Tapering Guidelines

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This document offers assistance for prescribers in tapering chronic opioid therapy. Reasons for reduction in dose or discontinuation may include resolution of pain, no significant functional improvements, intolerable side effects, medication diversion, or development of an opioid use disorder. Tapering opioids should ideally be a shared decision between patient and provider(s). Whereas voluntary opioid tapers have been associated with improved function, there is no evidence to support involuntary tapers of chronic opioid therapy for patients who are not otherwise diverting their medications. In the absence of an opioid use disorder, opioid misuse, diversion or confirmed non-medical use, social, emotional (e.g., patient fears of abandonment), and health factors must be considered. When the decision is made to taper down or off of opioids, an individualized tapering plan should be used. In general, tapering should occur gradually, though there may be cases in which a rapid taper or no taper is warranted.

This document offers support to providers when initiating an opioid taper in patients in the Oncology or Palliative Care Setting.

The BRAVO protocol, developed by the Oregon Pain Guidance Group, outlines a safe and compassionate strategy to approach opioid tapering, while also maintaining a therapeutic alliance, in patients with moderate to severe chronic pain, and co-occurring mental health disorders (depression, anxiety, PTSD). Expert consensus suggests the taper speed should be tailored to the individual needs of the patient. Some patients who have been on opioids for years to decades, may require years to taper their dose. With this complex chronic pain patient in mind, the BRAVO protocol discusses the following:

B = Broaching the Subject
R = Risk–Benefit Calculator
A = Addiction Happens
V = Velocity Matters (And So Does Validation)
O = Other Strategies for Coping with Pain

This guideline offers recommendations for initiating the discussion to taper/discontinue benzodiazepines, as well as  a guide to achieving complete cessation of benzodiazepines.

This algorithm, developed by the Bruyère Research Institute at the Université de Montréal, was developed from: Pottie K, et al. Evidenced-based clinical practice guideline for deprescribing benzodiazepine receptor agonists. Can Fam Physician 2018;64:339-51.

Equianalgesic Opioid Dosing Table and Conversion Example

This document provides a table of approximate equianalgesic doses (i.e., doses, in an opioid-naïve patient, that will provide a similar analgesic effect) for the most commonly used opioids. It also goes through a step-by-step example of how to do a conversion from one opioid to another, taking into account incomplete cross-tolerance.

Methadone Conversion Guideline

This document provides guidance on converting FROM another opioid TO methadone using an equianalgesic dosing table that takes into account methadone's dose-dependent potency. It also goes through a step-by-step example of how to do a conversion.

Online Opioid Conversion Program - single agent

This external program aides you in converting from one opioid to another (or one route to another) by performing the calculation for you after you enter the present daily opioid dose, the opioid you wish to convert to and the percent of incomplete cross tolerance you wish to use.

Online Opioid Conversion Program - multiple agents

This external program aides you in converting from a few different opioids to a single agent by performing the calculation for you after you enter the present daily opioid doses, the opioid you wish to convert to and the percent of incomplete cross tolerance you wish to use.