and are guided by the clinician who provides the patient’s pain management.
There are three reasons to taper chronic opioid analgesic therapy: 1) the patient requests a taper and the taper is safe; 2) the patient’s medical risks of continuing opioid therapy at the current dose outweigh the benefits of continued use; and 3) there is a lack of demonstrated benefit at the current dose and the taper is safe. Patient-requested opioid tapers are less common than clinician-led tapers, but the taper approach remains the same.
The discussion addresses the following core components of an opioid taper: 1) risk benefit analysis of continuing opioid therapy at the current dose and of a taper; 2) patient engagement; 3) the taper plan; and 4) patient support during the taper.
The harms associated with long-term opioid therapy require clinicians to actively assess the risks and benefits of continued use. See Section IV. Prescribing opioid therapy for chronic pain. If the risks appear to outweigh the benefits, clinicians should undertake a thorough risk benefit analysis in order to understand if a taper is indicated and if it is safe.
The presence of risk alone is not an indicator for a taper; the risk must also outweigh the benefit of continued use. If the risk outweighs the benefit, the severity and predictable onset of the harm should inform patient engagement strategies and the taper plan. For example, if the risk of harm is low, but there is no benefit to continued use, patient engagement and the taper timing can be very slow. On the other hand, if a patient experiences a life-threatening event, the severity of the risk requires a faster response.
Medical and psychological factors that may predict difficulties with a taper should be addressed as part of the risk benefit assessment. These factors include: certain medical conditions; depressive symptoms; anxiety; high pain scores; past failed taper; and high opioid dose. Patients with depressive symptoms at initiation of an opioid taper are more likely to drop-out of the taper and return to opioid use (Berna, 2015). Therefore, it is important to stabilize mental health to the extent possible or ensure adequate treatment of underlying metal health conditions prior to initiating a taper. Ensure that screening and treatment is offered for the following conditions before engaging with a patient about a taper:
The lifetime prevalence for OUD among patients receiving long-term opioid therapy is estimated to be 41.3%. (Boscarino, 2015) This includes 28.1% for mild symptoms, 9.7% for moderate symptoms, and 3.5% for severe symptoms. Clinicians should evaluate patients for OUD prior to initiating a taper using the DSM-5 criteria, and treat patients with OUD using an evidence-based treatment approach or refer the patient to a provider who offers medications for OUD, such as methadone or buprenorphine. Patients on long-term opioid therapy with untreated OUD who are tapered off opioids are at risk for harm unless referred to treatment.
During the course of an opioid taper, symptoms of OUD may be revealed or exacerbated. Clinicians should remain vigilant for signs and symptoms of OUD during the taper process. If an OUD is present, patients need both treatment of OUD using an evidence-based treatment, and on-going pain management support.
Not all patients on COAT are good candidates for an opioid taper. Circumstances in which a taper may not be appropriate in the near term include:
If a patient is not presently a good candidate for a taper, providers should continue to monitor the patient’s risk profile. Avoid insisting on opioid tapering or discontinuation when opioid use may be warranted (e.g., treatment of cancer pain, patients with a terminal illness, pain at the end of life, or other circumstances in which benefits outweigh risks of opioid therapy) (HHS, 2019a).
Successful taper programs actively engage the patient from the outset by discussing the patient’s risk profile, developing motivation to change, setting goals, developing priorities, and monitoring the taper progress. Depending on the patient’s readiness for change, providers may spend a significant amount of time developing the patient’s motivation to change, addressing barriers to tapering, or planning the taper. Providers should be aware that many patients have prior experience with tapering, which may not have been positive. Patients may equate an opioid taper with judgement, stigma and detoxification period or immediate cessation of therapy. (Henry, 2019)
Consider the timing of taper discussions in relation to other events in the patient’s life, and the primary purpose of the clinic visit. Consider scheduling a separate patient visit or extending the length of an existing appointment to discuss a taper. It may be counter-productive to introduce tapering when a patient is in the clinic for a refill.
Assure patients that the clinical relationship will not be harmed if they are not ready to taper.
Focus on the patient’s safety when initiating conversations about opioid therapy. Below are examples of ways to initiate the conversation:
The first step towards initiating a taper is to discuss with the patient their understanding and perceived risks and benefits of continued opioid therapy. Motivational interviewing strategies may be employed to discuss ongoing opioid therapy in a collaborative manner, and to assess the patient’s readiness for change (Crawley, 2018). Patient voluntariness and shared understanding should be the goal for each patient (but not an absolute requirement depending on the patient’s risk profile) prior to initiating a taper.
See Appendix E. Motivational interviewing techniques
Tapering opioid therapy often elicits fear and anxiety for patients as they consider ongoing pain management, ability to function and potential disruptions to daily life (Henry, 2019). Providers should be aware that fears of addiction and overdose may be less common. It is important that a patient’s concerns and fears are addressed prior to initiating a taper and throughout the taper process. Using a shared-decision making strategy about the taper process may help reduce some of that anxiety. Providers should also consider collaborating with mental health providers and with other specialists as needed to optimize psychosocial support for anxiety related to the taper (Dowell, 2016).
Shared decision making is a process in which clinicians and patients work together to make decisions and select treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values (HealthIT.gov, 2013). Patient involvement in developing the taper plan, when appropriate, is an important part of the patient provider communication and tapering success (Dowell, 2017; Lembke, 2018). The Agency for Healthcare Research and Quality’s SHARE model identifies the five essential steps of shared decision making (The SHARE Approach, 2018).
Remember that tapering often requires substantial effort across multiple domains of a patient’s everyday life. For example, patients may have to time when they take their medication based on daily activities or limit contact with individuals who do not support their taper. Patients’ social relationships can facilitate or impede the taper, yet this is not often discussed with providers. (Henry, 2019) However, incorporating these considerations into the shared-decision making process and ongoing support may reduce barriers or facilitate success.
A common mistake made with tapering opioid therapy is going too fast. A retrospective analysis of Vermont Medicaid data between 2013 and 2017 found that among long-term opioid recipients undergoing a taper, the median length of time to discontinuation was 1 day. Almost half of patient undergoing a taper had an opioid-related hospitalization or emergency room visit after the stopped treatment (Mark, 2019).
Flexible taper plans focused on sustained, gradual reductions, rather than a predetermined reduction rate, are often more successful. The taper approach should incorporate patient preferences, and be individualized based on the patient’s risk profile, goals and concerns. Consider the following when developing a taper plan:
Document the taper plan in the medical record and in patient materials, including prescription instructions. As the taper progresses or if conditions change, providers should update patient records with any changes to the plan. A case-control study in a large urban primary care setting found that taper plans documented in health records and prescription instructions were associated with an increased likelihood of sustained opioid taper (Sullivan, 2020).
Multi-disciplinary teams can help support the patient during the taper process, and may be required depending on the patient’s needs. They can also support increased safety, quality, efficiency and outcomes during a taper, as well as share the responsibility of supporting the patient with the prescribing clinician. Consider involving the following providers in the taper plan and process: primary care providers, mental health providers, pharmacists, physical therapists, addiction specialists.
All patients undergoing a taper are likely to benefit from enhanced mental health care. Mental health should be stabilized prior to starting the taper, but it is critically important that patients with underlying mental health conditions receive enhanced care during the taper. For patients without mental health comorbidities at the outset of the taper, providers should monitor the patient for signs of anxiety, depression, suicidal ideation, and opioid use disorder throughout the taper. The taper may reveal underlying mental health conditions that were previously masked by opioid therapy, or the taper itself may illicit depression and anxiety which needs to be addressed.
Research examining the use of behavioral health care during a taper suggest that integrating therapies before and during a taper can help manage pain and improve the likelihood of tapering success. (Frank, 2017) Access to behavioral health therapy is a challenge, especially in rural areas. When access to in-person behavioral health care is limited, providers should explore alternate options with patients. Evidence-based, low-cost approaches delivered through telehealth and the internet provide an alternative to in-person care. (Darnall, 2014; Kearns, 2018) Research suggests that brief telehealth and digitally delivered treatments allow for broad patient access and yield outcomes similar to in-person psychological interventions for chronic pain. (Heapy, 2017)
Ongoing pain management of the underlying conditions is an important part of the taper plan. Providers should recognize that social and emotional factors are dynamic, and may influence the patient’s pain and perceived need for pain relief on a daily basis. (Henry, 2019) Optimize non-opioid and non-pharmacologic treatment modalities for pain during the taper process. This includes:
See Section C. Non-opioid and non-pharmacologic treatment modalities
Consider sequential tapers for patients concomitantly on COAT and sedative hypnotics. There is a paucity of evidence related to which medication should be tapered first, therefore the approach should be individualized. The 2016 CDC Chronic Pain Prescribing Guidelines suggest tapering the opioid first, given the greater risks of benzodiazepine withdrawal relative to opioid withdrawal and the possibility of increased anxiety related to the opioid taper (CDC, 2016). However, concurrent use of benzodiazepines and opioids multiplies the risk of opioid-related harm. Given that benzodiazepines are risk multipliers, tapering the benzodiazepine first may be appropriate. Patients receiving high daily MME and intermittent benzodiazepines may be able to successfully taper the benzodiazepine first. For patients who receive therapies from two different clinicians, care must be coordinated between the prescribers.
Special consideration must be given to pregnant women on COAT who request a taper, or when a taper is indicated. Maternal opioid use is associated with pregnancy-related maternal and fetal morbidity and mortality. Babies exposed to opioids in utero are likely to develop symptoms of Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). NAS or NOWS are terms used to represent the pattern of clinical findings typically associated with opioid withdrawal in newborns. While the possibility of NAS or NOWS is a significant concern, opioid withdrawal during pregnancy may lead to spontaneous abortion or premature labor (CDC, 2016). Providers managing long-term opioid therapy in pregnant women should consult with relevant experts prior to initiating a taper, including maternal-fetal medicine, and addiction medicine specialists.
