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Opioid Tapering Flowsheet

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Consider opioid taper for patients with opioid MME > 90 mg/d or Methadone > 30 mg/d, aberrant behaviors, significant behavioral/physical risks, lack of improvement in pain and function.

  1. Frame the conversation around tapering as a safety issue.
  2. Determine rate of taper based on degree of risk.
  3. If multiple drugs are involved, taper one at a time (e.g., start with opioids, follow with BZPs).
  4. Set a date to begin and set a reasonable date for completion. Provide information to the patient and establish behavioral supports prior to instituting the taper. See OPG guidelines.

Opioids
Basic principle: For longer-acting drugs and a more stable patient, use slower taper. For shorter-acting drugs, less stable patient, use faster taper.

  1. Use an MME calculator to help plan your tapering strategy. Methadone MME calculations increase exponentially as the dose increases, so Methadone tapering is generally a slower process.
  2. Long-acting opioid: Decrease total daily dose by 5-10% of initial dose per week.
  3. Short-acting opioids: Decrease total daily dose by 5-15% per week.
  4. See patient frequently during process and stress behavioral supports. Consider UDS, pill counts and PDMP to help determine adherence.
  5. After ¼ to ½ of the dose has been reached, with a cooperative patient, you can slow the process down.
  6. Consider adjuvant medications: antidepressants, Gabapentin, NSAIDs,Clonidine, anti-nausea, anti-diarrhea agents.
MME for Selected Opioids
Opioid Approx. Equianalgesic Dose (oral and transdermal)
Morphine 30mg
Fentanyl/transdermal 12.5mcg/hr
Hydromorphone 7.5mg
Oxycodone 20mg
Tapentodol 75mg
Codeine 200mg
Hydrocodone 30mg
Methadone Chronic 4mg
Oxymorphone 10mg
Tramodol 300mg