How to Stop Opioid Therapy

Discontinuing opioid therapy should be a thoughtful and structured process to ensure patient safety and minimize withdrawal symptoms. The degree of physical dependence and the patient’s overall clinical condition will influence the tapering strategy, or in some cases, the decision not to taper at all.

Degree of Physical Dependence and Tapering Approach

1. Short-Acting Opioids
  • Patients taking 4 pills per day (any strength of short-acting opioids) may be able to stop without the need for a taper. In these cases, a sudden discontinuation may be manageable because short-acting opioids typically have a shorter half-life and result in less severe withdrawal symptoms.
2. Long-Acting Opioids
  • Patients on long-acting opioids (e.g., OxyContin, extended-release morphine) may require a gradual taper due to the prolonged effects and slower drug clearance. Long-acting opioids tend to lead to more significant physical dependence and withdrawal symptoms when stopped abruptly.
3. High-Dose Opioids
  • Patients taking more than 50 mg Morphine Equivalent Daily Dose (MED) may also require a taper. The higher the dose, the more gradual the reduction should be, as higher opioid doses are associated with more severe withdrawal symptoms upon discontinuation. Morphine Equivalent Calculators can help determine the correct equivalent dose of other opioids and facilitate appropriate tapering schedules.

Factors Influencing the Tapering Process

1. Intensity of Withdrawal Symptoms
  • The intensity of withdrawal symptoms increases with:
    • Higher steady-state levels of opioids in the body
    • Long-term opioid exposure
    • Faster medication clearance (i.e., short-acting opioids clear more quickly than long-acting agents)
  • Withdrawal symptoms may include irritability, anxiety, muscle aches, nausea, vomiting, insomnia, and more severe effects such as diarrhea or tachycardia. The tapering process should aim to reduce withdrawal symptoms gradually and safely.

When NOT to Taper

In some cases, tapering opioids may not be appropriate. These situations include:

1. Evidence of Illegal Diversion or Tampering
  • If there is evidence that the patient is involved in illicit drug diversion (e.g., selling or sharing opioids) or tampering with their prescriptions (e.g., forging or altering prescriptions), it is critical to stop opioid therapy immediately. In these cases, a taper is not recommended, and further investigation or referral for substance use treatment may be required.
2. Suspected Addiction Not Willing to Engage in Treatment
  • If the patient exhibits signs of addiction but is unwilling to engage in a structured treatment plan (e.g., addiction counseling, behavioral therapy), opioids should be discontinued. If opioid dependence is suspected, and the patient does not seek help, they may need to be referred to an addiction treatment program. Tapering in such cases would be ineffective without the patient’s willingness to address the underlying addiction.
3. Lack of Evidence of Medication Use
  • If the patient has multiple negative urine drug screens despite being prescribed high-dose or long-acting opioids, it may indicate the patient is not taking the medication as prescribed. In this case, the therapist should evaluate whether the opioids are being used appropriately before deciding to taper or discontinue.
4. Low-Dose Short-Acting Medications
  • Patients on low-dose short-acting opioids (e.g., 1–2 tablets per day) may not require a taper and can typically stop without significant withdrawal symptoms. These patients should be monitored for signs of dependence, but most can safely discontinue their medication without tapering.

Adjunctive Treatments for Opioid Withdrawal

For some patients, adjunctive treatments may help alleviate discomfort during the opioid withdrawal process.

1. Non-Opioid Pharmacotherapy
  • Non-opioid medications can help manage withdrawal symptoms, such as:
    • Clonidine (for autonomic symptoms like sweating, anxiety, and elevated heart rate)
    • Antiemetics (for nausea)
    • Laxatives (for constipation relief)
    • Muscle relaxants (for muscle cramps or aches)
2. Behavioral Treatment
  • Behavioral therapies, such as cognitive-behavioral therapy (CBT), can help manage the psychological aspects of opioid withdrawal and dependence. These therapies help patients cope with cravings, triggers, and the emotional stress associated with discontinuation.
  • Support Groups and Counseling: Referral to support groups (e.g., Narcotics Anonymous) or one-on-one counseling can also provide additional emotional support for patients going through opioid withdrawal.

How to Discuss Stopping Opioid Therapy with the Patient

It is important to approach the conversation about stopping opioid therapy in a compassionate, clear, and non-judgmental manner. Here are some key points to include in the discussion:

  1. Explain the Reasons: Discuss why opioid therapy is being stopped (e.g., ineffective pain control, concerns about misuse, or risks outweighing benefits). Be transparent about the need for discontinuation.
  2. Set Expectations: Clearly outline what the patient can expect during the discontinuation process, including potential withdrawal symptoms and a plan for managing those symptoms.
  3. Offer Support: Emphasize that you will be there to support them throughout the process. This may include referring them for addiction treatment or offering non-opioid pain management options.
  4. Discuss Alternatives: Provide alternatives for managing pain, such as physical therapy, cognitive-behavioral therapy, or non-opioid medications. A multi-disciplinary approach may be necessary to effectively manage their pain.

Additional Resources

  • U.S. Department of Veterans Affairs – Pain Management Opioid Taper Decision Tool
  • Morphine Equivalent Dose Calculator – For opioid dose conversion
  • Guidelines on Opioid Discontinuation – From the CDC and other relevant authorities

Sources:

These guidelines are based on expert consensus and clinical practices regarding opioid tapering and discontinuation:

  • Katz N. Patient Level Opioid Risk Management: A Supplement to the PainEDU.org Manual. Newton, MA: Inflexxion, Inc.; 2007.
  • Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guideline for Practitioners. 1st Edition. North Branch, MN: Sunrise Press; 2007.
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