One of the leading causes of the current opioid epidemic in the United States are physicians who prescribe too many pain medications to patients to help manage their post-surgery pain. They also all too often fail to actively help patients taper off of those medications in a systematic, planned way.
Opioids are an important part of many people’s medical treatment. However, opioids are primarily meant as a short-term treatment for intense, severe pain. Having a plan to end opioid treatment is an important component of your treatment plan. Ensure your doctor has talked to you about the tapering schedule that makes sense for your dose and procedure. If your doctor doesn’t have a plan or refuses the need for such a plan, ask to speak to a physician who will work with you on such a plan.
People who have had a history of substance or alcohol abuse should not take opioids, because the risk of dependency is too great. Opioids generally should not be prescribed for longer than 6 months without a clear justification for their continued use. Some guidelines, such as the Minnesota Opioid Prescribing Work Group draft, suggest most patients not receive more than 3 days’ supply of opioids after surgery, and not continue on opioids for more than 45 days.
Your Tapering Schedule for Opioids
Keep in mind that tapering should never be done on your own, but rather in conjunction with your healthcare professional or physician. Your tapering schedule will be dependent upon your pain levels and the dose of the opioids prescribed.
The following tapering protocol for doctors was published by The College of Physicians and Surgeons of Ontario (2012) and offers guidance on tapering opioids. It’s been adopted for this article.
- Sustained release preferred (until low dose reached)
- Scheduled doses rather than taking medication as needed for pain (PRN)
- Keep dosing interval the same for as long as possible (twice or three times/day)
- Do not skip or delay any doses
Rate of taper
- Taper slowly. Rate may vary from 10 percent of the total daily dose EVERY DAY (for inpatient, hospital tapering) to 10 percent of total daily dose EVERY 1-2 WEEKS (for outpatients).
- Let patient choose which dose is decreased
- Taper even more slowly when 1/3 of total dose is reached
- If you run out of your dose early, increase frequency to weekly, alternate day or daily
End point of tapering
- Less than or up to 200 mg of morphine equivalent dose
- This dose should control pain with minimal side effects
- Frequency of visits depends on rate of taper
- If possible, see your doctor prior to each dose decrease
- Your physician should ask not just about withdrawal symptoms and pain, but also the benefits of tapering: more alert, less fatigued, less constipated
What if Tapering is Too Hard?
The Canadian Medical Association recommends a multidisciplinary team approach if tapering opioids is too difficult, causes too much pain, or otherwise becomes problematic (Busse et al., 2017):
For patients […] who are using opioids and experiencing serious challenges in tapering, we recommend a formal multidisciplinary program. In recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist).
Some people’s prescription opioid use can turn into opioid use disorder, a serious complication of prescription opioid use and a major cause of overdose. Buprenorphine/naloxone and methadone treatments have been shown to reduce overdose deaths. If you fear you may be addicted to opioids or find tapering impossible, talk to your doctor about this possibility.
Chronic Pain is Different
Chronic, severe non-cancer pain is different than post-operative pain management. While many people respond to opioid treatment for such problems, some people do not. The Canadian Medical Association recommends considering a trial of opioids versus a full course of treatment to see whether you will respond to opioid treatment or not (Busse et al., 2017):
By a trial of opioids, we mean initiation, titration and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. A reasonable trial of therapy should be accomplished within three to six months; opioids provide less pain relief after three months and some patients may continue use to address inter-dose withdrawal symptoms.
Talk to Your Physician
Your physician is ultimately responsible as your partner in care to help you successfully titrate off of opioids in a responsible and planned manner. Please talk to your physician before beginning or stopping any medical treatment.
Busse, JW et al. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017 May 8;189:E659-66. doi: 10.1503/cmaj.170363
The College of Physicians and Surgeons of Ontario. (2012). When and how to taper opioids. Practice Partner Dialogue, 1.