My path to understanding opioids has been a winding one. As an anesthesiologist, I built my career around these powerful medications. Yet through years of experience, I've also become board-certified in addiction medicine. This dual perspective has shown me both the necessity and dangers of opioids.
It's perplexing. Why would an anesthesiologist turn against the very drugs that enable my profession?
Well, I've seen how opioids can unravel lives when used inappropriately and long-term. Within just days or weeks, people grow dependent, suffering withdrawal without their next dose. Even patients taking them responsibly find opioids lose effectiveness over time - by one month, doses may need an increase to keep up with tolerance.
Meanwhile, the misuse of prescription opioids has exploded into crisis. The risks have become impossible to justify as an automatic treatment for chronic pain. My own view shifted as the human costs became clear. When I meet a new chronic pain patient, I don't immediately aim to just take away their opioids. That would abandon them to suffer in agony. Instead, I ensure the diagnosis is correct. I search for alternative treatments - other ways we might ease their pain. And if opioids remain part of care, my duty is minimizing harm. Can we improve pain control with safer opioids? Lower doses? Less risk of dependence?
Now, as an addiction specialist, I help patients taper off opioids safely under medical supervision. To help my patients and others develop a better understanding for the tapering process, I wrote this guide. This guide examines 9 types of medically-assisted opioid tapering protocols and how to work with your doctor to develop an effective, individualized treatment plan.
Why Taper from Opioids?
There are several reasons why a provider may recommend tapering or detoxing from opioid medications:
To prevent long-term risks such as hormonal changes, hyperalgesia, allodynia, sleep apnea and overdose.
Opioids are no longer providing analgesic benefits or improving quality of life.
Development of an opioid use disorder (OUD).
Achieving life goals related to overall wellbeing and sobriety.
Planning for surgery where opioids will be used.
The patient wants to discontinue opioids.
Patient may wan to stop using long-term opioids after surgery.
Opioid treatment extended beyond the acute pain.
While using opioids can provide short-term pain relief, the benefits often diminish over time due to tolerance. Providers may suggest tapering for patients using high doses of opioids without significant improvements in pain and function because the risks of accidental overdose may increase by several folds.
For patients with OUD, medically-supervised opioid tapering in an addiction treatment program can help achieve sobriety. Sometimes, converting to a medication assisted treatment (MAT) with Suboxone or methadone my be best. However, counseling and support are also critical during and after tapering to prevent relapse.
Key Principles of Opioid Tapering
When developing an opioid tapering protocol, there are some key principles to consider:
Gradual dose reductions are generally better tolerated than rapid tapering. Reducing the opioid dose by 10% or less per week is a common approach and the one I highly disagree with. I will explain later.
The rate of tapering should be individualized based on factors like the opioid dose, duration of use, patient goals and comorbidities.
Communication and collaboration between the patient and provider is crucial throughout the tapering process.
Slowing or pausing the taper may be necessary if withdrawal symptoms become unpleasant or new medical issues arise.
Adjunctive medications can help manage withdrawal symptoms and pain during the taper.
Supportive services like counseling and support groups promote safety and reduce risk of relapse.
An aftercare plan provides ongoing support following the taper to help sustain sobriety.
With careful planning guided by these principles, many patients can successfully taper off of opioid medications.
9 Types of Medically-Supervised Opioid Tapering Protocols
There are several different protocols that can be used to taper opioids under medical supervision. The protocol chosen depends on the patient's opioid tolerance, comorbidities, treatment goals and available resources. Below are 9 common types of opioid tapering approaches:
1. Tapering with the Opioid Already Being Used
With this protocol, the patient tapers using the same opioid they have already been prescribed such as oxycodone or fentanyl. No other opioids are substituted in the taper. This helps avoid errors converting between different opioids.
The provider calculates an individualized tapering dosage schedule typically decreasing the dose by 10-25% every 5-7 days. Adjuvant medications like clonidine may be added to help with withdrawal symptoms. This protocol works well for mild cases with lower opioid doses.
2. Tapering with Alpha-2 Adrenergic Agonists
Alpha-2 agonists like clonidine and lofexidine reduce opioid withdrawal symptoms by targeting adrenoreceptors in the brain. The patient stops taking opioids and instead takes gradually decreasing doses of clonidine or lofexidine over a period of 2-3 weeks.
This expedited protocol works best for patients with relatively low opioid dependence and no major medical comorbidities. Alpha-2 agonists must also then be tapered off slowly.
3. Tapering with Methadone
Due to its long half-life, methadone can be used to gradually taper patients off shorter-acting opioids like oxycodone. After calculating a conversion dose, methadone is slowly reduced over weeks to months. This helps avoid repeated withdrawal symptoms during the taper.
Methadone can only be prescribed for opioid dependence in specially licensed opioid treatment programs. It must be tapered very slowly due to risks of toxicity and severe withdrawal.
4. Tapering with Buprenorphine
A long-acting partial opioid agonist, buprenorphine has a lower risk of respiratory depression and overdose than methadone. It binds tightly to opioid receptors, reducing cravings and withdrawal during the taper.
Patients must be in moderate opioid withdrawal before starting buprenorphine to avoid precipitated withdrawal. Buprenorphine is then gradually reduced over several weeks. This protocol works well for mild to moderate cases of physical dependence.
5. Opioid Tapering with Alpha-2 Agonists
Alpha-2 agonists like clonidine can be safely combined with other opioid tapering protocols to help control withdrawal symptoms. This helps patients remain comfortable even with faster opioid dose reductions.
The alpha-2 agonist is started when withdrawal symptoms emerge during the taper and discontinued gradually after completing the opioid taper. Lofexidine has fewer side effects than clonidine. However, it is considerably more expensive than clonidine.
6. Opioid Tapering with Naltrexone
After completing an opioid taper, some protocols introduce the opioid receptor antagonist naltrexone to support sobriety. Naltrexone blocks the euphoric and reinforcing effects of opioids. This helps reduce cravings and prevent relapse. Naltrexone is started at low doses and increased gradually soon after opioids are fully discontinued to avoid a life-threatening precipitated withdrawal.
In my view, this confuses two distinct phases: the taper itself and preventing relapse after.
Naltrexone has no role during an active opioid taper, when withdrawal remains a risk. It can precipitate agony if opioids still occupy the receptors. Instead, I see naltrexone's purpose only after full detox. When opioids are completely washed away. This may take 2-6 weeks.
So I make this distinction clear to my patients: The winding path of tapering ends when opioids are stopped. Naltrexone is a guide for the new path ahead, walking freely without opioids' grip. We must mark these milestones clearly, to know how far we've come and where yet to go.
7. Tapering with Weaker Opioids Like Tramadol
Some providers utilize tramadol, a weaker opioid, to gradually taper patients off high-dose opioids like oxycodone. The patient is rotated to a tramadol regimen which is then reduced by 25-50% per week.
Compared to clonidine, tramadol controls withdrawal symptoms better but has more opioid activity. Gabapentin may also be used to reduce withdrawal during opioid tapering.
8. Rapid Opioid Detoxification Under Anesthesia
Rapid or ultrarapid opioid detox involves putting the patient under general anesthesia while administering opioid receptor antagonists to precipitate withdrawal. This abruptly eliminates opioids from receptors. The whole process typically lasts less than 24 hours.
While rapid, this approach can lead to severe stress on the body and significant post-procedure pain. It has resulted in deaths in some cases and is not widely recommended.
9. Non-Anesthetic Precipitated Opioid Withdrawal
Similar to rapid detox, precipitated withdrawal can also be achieved while the patient is awake using an opioid antagonist alongside alpha-2 agonists for comfort. This protocol lasts around 1 week as the antagonist dose gradually increases.
Though gentler than rapid detox under anesthesia, precipitated withdrawal still carries risks of severe symptoms like delirium. Very close medical monitoring is required.
Key Considerations in Developing an Opioid Tapering Plan
The most appropriate opioid tapering protocol depends on the patient’s medical history, treatment goals and resources. Here are some key factors prescribers consider:
Opioid tolerance – Patients using higher opioid doses and those with a longer duration of use require slower tapers. The recommendations to decrease opioids by 10% or more weekly has no medical evidence to support its use.
Withdrawal risk – Those at higher risk for severe withdrawal may benefit from more gradual tapering over months and sometimes years.
Pain condition – Patients with severe pain may require very slow tapering and optimization of non-opioid pain management.
Psychiatric conditions – Co-occurring depression, anxiety or trauma will need ongoing treatment during the taper. If these psychiatric conditions aren't optimized, the taper should be stopped or abandoned altogether.
Support system – Patients with more social support and recovery capital can better tolerate faster tapering.
Treatment goals – Those seeking full sobriety may require different protocols than those looking only to reduce their opioid dose.
Treatment setting – Inpatient medically-managed opioid detox may be necessary for complex medical cases. Outpatient tapering works well for stable patients with good social support.
Resources – The protocol must fit with the clinic and community resources available for managing opioid dependence.
The ultimate goal is to create a customized opioid tapering plan suited to the patient's needs and circumstances. Having a compassionate, harm reduction approach helps patients remain committed to their taper.
Medications Used When Tapering Off Opioids
Several types of medications may be used to help manage withdrawal symptoms and pain during opioid tapering:
Alpha-2 agonists like clonidine and lofexidine reduce autonomic withdrawal symptoms such as hypertension, tachycardia, anxiety and sweating.
Anticonvulsants like gabapentin help reduce aches, pains and agitation from opioid withdrawal. They may also help with anxiety.
Antiemetics like ondansetron control nausea and vomiting during withdrawal.
Over-the-counter medications like NSAIDs and acetaminophen are used for muscular aches and pain.
Antidiarrheals like loperamide can help control gastrointestinal withdrawal symptoms.
Anxiolytics like hydroxyzine, buspirone and benzodiazepines may be used very cautiously and short-term to manage anxiety and insomnia during withdrawal.
NMDA Receptor Antagonists like ketamine, memantine, dextromethorphan, and amantadine have a remarkable ability to decrease opioid needs. Thus, allowing patients to tolerate the lower doses of opioids.
Of note, benzodiazepines and ketamine are also addictive and carry overdose risks. Their use should be limited and closely monitored if prescribed during opioid tapering.
Managing Pain During Opioid Tapering
Since opioid doses are reduced during tapering, providers also work to optimize non-opioid pain management strategies:
Medications – Trying NSAIDs, anticonvulsants, topical analgesics, SNRIs or tricyclic antidepressants.
Physical modalities – Using physical therapy, occupational therapy, acupuncture, massage, chiropractic treatment and others.
Behavioral techniques – Coping strategies like cognitive behavioral therapy (CBT), mindfulness, and relaxation training.
Integrative approaches – Looking at lifestyle changes like exercise, nutrition, reducing stress, and more.
Interventional options – Procedures like nerve blocks and neurostimulators may provide relief in specific conditions.
A multidisciplinary approach combining medications, physical rehabilitation, behavioral health and lifestyle changes results in the best pain control during an opioid taper.
Ways to Manage Opioid Withdrawal Symptoms During a Medical Detox
Despite slow opioid tapering, some withdrawal symptoms are still common:
Flu-like symptoms – Muscle aches, runny nose, nausea
Cardiovascular effects – Rapid heart rate, increased blood pressure
Neuropsychiatric effects – Anxiety, irritability, insomnia
Gastrointestinal effects – Abdominal cramping, diarrhea
Ongoing communication with your provider helps determine whether withdrawal symptoms require adjustments to the taper rate or additional medications. Slowing down the taper may provide relief when symptoms are severe.
Here are some specific medications that can provide symptom relief:
Clonidine, lofexidine, tizanidine for hypertension, tachycardia, sweating and anxiety
Antiemetics like ondansetron for nausea and vomiting
Antidiarrheals like loperamide for diarrhea
Anxiolytics like buspirone for anxiety and agitation
Over-the-counter analgesics for muscular aches and pains
Memantine, ketamine, dextromethorphan for anxiety, agitation, insomnia and sweating
Some natural remedies like chamomile tea, ginger and epsom salt baths may also provide comfort during withdrawal. Creating a calm, soothing environment can help manage anxiety and insomnia during this period.
Seeking Support During Opioid Tapering
A strong support system makes an opioid taper much more feasible to complete. Consider sharing your process with close friends and family. Their encouragement can motivate you to persist even through uncomfortable withdrawal symptoms.
Peer support groups related to addiction and recovery can provide understanding from others who have been through similar challenges. Many find 12-step programs like Narcotics Anonymous helpful.
Working with a mental health professional provides strategies to cope with stress, anxiety, depression and any trauma underlying substance use. Having social support and healthy outlets gives you strength through this difficult transition.
I am Here to Help
I lead a team with decades of experience, and a commitment to providing you with comfort, care, and respect as you navigate this challenging time in your life. We also make treatment super convenient with hours of operation that extend from 0800 AM to 0900 PM, 7 days a week through scheduled appointments, accept most insurances, making addiction treatment accessible to practically all who call 918-518-1636. We are conveniently located in Tulsa, Oklahoma and The Woodlands, TX. We are waiting for your call.
Post Acute Withdrawal Syndrome (PAWS)
After tapering off opioids, many experience lingering withdrawal - the Rolling Stones' "Monkey on My Back." Symptoms like depression, anxiety and brain fog haunt weeks or months after abstinence. This is an under-appreciated syndrome of discontinuing opioids. Symptoms may persist for up to 2 years after discontinuing opioids. I will write an article to explain this very important problem.
Sustaining Sobriety After Opioid Tapering
After completing an opioid taper, establishing an aftercare plan is crucial to sustaining sobriety. Withdrawal symptoms and cravings may persist for weeks after stopping opioid use. Ongoing treatment helps prevent relapse during this vulnerable period.
Many choose to continue seeing their prescriber or treatment team. Medications like extended-release naltrexone can help reduce cravings. Continuing counseling provides skills to prevent relapse when cravings arise.
Being part of a recovery community gives you accountability and healthy connections during recovery. Finding new hobbies, routines and social activities helps establish a lifestyle not centered on opioid use.
While challenging, tapering off opioids with medical and social support provides an opportunity for improved wellbeing, health and quality of life. A compassionate, evidence-based approach promotes successful outcomes.
In Summary
Seek medical advice regardless of whether you feel confident you can do this alone.
Work closely with your prescriber to create an individualized supervised opioid tapering schedule based on your needs and goals.
It's important to have a plan to manage chronic pain without opioids before you start tapering.
Very slow dose reductions of 10% a month or less can help minimize difficult withdrawal symptoms.
Certain medications can help manage increased pain, cravings, anxiety, diarrhea, nausea and other withdrawal symptoms during the taper process.
Support groups, counseling, healthy lifestyle changes and non-opioid pain management options help promote comfort and function.
After completing the taper, be sure to have an aftercare plan in place focused on relapse prevention and sustaining sobriety.
With the right psychosocial supports and customized medical protocol, many people can successfully taper off of opioid medications.
Discuss your options thoroughly with your healthcare provider before making any decisions. An evidence-based, patient-centered approach provides the greatest likelihood of safely tapering from opioids. There are many paths to achieving improved wellbeing, functioning and quality of life after prescription opioid dependence.
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
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