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Y. Educate on Withdrawal Symptoms; Taper Medications

OBJECTIVE

Prepare the patient to discontinue opioids with a minimum of withdrawal symptoms.

BACKGROUND Discontinuing opioids for patients who elect to stop therapy due to adverse effects or lack of efficacy can easily be done on an outpatient basis with minimal withdrawal symptoms. Pain may temporarily increase during the tapering if withdrawal symptoms occur. Patients who are having opioid therapy discontinued due to non-adherence may need additional support and counseling to understand the reasons regarding the decision to discontinue their opioid therapy.

RECOMMENDATIONS

  1. Complete evaluation of treatment, comorbidity, psychological condition, and other relevant factors should be completed prior to the initiation of the taper.
  2. Clear, written instructions should be given to patients/family to educate them about the slow taper protocol that will minimize abstinence (withdrawal) syndromes.
  3. Patients who are unable to tolerate the taper as described should be considered for referral to or consultation with a pain specialist, substance use specialist or other expert.
  4. Detoxification for addicted patients is not part of this guideline. Refer to the VA/DoD Guideline for the Management of Substance Use Disorders.

Protocol for Tapering:

  • Taper by 20%-50% per week [of original dose] for patients who are not addicted. The goal is to minimize adverse/withdrawal effects.
  • The rapid detoxification literature indicates that a patient needs 20% of the previous day’s dose to prevent withdrawal symptoms.
  • Decisions regarding tapering schedule should be made on an individual basis. Sometimes faster or slower tapering may be warranted.
  • Some experts suggest that the longer the person has been on opioids, the slower the taper should be.
  • Remain engaged with the patient through the tapering process, and provide psychosocial support as needed.

DISCUSSION

Opiate withdrawal can develop within hours of cessation of the drug. While it is not life threatening, it can be quite uncomfortable. Signs and symptoms include gastrointestinal symptoms (such as abdominal cramping, nausea, vomiting and diarrhea), musculoskeletal symptoms (such as myalgias, arthralgias, or muscle spasms), anorexia, yawning, lacrimation, salivation, rhinorrhea, piloerection, insomnia, anxiety, irritability, dysphoria, and manifestations of sympathetic hyperactivity such as diaphoresis, tachycardia, fever, mydriasis, or mildly elevated blood pressures.

According to Mattick & Hall (1996), detoxification is successful to the degree the patient:

  • Is physiologically stable
  • Avoids hazardous medical consequences of withdrawal
  • Experiences minimal discomfort
  • Reports being treated with respect for his or her dignity
  • Completes the detoxification protocol (e.g., no longer requires medication for withdrawal symptom management)
  • Engages in continuing care for SUD

The suggestions below represent a relatively rapid taper. The duration of the taper can always be longer.

  • Methadone:
    • Decrease dose by 20-50%per day until you reach 30 mg/day.
    • Then decrease by 5 mg/day every 3-5 days to 10 mg/day
    • Then decrease by 2.5 mg/day every 3-5 days.
  • Morphine SR/CR:
    • Decrease dose by 20-50%per day until you reach 45 mg/day.
    • Then decrease by 15 mg/day every 2-5 days
  • Oxycodone CR:
    • Decrease dose by 20-50%per day until you reach 30 mg/day.
    • Then decrease by 10 mg/day every 2-5 days
  • IR Opioids similar schedule
  • Clonidine 0.1 mg BID or TID may be used if there are no contraindications to control any withdrawal symptoms.
  • The patient on fentanyl should be rotated to a different opioid, either long-acting morphine or to methadone. Once the patient is converted the same guidelines will apply.
Table 4c. Case Examples
1. Serious Uncontrollable and Intolerable Adverse Effects Action Rapid Taper Slow Taper
Hyperalgesia – complains of gradually increasing pain until everything hurts. Morphine had previously been effective, now no longer effective. Patient has pain all over.
Slow taper over 2-4 weeks.
Decrease dose by 25% every 3-7 days 		Current: Morphine SR 90 mg bid PO
Day 1-3 – 90 mg PO bid.
Day 4-6 – 60 mg PO bid;
Day 7-9 – 30 mg PO bid;
Day 10-13 –15 mg PO bid;
Day 14 - DC morphine.		 Day 1 – Morphine SR 90 mg PO bid.
Day 8- 60 mg PO bid;
Day 15 -30 mg PO bid;
Day 22 - 15 mg PO bid;
Day 29 - DC
2. Serious Adverse effect Action Rapid Taper Slow Taper
50 year old male obese patient on morphine controlled-release 30 mg tid for LBP. Patient noted to stop breathing at night and snore heavily. Opioid discontinued for suspected sleep apnea.
Rapid taper over 7 days. Decrease dose by 30% - 50% every 2-3 days		 Current: 30 mg morphine controlled-release tid
Day 1 - 15 mg tid
Day 2 - 15 mg bid
Day 3 - 15 mg qd
Day 4 - 15 mg qd
Day 5 – 15 mg qd
Day 6 – 15 mg qd

Educate on withdrawal symptomsReferral for sleep evaluation and possible CPAP.Consider restarting opiate after evaluation and CPAP.		 N/A
3. Adverse Effects Action
Patient on high-dose oxycodone CR and experiencing hallucinations with poor pain relief despite reduction to current dose of 320 mg q12h of oxycodone CR. A trial of opioid rotation to methadone will be attempted. The total 24-hour dose of current opioid is oxycodone 640 mg/d.
The oral morphine equianalgesic dose is about 960 to 1280 mg/d.
Because the oral morphine equivalent dose is greater than 500 mg/d, a pain specialist is consulted and inpatient hospitalization considered.
A rapid “stop and go” conversion will be undertaken to avoid confusion in case the patient develops adverse effects. The conversion dose of methadone for an oral morphine equivalent dose of about 1000 mg is 48 to 64 mg/d (5% of oral morphine equivalent dose) given in divided doses q8h.
Methadone 20 mg q8h (60 mg/d) is started and oxycodone CR is discontinued.
The dose of methadone is subsequently titrated to patient’s response.
4. Opioid Unresponsive Action Rapid Taper Slow Taper
49 year old male with chronic bilateral foot pain secondary to chemotherapy induced neuropathy, who has failed a trial of 3 opioids, including methadone, morphine CR and oxycodone CR. Patient is currently taking 120 mg of oxycodone CR BID and would like to taper off the medication. Current: 120 mg of oxycodone CR BID
Week 1: 90 mg bid
Week 2: 70 mg bid
Week 3: 50 mg bid
Week 4: 40 mg bid
Week 5: 30 mg bid
Week 6: 20 mg bid
Week 7: 10 mg bid
Week 8: DC oxycodone CR		 N/A
5. Elective Decision Action    
78 year old female tolerating taking two tab of oxycodone/acetaminophen every 6 hours for past two years due to arthritis. She wants to stop her medication due to financial constraints. Discuss withdrawal symptoms Taper by 25% per week
Wk 1: 2 every 8 hrs
Wk 2: 2 every 12 hrs
Wk 3: 1 every 12 hrs
Wk 4: 1/2 every 12 hrs
Day 28 DC oxycodone/acetaminophen 		Discuss withdrawal symptoms
Taper by 50% per 3 days
Day 1-3 2 every 8 hours
Day 4-7 2 every 12 hrs
Day 8-11 1 every 12 hours
Day 12-14 1/2 every 12 hours
Day 14 DC oxycodone/acetaminophen