Opioid Tapering Template
This tool is to support primary care providers in discussing the value of opioid tapering
with all adult patients currently prescribed an opioid and to support their patients in
reducing opioid dosages in a safe and effective way.
Section A: Important considerations for opioid tapering
• Clinicians should engage patients in shared decision-making, including • For patients starting or continuing an opioid trial, discuss and document
consideration of the patient’s values, goals, concerns and preferences prior to patients’ goals on a regular basis. (SMART goals: Specific, Measurable,
tapering.1,2 Agreed-upon, Realistic, Time-based).
• When possible, an interdisciplinary team approach should be used during • Consider the potential opioid harms and safety concerns.
the tapering process to support complementary non-pharmacological and
pharmacological management.1,2
CAUTION: • Pregnancy - spontaneous abortion and premature labour have been associated with opioid withdrawal during pregnancy.
• When you have concerns about tapers destabilizing mental illnesses, destabilizing or unmasking substance use disorders including opioid use
disorders or medically unstable conditions (e.g. severe hypertension, unstable CAD) consider seeking out additional consultation or supports.
Naloxone
• Naloxone is a medication that can reverse the effects of an opioid • Ontarians with a health card are eligible for a free take-home naloxone
overdose. It is recommended to keep naloxone on hand in case of an kit. You can receive these kits and training on their use from pharmacies,
accidental overdose. This is particularly important for patients on doses of community organizations and provincial correctional facilities.
>50 morphine equivalent dose (MED)/day, those with a history of overdose
or concurrent benzodiazepine use.
For more information on where, how and when to use these kits visit: https://www.ontario.ca/page/get-naloxone-kits-free#section-5
Reasons to consider opioid Opioid use disorder criteria4
tapering, reduction or ☐☐ Opioids are often taken in larger Talking Points
discontinuation amounts or over a longer period than
was intended Provide information about why a taper might be needed:
☐☐Patient requests dosage reduction
☐☐Problematic opioid behaviour ☐☐ Persistent desire or unsuccessful • “Chronic pain is a complex disease and opioids alone
(e.g. diversion, altering the route efforts to cut down or control opioid use cannot adequately address all of your pain-related
of delivery, accessing opioids from needs.”
☐☐ Spending a lot of time obtaining the
other sources) opioid, using the opioid, or recovering • “I think it is time to consider the opioid dose you are on
☐☐Clear evidence of opioid use from its effects and its risk of harm. The risk of overdose and the risk of
disorder (OUD) ☐☐ Craving or a strong desire to use opioids dying from overdose go up as the dose goes up.”
☐☐ Recurrent opioid use resulting in a • “Did you know that most of the evidence showing
Tapering alone is not likely an effective
failure to fulfill major role obligations at benefits from opioid use for chronic non-cancer pain
treatment for OUD. It may require
work, school, or home supports relatively low doses (less than 100 MED)?”1,2
further assessment and possible
consultation to identify the optimal ☐☐ Continued use despite persistent • “In some people, opioids can make their pain worse
therapeutic options. or recurring social or interpersonal rather than better. Hyperalgesia resulting from an opioid
problems caused or made worse by is when the opioid makes one more sensitive to pain
☐☐Adverse effects:
opioid use instead of less.”
☐☐ Experiences overdose or early
☐☐ Stopping or reducing important social, Ensure patients have clear expectations of tapering:
warning signs for overdose risk
(e.g. confusion, sedation, slurred occupational, or recreational activities • “Some patients suffering with pain do better if they
speech) due to opioid use reduce their use of opioids.”
☐☐ Recurrent use of opioids in physically • “Dose reduction or discontinuation of opioids frequently
☐☐ Medical complications (e.g.
hazardous situations improves function, quality of life and pain control. This
sleep apnea, hyperalgesia and
☐☐ Consistent use of opioids despite may take some time, and your pain may briefly get worse
withdrawal mediated pain)
acknowledgment of persistent or at first.”
☐☐ Adverse effects impair recurrent physical or psychological Address discrepancies between the patient’s goals and their
functioning below baseline level difficulties from using opioids current pain management:
☐☐ Patient does not tolerate adverse Tolerance* as defined by: • “I want to make sure your pain management is as safe
effects ☐☐ Need for markedly increased amounts as possible and I want to get you back to your regular
☐☐Opioid dosages >90 MED1 to achieve intoxication or desired effect activities.”
☐☐Opioid dosages >50 MED without ☐☐ Markedly diminished effect with Adjust to any resistance to opioid reduction by reframing the
benefit in improving pain and/or continued use of the same amount conversation:
function Withdrawal* manifesting as either: • “Opioids can have an effect on your central nervous
☐☐Opioid is combined with ☐☐ Characteristic opioid withdrawal system – they may be causing fatigue or lessening your
benzodiazepines3 syndrome (see Section C: Withdrawal ability to do daily activities. It is common to see one’s
☐☐Other: symptoms & management) alertness and function level go down when the opioid
☐☐ Same (or a closely related) substance dose goes up.”
is taken to relieve or avoid withdrawal • “Sounds like your pain has not improved even with
symptoms the high dose you have been trying. It may be time to
• Mild: Presence of 2 to 3 criteria consider a lower dose.”
If pain and function are not improving • Moderate: Presence of 4 to 5 criteria Conversations about tapering require empathy and patient
despite opioid therapy, one should • Severe: Presence of 6 or more self-efficacy and should ideally be a joint decision. They may
consider the potential harms relative criteria need to be revisited periodically depending on the patient’s
to the lack of benefits, reduce opioid
readiness. As this process unfolds, continue to work with
use and focus on other approaches. *These criteria may be met by patients who are
prescribed opioid medications for analgesia without your patients to provide care that is safe.
in itself being indicative of opioid use disorder.
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Section B: How to taper, reduce, or discontinue
For those on a higher dose and/or longer term opioids there is an increased potential for more challenges to tapering, including withdrawal symptoms.
General approach
• Establish the opioid formulation to be used for tapering
• Switching from immediate release to controlled release opioids on a fixed dosing schedule may assist some patients in adhering to the
withdrawal plan1
• Establish the dosing interval
• Scheduled doses are preferred over PRN doses (to help with better pain control and withdrawal)
• Keep the dosing interval constant (e.g. bid)
• Establish the rate of taper based on patient health, preference and other circumstances
Individualize tapering schedule – there is insufficient evidence to recommend for or against specific tapering strategies and schedules1,2
☐☐Slow taper should be followed unless otherwise indicated (e.g. patient preference)
☐☐Rapid taper over 2–3 weeks
CAUTION: Reducing the dose immediately or rapidly over a few days/weeks, may result in severe withdrawal symptoms and is best carried out in a
medically-supervised withdrawal centre.1
Example of a slow tapering regimen
Current opioid: Morphine SR 120mg bid
☐☐ Calculate total opioid dose:
Total Daily Morphine Dose = 240mg/d
☐☐ Calculate daily opioid dose - typically 5–10%
5% = 12mg
10% = 24mg
Reduce the dose every 2 to 4 weeks depending on how the patient is tolerating the taper and their desire to taper.
NOTE: Lowest available Morphine SR formulation is 15mg tablet or Morphine ER 10mg capsule
• Follow up with the patient frequently (e.g. every 1–4 weeks)2
• Adjust the rate, intensity, and duration of the taper according to the patient’s response (e.g. pain, function, withdrawal symptoms)
Tapering may be paused and potentially abandoned in patients who experience distressing or intolerable pain, withdrawal symptoms or a
decrease in function that persists for more than 1 month after a small dose reduction.1
• Treat pain and function with non-opioids (see Management of Chronic Non Cancer Pain tool)
• Treat withdrawal symptoms PRN (see Section C: Withdrawal symptoms & management)
• Taper to the lowest effective dose
How long a taper should take is difficult to predict and needs to be individualized to each patient, for some a very gradual taper is required that can take months and at
times years.
Legend
PRN = when necessary bid = twice a day SR = slow release IR = immediate release
ER = extended release qam = in the morning qhs = at bedtime
Example of slow taper Example of rapid taper
Current opioid: Morphine SR 120mg bid Current opioid: Morphine SR 120mg bid
Decrease Morphine SR by 15 mg
Decrease Morphine SR 120mg bid to 90mg bid x 3 days, then 60mg bid x
Weeks 1 & 2 Morphine SR 105mg qam and 120mg qhs 3 days, then 30mg bid x 3 days, then 15mg bid x 3 days, then 15mg qhs x 3
Weeks 3 & 4 Morphine SR 105mg bid days, then stop
Weeks 5 & 6 Morphine SR 90mg qam and 105mg qhs
Weeks 7 & 8 Morphine SR 90mg bid Other methods used to reduce dose, taper or
Weeks 9 &10 Morphine SR 75mg qam and 90mg qhs discontinue:
Weeks 11 & 12 Morphine SR 75mg bid • Switch current opioid to another opioid and reduce MED by 25%
Weeks 13 & 14 Morphine SR 60mg qam and 75mg qhs to 50% – see Opioid Manager Appendix C - Switching Opioids
Weeks 15 & 16 Morphine SR 60mg bid • Switch to opioid agonist therapy such as buprenorphine-naloxone
Weeks 17 & 18 Morphine SR 45mg qam and 60mg qhs or methadone. If unfamiliar with protocol, clinicians should
Weeks 19 & 20 Morphine SR 45mg bid consult with someone knowledgeable with buprenorphine-
naloxone use.1 Online courses are available for providers to learn
Continue until the lowest effective dose is found for the patient. more about buprenorphine-naloxone use.
• In Canada, all physicians prescribing methadone require a federal
Slow taper tips
exemption for pain or addictions.
Tapering reductions can be lower than 5% if gentler reductions are needed.
For q24h formulation a gentler taper option is to reduce the dose by 10mg
increments every 2 weeks.
For patients with no acute safety concerns (e.g. 5–10% of MED every 2–4
weeks),1 tapers might need to be slowed once low dosages have been reached.
Once the smallest available dose is reached, the interval between doses can be
extended. Opioids may be stopped when taken less frequently than once a day.3
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Section C: Withdrawal symptoms & management
Withdrawal symptoms5,6
Opioid withdrawal can be very uncomfortable and difficult for the patient and can feel like a very Talking Points
bad flu. Opioid withdrawal is not usually life-threatening.
Ensure patients have clear expectations of
Onset and duration of withdrawal symptoms tapering:
“Dose reduction or discontinuation of opioids
Opioids Onset Duration
could lead to withdrawal symptoms. During this
Short-acting ~6–24 hours after last use ~3–10 days time, your pain may get worse for a brief period
Long-acting ~12–72 hours after last use ~10–20 days of time, but your pain will decrease as your
withdrawal symptoms lessen.”
Some symptoms may last for weeks or months (e.g. cravings, insomnia, dysphoria).
Symptoms and management 5,6
Symptoms Management
Muscle pain • Non-opioid medication (e.g. acetaminophen, ibuprofen, NSAIDs)
Slower taper may be required to address these • Refer to Management of Chronic Non Cancer Pain tool and Opioid Manager tool
symptoms
Neuropathic pain • Tricyclic antidepressants (e.g. amitriptyline/nortriptyline)
Slower taper may be required to address these • SNRIs (e.g. duloxetine, venlafaxine)
symptoms • Gabapentinoids (e.g. gabapentin/pregabalin)
• Refer to Management of Chronic Non Cancer Pain tool and Opioid Manager tool
Physical symptoms of withdrawal • If BP >90/50 mmHg, may give clonidine 0.1mg. Check BP & HR 1 hour later. If BP <90/50, HR <50 or
(e.g. sweating, diarrhea, vomiting, abdominal dizziness, do not prescribe further. May titrate up to qid prn, then taper.
cramps, chills, anxiety, insomnia and tremor) • Do not give clonidine if BP < 90/50 mmHg or HR < 50 bpm
Diarrhea • Stop stool softeners and/or laxatives (e.g. sennosides, docusate sodium, lactulose) if applicable
• Loperamide (if necessary) 4mg STAT, then 2mg after each unformed stool up to a maximum of
16mg per day
Insomnia • Cognitive Behaviour Therapy for Insomnia (CBT–I) (see Management of Chronic Insomnia tool)
• Do not prescribe benzodiazepines, zopiclone or zolpidem
• For patients already on benzodiazepine, zopiclone or zolpidem discuss the increased risk of harm
and consider tapering once the patients are tapered off opioids.
Nausea/vomiting • Dimenhydrinate 25–100mg q4h prn
• Prochlorperazine 5–10mg q6h prn
• Haloperidol 0.5–1mg q12h prn
• Metoclopramide 10mg q4–6h prn
Abdominal cramps • Hyoscine butylbromide 20mg tid-qid prn for 2–3 days
Muscle cramps • Quinine sulfate 300mg bid prn
Sweating • Oxybutynin 2.5–5mg bid prn (short-term use)
• Ensure patient is well-hydrated
Overdose prevention • Naloxone kit
Tolerance of previous dose of opioids is lost after
1–2 weeks. Patients may inadvertently take the
original dose to help with withdrawal symptoms or pain
resulting in possible overdose and mortality risk.
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Section D: Tapering plan
Tapering plan
This form is designed to help primary care providers document the tapering plan agreed upon by both the patient and the primary care provider. Ensuring
the patient has been part of the planning process is important for buy-in and adherence to the agreed upon plan. Have the patient repeat the plan back to
you to ensure that they understand it.
When undertaking an opioid taper plan, please keep in mind that although there may be a taper schedule in place there may be a need to deviate from the
plan (e.g. pausing) or adjust the rate, intensity or duration of the taper depending on how the patient is responding with regards to their pain, function,
withdrawal symptoms and other life events.
Baseline details
Patient name: DOB:
SMART goal(s): Reason for taper:
Start date of taper: Proposed end date of taper:
Possible target dose:
Baseline patient
Check for:
☐☐ Brief Pain Inventory (BPI) Scores
☐☐ Pain (BPI scores for 3 domains, 0–10): Domain score 1: Domain score 2: Domain score 3:
☐☐ Function (BPI score, 0–10): Domain score:
☐☐ General Activity (BPI score, 0–10): Domain score:
☐☐ Mental health stability: Consider slowing down or pausing the taper in the presence of a mental health issue.
☐☐ PHQ-9
☐☐ GAD-7
Notes:
☐☐ Withdrawal symptoms discussed with patient.
Taper plan
Date Dose Frequency Total daily dose Planned duration on Notes
dose
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Section E: Follow-up tapering visits (part 1 of 2)
Follow-up tapering visits
This form is designed to help primary care providers document the patient’s tolerance to tapering. If the patient is experiencing a high degree of
withdrawal symptoms, consider adjusting the rate of taper, pausing the taper, treating withdrawal symptoms or monitoring if the patient is tolerating
symptoms and is motivated to continue.
Baseline details
Patient name: DOB:
SMART goal(s): Progress to goal(s):
Follow-up patient assessment
Check for:
☐☐ Brief Pain Inventory (BPI) Scores
☐☐ Pain (BPI scores for 3 domains, 0–10): Domain score 1: Domain score 2: Domain score 3:
☐☐ Function (BPI score, 0–10): Domain score:
☐☐ General Activity (BPI score, 0–10): Domain score:
☐☐ Mental health stability: Consider slowing down or pausing the taper in the presence of a mental health issue.
☐☐ PHQ-9
☐☐GAD-7
☐☐Ask patient if they are taking over-the-counter products (e.g. herbals, acetaminophen, NSAIDs):
Notes:
Management plan
Withdrawal symptoms to consider Management (see Section C: Withdrawal Notes
symptoms & management)
☐☐ Blood pressure: / mmHg
☐☐ Sweating (hot or cold flushes)
☐☐ Restlessness
☐☐ Pupil size
☐☐ Bone, muscle or joint aches
☐☐ Rhinitis or excessive tearing
(not caused by cold symptoms or allergies)
☐☐ Gastrointestinal upset or abdominal cramps
☐☐ Diarrhea
☐☐ Nausea/vomiting
☐☐ Tremor observation of outstretched hands
☐☐ Insomnia
☐☐ Yawning
☐☐ Anxiety or irritability
☐☐ Gooseflesh skin (pilorection)
☐☐ Other symptoms
February 2018 thewellhealth.ca/opioidtaperingtool Page 5 of 7
Section E: Follow-up tapering visits (part 2 of 2)
Pain management plan*
Physical activity Activity: Notes:
Frequency:
Duration:
Self- Therapy: Notes:
management/
psychological
therapy Frequency:
Duration:
Non-opioid Dosing: Notes:
medication
A/E:
Adherence:
Referral ☐☐ Specialist Notes:
☐☐ Multi-disciplinary clinic
☐☐ Intervention procedure
*For a full pain management plan please see Management of Chronic Non-Cancer Pain tool
After you have assessed how well the patient is tolerating tapering, determine if they are ready to continue with the taper as planned at this time or
decide if you will need to deviate from the plan or pause the taper.
If the patient is NOT tolerating the taper please consider:
☐☐ Pause taper
☐☐ Change taper
☐☐ Rate (percentage or frequency):
☐☐ Duration:
☐☐ Other:
☐☐Planned next visit:
If the patient is tolerating the taper, please consider:
☐☐ Current opioid dose:
☐☐ Week of taper:
☐☐ Next planned opioid dose:
☐☐ Planned next visit:
February 2018 thewellhealth.ca/opioidtaperingtool Page 6 of 7
Section F: Supporting material*
[I] Management of Chronic Non Cancer Pain - Appendices
https://thewellhealth.ca/cncp
[II] Opioid Manager
https://thewellhealth.ca/pain
[III] Management of Chronic Insomnia
https://thewellhealth.ca/insomnia
[IV] Naloxone and Opioid Crisis Training Resources
https://uwaterloo.ca/pharmacy/naloxone-and-opioid-crisis-resources
[V] Ontario Naloxone Kit Access & Resources
https://www.ontario.ca/page/get-naloxone-kits-free
[VI] Buprenorphine-Assisted Treatment of Opioid Dependence: An Online Course for Front-Line Clinicians
http://www.camh.ca/en/education/about/AZCourses/Pages/BUP.aspx
[VII] Opioid Tapering- Information for Patients
http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20Information%20(english).pdf
[VIII] Brief Pain Inventory (BPI)
http://nationalpaincentre.mcmaster.ca/documents/brief_pain_ inventory.pdf
[IX] PHQ-9 and GAD-7 Screeners
http://www.phqscreeners.com/select-screener/41
*These supporting materials are hosted by external organizations and as such, the accuracy and accessibility of their links are not guaranteed. The CEP will make
every effort to keep these links up to date.
Section G: Resources
[1] Michael G. DeGroote National Pain Centre, McMaster University. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. 2017; [cited Jan 4,
2018]. Available from: http://nationalpaincentre.mcmaster.ca/opioid/
[2] Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guideline for opioid therapy for chronic pain. 2017 ; [cited Jan 4, 2018]. Available
from: https://www.healthquality.va.gov/guidelines/pain/cot/
[3] Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain. 2016 ; [cited Jan 4, 2018]. Available from: http://www.cdc.
gov/drugoverdose/prescribing/guideline.html
[4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington: American Psychiatric Association; c2013.
[5] Michael G. DeGroote National Pain Centre, McMaster University. Opioid tapering – information for patients. [cited Jan 4, 2018]. Available from:
http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20Information%20(english).pdf
[6] World Health Organization. Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. Geneva: 2009 ; [cited Jan 4 2018].
Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/
This Tool was developed as part of the Knowledge Translation in Primary Care Initiative, led by the Centre for Effective Practice with in collaboration with from the Ontario College of Family Physicians
and the Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the tool was provided by Dr. Arun Radhakrishnan, MSc, MD, CM CCFP and was subject to external review
by health care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.
This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Health care professionals are required to exer-
cise their own clinical judgement in using this Tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government
of Ontario, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through
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Opioid Tapering Template is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material is for all non-commercial and research purposes
is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of
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(Email: [email protected]).
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Please use the below citation when referencing the Tool:
Reprinted with Permission from Centre for Effective Practice. (February 2018). Opioid Tapering Template: Ontario. Toronto: Centre for Effective Practice.
Developed by: In collaboration with:
February 2018 thewellhealth.ca/opioidtaperingtool Page 7 of 7
