Do not abruptly discontinue chronic opioid therapy, because this can precipitate acute opioid withdrawal.

Taper opioid therapy gradually, especially in patients who experience intolerable withdrawal. Standard recommendations60 to decrease the dosage by 5% to 10% of the starting dosage every one to four weeks may still be too fast for some patients, especially those receiving high doses. Some patients may need to decrease the dosage by 5% or less every two to three months, with even smaller decrements toward the end of the taper. It is not unreasonable to take many months to wean some patients off chronic opioid therapy.

If the patient is unable to taper off short-acting opioids, switch to equianalgesic doses of longer-acting opioids, such as methadone or buprenorphine, and then taper. Beware of problems with morphine milligram equivalent dose conversion (Table 1) and buprenorphine-precipitated withdrawal.

Warn patients about what to expect during each dosage reduction, including a resurgence of pain, which they may mistakenly attribute to an exacerbation of their original injury or condition. Assure them that the pain is withdrawal mediated, time limited, and not usually life threatening. Some patients require intense psychosocial support when tapering off chronic opioid therapy.

Provide nonaddictive medications to lessen symptoms of withdrawal, including antinausea and antidiarrheal agents, muscle relaxants, and alpha-adrenergic receptor agonists (clonidine). Use benzodiazepines sparingly, because they can lead to cross-dependence in some persons. Inform patients that every time they decrease the dose, they will have withdrawal symptoms, including withdrawal-mediated pain.