Opioid tapering algorithm, a flowchart
This is an accessible text version of the NPS MedicineWise opioid tapering algorithm, 2020
This page explains the flow chart on opioid tapering for patients with chronic non-cancer pain.
Preliminary notes
Considerations for patients at high risk of opioid harm
If a patient is at high risk of opioid harm, more frequent review appointments should be scheduled.
At each appointment:
- assess the risk of harm and emphasize the benefits of tapering opioids
- facilitate psychosocial support for the patient
- check for co-prescription of benzodiazepines and other sedatives that significantly increase the risk of serious harm
- consider rationalizing to a single opioid medicine if applicable
- consider staged supply of the opioid and a prescription for naloxone.
Consider specialist input if the patient is experiencing serious challenges, or if the main problem is opioid dependency rather than pain.
When a patient is taking opioids, there are several clinical situations where tapering could be considered.
- When there has been no meaningful improvement in pain or function despite opioid therapy.
- When opioid-related adverse effects are intolerable.
- When the risk of harm from opioids outweighs the potential benefits.
- When the patient is displaying signs of aberrant opioid-related behaviour.
- When the cause of pain has resolved. (Note that opioids used for acute pain should be weaned and ceased within 90 days).
If a patient presents with one or more of the abovementioned clinical situations, tapering should be considered.
Starting the conversation about tapering
Start by discussing the decision to taper an opioid with the patient.
- Ask each patient about their treatment goals, and their perceived benefits and harms of opioid treatment.
- Ask about the patient’s motivations for tapering, and listen to their beliefs and concerns about tapering.
- Discuss the benefits of tapering.
- Ensure the patient knows that tapering may take several months.
- Reassure the patient and discuss how you can monitor and support them.
Does the patient agree to tapering?
Having discussed the treatment goals, potential benefits and harms of tapering opioids, and the patient’s motivations, beliefs and concerns about tapering, ask the patient if they agree to commencing a tapering plan.
If the patient agrees to tapering
Establish the rate of the taper, considering the patient’s circumstances, goals and preferences.
The taper can be fast or slow.
Fast taper
A fast taper is appropriate for patients who have been on opioids for less than 3 months.
During a fast taper the daily opioid dose is reduced each week by 10 to 25% of the starting dose.
Slow taper
A slow taper is appropriate after a longer period of opioid treatment.
During a slow taper the daily opioid dose is reduced each month by 10 to 25% of the starting dose.
Determine the success of tapering
Once the taper has commenced, review the patient frequently, emphasize the benefits of tapering, and assess the response against the patient’s set goals.
If the tapering is progressing well
A successful taper is recognised by improved function, controlled pain and reduced side effects.
If the tapering is progressing well, taper to the lowest effective dose. This may mean stopping the opioid.
Some patients may not entirely stop using opioids, but any dose reduction is beneficial.
Note that the total tapering duration is difficult to predict, and each tapering schedule will need to be individualized.
If the tapering is challenging
Patients who are tapering opioids may encounter challenges during the taper. These may include increased pain, withdrawal symptoms, or previously unrecognized opioid use disorder.
If challenges are encountered, pause the taper and re-evaluate the patient’s goals, pain, clinical status, coping mechanisms, and tapering rate.
If the patient is experiencing withdrawal symptoms, consider simple supportive therapy or clonidine to manage symptoms.
Consider specialist input if the patient is experiencing serious challenges in tapering.
The algorithm ends here for these patients.
If the patient does not agree to tapering
Revisit the patient’s beliefs and concerns about tapering opioids.
Reinforce the rationale for tapering, including potential benefits of tapering, and potential harm of continuing opioids long term.
Book another appointment to discuss tapering.
At the next appointment revisit the patient’s treatment goals, and their perceptions of the benefits and harms of opioid therapy.
- Ask about the patient’s motivations for tapering, and listen to their beliefs and concerns about tapering.
- Discuss the benefits of tapering.
- Reassure the patient and discuss how you can monitor and support them.
Continue to review these patients periodically, to assess their willingness to consider tapering.
The algorithm ends here for these patients.
What does Choosing Wisely Australia recommend?
The Choosing Wisely Australia recommendation, developed by the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists, states:
Do not continue opioid prescription for chronic non-cancer pain, without ongoing demonstration of functional benefit, periodic attempts at dose reduction, and screening for long term harms.