Guide to Tapering Opioids and Benzodiazepines

• Collaborate with patients to determine the appropriateness of tapering off one or more medications, which agent to taper first, and rate of taper.⁵
• Address patient perceptions and provide education on the risks, benefits, and side effects of tapering.^5,6
• Individualize taper plans based on patient goals and concerns.^3,6
• Taper one agent at a time to improve safety and success of tapering.^4,5
• Consider individual patient factors, preferences, and risks when determining which agent to taper first.
• Coordinate tapering decisions and plans with all prescribers involved in the patient’s care.^5,6
• Assess patients throughout the taper process, especially with each dose change.⁴

Opioids may be tapered using a slow or rapid taper method.⁶ The rate of taper may be determined by treatment history, degree of risk, and individual patient factors.^6,7 Below are taper recommendations from the US Department of Health and Human Services.

Rapid Taper

• Reduce dose by 10% or less each week.⁶
• Consider a rapid taper in patients on opioid therapy for weeks to months.

Slow Taper

• Reduce dose by 10% or less each month.⁶
• Consider a slow taper in patients on opioid therapy for more than a year. This may take several months to years to complete.

General Recommendations

• Increase intervals between dose reductions and/or pause the taper and restart when the patient is ready. This allows the patient time to adjust to the newly reduced dose and allows for the start of non-opioid pharmacologic and non-pharmacologic therapies.⁶
• Extend the dosing interval for motivated patients once the lowest effective dose is reached to slow the taper process further.
• Utilize a taper strategy and timeframe that will minimize opioid withdrawal symptoms.
• Provide additional reinforcement with psychosocial support and cognitive behavioral therapies throughout the taper process.

For additional information regarding opioid tapering strategies, clinical pearls, and opioid taper examples from the Veterans Affairs, please refer to the Drug Information Group FAQ about guidance on tapering long-term opioid analgesics.

Sample Opioid Slow Taper Schedule

Benzodiazepines may be tapered using a slow or rapid taper method.⁷ Abrupt withdrawal is not recommended, as it may lead to life-threatening events. Specific taper strategies may vary, depending on treatment history, degree of risk, and individual patient factors. Below are taper recommendations from the Oregon Pain Guidance.

Rapid Taper

• Premedicate with an anti-epileptic medication (eg, valproate, carbamazepine) for 2 weeks prior to initiating a taper and continue for 4 weeks after completion of the BZD taper.⁷
• Discontinue the current BZD and switch to a long-acting BZD (eg, diazepam).
• Rapid taper may take approximately 3 months.⁸
  

Slow Taper

• Switch from a short-acting BZD to a long-acting BZD (eg, diazepam).⁷
• Calculate the dose equivalence of the short-acting agent to the long-acting agent.
• Consider an initial dose reduction of 25-50% of the calculated equivalent dose.
• Continue dose reductions by 5-10% each week in divided doses, as tolerated.
• Consider further slowing taper down to 5% or less each week after the patient has reached 25-50% of the starting dose.
• Slow taper may take approximately 6 months.⁸

General Recommendations

• Recommend adjunctive psychosocial support and cognitive behavioral therapies while tapering to aid in long-term abstinence from BZD.⁷
• Use additional agents such as trazodone, antidepressants, anxiolytics (eg, buspirone, hydroxyzine), alpha agonists (eg, clonidine), or neuroleptics to help manage rebound anxiety and other withdrawal symptoms.
• Conduct taper slowly to avoid serious or life-threatening withdrawal symptoms such as rebound anxiety, seizures, tremors, disorientation, death.^3,7
• Use liquid formulations towards the end of the taper for more precise dosing, if needed.
• Consider inpatient treatment for taper in patients who are at a higher risk of life-threatening withdrawal symptoms such as those with a history of substance abuse, overdose, or seizure disorder.

Opioid Tapering Flow Sheet from Oregon Pain Guidance
Taper recommendations for opioids and BZDs
https://www.oregonpainguidance.org/app/content/uploads/2016/05/Opioid-and-Benzodiazepine-Tapering-flow-sheets.pdf

The National Center for Posttraumatic Stress Disorder
Prescriber considerations for BZD taper
https://www.va.gov/painmanagement/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf

The Veterans Health Administration
BZD dose conversion chart and sample tapering schedule
https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_%20Risk_Discussion_Guide.pdf

Several risks are associated with the concurrent use of benzodiazepines and opioids. Tapering one or both medications may be necessary to reduce these risks. Set specific goals and follow-up visits before implementing a taper plan. Support patients with pain by offering alternative therapies during an opioid taper (ie, non-pharmacologic and non-opioid medications) for effective pain management during and after the taper. During a BZD taper, consider optimization of first-line agents for any underlying disorder. Use supportive medications to alleviate withdrawal symptoms during the taper process. Effective and successful tapering can improve a patient’s quality of life and often requires collaboration between prescribers and patients.