How can I safely taper opioid medications in a patient who has developed dependence?

To safely taper opioid medications in a patient who has developed dependence, follow a structured, person-centred approach involving shared decision-making and gradual dose reduction.

• Assess and discuss: Review the benefits and risks of continuing opioids with the patient, acknowledging their preferences and any concerns about dependence. Reassure them that dependence is an expected effect and discuss the rationale and benefits of tapering the medication ².
• Plan the tapering regimen: Determine the starting dose, duration, and tapering schedule based on the severity of dependence, patient stability (including comorbidities and polydrug use), and the pharmacology of the opioid ³.
• Use appropriate medications: Methadone or buprenorphine are first-line options for opioid detoxification and tapering, ideally continuing the same medication if the patient is already on maintenance treatment ³. Lofexidine may be considered in selected cases, but clonidine and dihydrocodeine are not routinely recommended ³.
• Duration and setting: Tapering usually lasts up to 12 weeks in community settings and up to 4 weeks in inpatient settings, with flexibility based on patient response ³.
• Monitor and support: Provide frequent reviews, especially during dose reductions, to identify withdrawal symptoms or re-emergence of underlying conditions. Adjust the tapering pace if distressing withdrawal symptoms occur, possibly delaying dose reductions or reverting to a previous dose ².
• Psychosocial support: Integrate psychosocial interventions such as motivational interviewing, relapse prevention, and peer support to enhance resilience and reduce relapse risk ¹.
• Safety measures: Educate on overdose risks, safe storage of medications, and offer take-home naloxone. Also, ensure immunizations against hepatitis A, B, and tetanus are up to date ¹.