Making a taper plan
Having chronic pain and figuring out the right treatment for that pain is a life-long journey.
Figuring out the best way to manage your chronic pain is a journey. And this journey may not be a straight line. There’s not one path that’s right for everyone, and you may try (and retry) different approaches. It’s also possible that you may not always have control over every choice. For example, doctors sometimes need to reduce a patient’s dose or stop prescribing opioids altogether, even if the patient doesn’t want that.
In this module, we walk you through the choices you can make when reducing your opioids (tapering). Our goal is to highlight areas where you can feel empowered to make choices, even if some aspects of the process are out of your control.
Check Your Understanding
Here are a few questions for you to try answering. You won’t be graded on your answers. These are just for you to see what you already know about this topic.
Learn/Refresh
There is no one way to taper. You can make decisions to shape your tapering experience so it reflects your goals, priorities, and preferences.
When to taper
You can usually choose when to start a taper. An exception to this is if your doctor feels your immediate safety is at risk.
Some people schedule tapering around work, travel, or other key life events, such as family gatherings.
Your decision to taper isn’t set in stone — you can change your mind. But remember that your doctor may want to reduce the opioids they prescribe because of growing evidence of how little benefit and how many risks they pose when used for more than a few days. If you think you’d like to try tapering but want to make sure you’ll have the option to reconsider, you can talk with your doctor about a trying out a taper without changing the amount of opioids you are prescribed. If you aren’t sure your doctor will listen to your ideas, see the tips on working with your doctor in Module 6.
When deciding when to taper, keep this in mind: Opioids don't promote healing or even retrain your body to stop feeling pain. So, there’s no natural stopping point where opioids will have gotten rid of your chronic pain. In fact, opioids may be increasing your pain by causing “between dose” withdrawal pain and making your nerves and brain more sensitive to pain.
By taking opioids as usual, you may think you are not making a decision. But, actually, every day you are making a decision to continue taking opioids.
Brian, age 33, sickle cell
“It was basically simple. … I just let [my doctor] know that I was ready to wean off and they gave me a list of instructions on how to wean off. But I felt that it wasn't tailored to what I needed. … I think it was like you go down a half dose or 0.5 every 2 weeks. For me, I thought that was too fast. So, what I did was I weaned off 0.5 just whenever I felt like it. So that may have been 2 months in between, it may have been 3 or 4 months in between, but whenever I felt that my mind and body was ready to go down another dose, I did that. Because the thing is for me, I wanted to plan it around my life, so if I knew I had important events coming up or family gatherings, I didn't want to be weaning off during those times. So, I kind of wanted to wean off during times where my life was kind of calm. So, I did it that way and it turned out to be the perfect way and I got off the medication. It was a really long, hard process, but I did it."
Managing withdrawal symptoms
You may get withdrawal symptoms when tapering off opioids. Withdrawal symptoms are rarely life threatening. But they can be unpleasant.
Withdrawal symptoms are different for everyone. Some of the more common ones are anxiety, restlessness, trouble sleeping, nausea, stomach cramps, vomiting, diarrhea, fever, chills, sweating, muscle spasms, tremor, rapid heartbeat, and high blood pressure.
Initial withdrawal symptoms often last from 4 to 10 days. But they may last weeks to months depending on how long you were taking opioids and your dose. You might get them each time you reduce your dose.
Some withdrawal symptoms can happen later in your taper, when your dose is lower. These later symptoms could include changes in mood and being more sensitive to pain.
Your doctor may prescribe medications to help ease withdrawal symptoms like nausea, anxiety, and muscle spasms.
You can also use self-care techniques — for example, meditation and other relaxation techniques can help with anxiety or trouble sleeping, and drinking plenty of water can replenish fluids lost from vomiting or diarrhea.
Managing your pain without opioids
It is important that your taper plan include other ways to help you manage your pain. As we discussed in Module 5, you have many treatment options, including physical therapy, talk therapy, massage, acupuncture, and other approaches.
It’s a good idea to start (or restart) these treatments before you begin to taper. It can take a while for them to help you feel better.
Research shows that many non-opioid options are effective at reducing pain. Since a symptom of opioid withdrawal can be increased pain, it is important to have plans to manage the pain caused by withdrawal itself. This increased pain should resolve after you have stopped taking opioids.
Many of the people we talked to found that they did best with a combination of different approaches.
Supporting the whole person
Tapering can affect many parts of your life. If you decide to taper, you may want to set up some supports before you start to help ease the process
Work with someone on your health care team. It can be helpful to get good professional advice throughout the process. Your doctor can also prescribe medications and recommend self-care approaches to help with withdrawal symptoms.
Have an emotional support system in place. You may have emotional reactions to tapering. It can be helpful to talk through these with a trusted person. This could be a friend or family member or a counselor or therapist. And it's probably a good idea to think about (and discuss) how any emotional changes may be affecting your relationships.
Have a support system in place for practical matters. For example, if you choose a rapid taper, make sure someone is available to help if you have trouble with withdrawal symptoms and need support with cooking, cleaning or other daily activities.
Find your own motivation. It can be easier to do hard things when you have a plan that leads to a goal that’s important to you.
Practice self-care. Self-care can mean treating pain at home in the ways that work for you, like heat, rest, or stretching. It can also mean making sure to do things you enjoy. For some people, this can mean meditation or prayer. See Module 5 to learn more about self-care options.
Tapering on your own
Some people choose to taper on their own (self-taper) instead of working with their health care team. This means they reduce their own dose rather than having their doctor gradually reduce their prescription.
You may choose to self-taper for many reasons. For example, you may decide you want to be fully in control of your own body and taper experience. Some people also worry that their doctor may not be willing to re-prescribe opioids at their previous dose if they change their mind about tapering.
Withdrawal symptoms can be different for everyone, but it’s important to know what the common ones are and how you will take care of yourself if you have them. If you aren’t working with your doctor to taper, you won’t be able to get prescription medications to help ease withdrawal symptoms.
Be aware of the potential for overdose when tapering. When you reduce the amount of opioids you take, your body may become more sensitive to opioids. This means that a higher dose — even one you used to take safely — may put you at risk for an overdose.
If you are self-tapering, you may end up having unused opioids in your home. This can increase the chance of someone else finding them and taking them unsafely. Consider contacting drug take-back programs or local pharmacies that can help you safely dispose of unused opioids.
Whether you choose to taper with a doctor’s help or on your own, the physical, mental, and social supports described above are still key for having a successful taper.
Speed of taper
Each person we talked to had a different take on the best speed of taper. Below we look at 3 common approaches.
Slow taper
Slow tapers aim to gradually reduce the amount of opioids you are taking.
A slow taper may mean reducing your daily dose by half a pill once a month — or it can be as slow as decreasing your daily dose by half a pill every 3 to 4 months.
Slow tapers often reduce withdrawal symptoms and can allow you to control the speed of your taper as you assess when you are ready to reduce again.
However, some people may still have withdrawal symptoms, such as pain and anxiety. Also your experience of “between dose” withdrawal pain may increase as your body starts to go into withdrawal between each dose.
A slow taper may take months or even years.
Moderate Taper
Like a slow taper, a moderate taper sets clear goals and aims to minimize withdrawal symptoms. But it sets a relatively fast pace for reducing your opioid use.
A moderate taper might mean decreasing your daily dose by half a pill once a week — or once every other week.
A moderate taper has the advantage of minimizing withdrawal symptoms while also allowing you to see rapid progress toward a goal.
This taper will take about 4 to 12 weeks, depending on your starting dose and how quickly you taper.
Fast taper
A fast taper usually refer to stopping opioids completely without any ramp down period, sometimes called “going cold turkey.”
Fast tapers may be a personal choice — or they may be the result of your doctor deciding that your safety is at risk. Fast tapers may also result from losing contact with your doctor — for example, if they retire or move.
Some people choose a fast taper because they are ready to be done with opioids. They want to not think about them after a period of withdrawal.
However, keep in mind that a fast taper may result in difficult withdrawal symptoms, depending on how long you have taken opioids and your dose.
Gloria, age 77, back and neck pain
“[My doctor is] doing her part, but I’m not relying on her to get off these drugs. That was a contract between her and me, to get me off of these drugs. She did her part, I did my part. If she didn’t do her part, I probably still would have done my part by not taking them.”
Linda, age 45, back pain from scoliosis
I wanted to be on an aggressive plan because I’m an all-in or all- out person. We’re either going to do it or not going to do it. So I asked to go on the fastest taper plan they would allow me to do without being hospitalized, and that came up as a three-day taper. So every three days I was going down a certain percentage of however much I was taking… It was like a 4 month plan or something like that. I’m like dude, I can’t do this for 4 months. I get what they’re saying, but I can’t do this for this long. So I probably did one of the worst things ever but it worked for me, I don’t recommend it…I went off everything cold turkey. I honestly for the first time understood what an addict would feel because my body was so addicted that for two weeks I puked, laid on the floor, cried, screamed, yelled. My family was amazing. They'd drop food at the door, check on me, and while I don’t recommend that, it’s what I needed to do. I just couldn’t have done the three-day taper plan for four months. I would have went insane.
Donna, age 77, fibromyalgia, rheumatoid arthritis, osteoarthritis
“I had a clinical pharmacist that helped me. She would call on a pretty regular basis. She praised me and said I was doing a great job. I would also go ahead to the next step, and step down more on my own.”
Carla, age 55, osteoarthritis
“I've had a lot of joint pain. I worked hard, yes, and did physical things that probably broke some of my body, but I also had an emotional issue with regulation. I definitely believe any drug — alcohol, opiates, any kind of pain medication — helps people feel like they're managing their feelings. That is probably the biggest thing I had to go through. As far as withdrawal, I didn't physically withdraw, but mentally, emotionally, and everything. That was a huge piece, learning how to manage feelings.”
George, age 67, migraines
To be honest, I kind of did it myself. Because once I overdosed, I had just a few left and I think I took those but didn’t go back for an additional refill or anything. It was like a month and a half to two months before I was able to see my neurologist again, so during that time I wasn’t supposed to drive or anything, my wife would take me to work. But to be honest with you, I had already quit taking them before I got in to see my neurologist again. In part, I just didn’t want to put my family through that. My grand kids happened to be there that day. It was just – yeah, wouldn’t want that to happen again.
Reflection Exercise:
Patient-centered taper plan
Use this exercise to think through all the different aspects of tapering that might be important to you. What do you need more information about? What are your most pressing questions for your health care team? What support do you need to make the plan a reality?
You can then talk to your health care team about how to get the support you need. If you are self-tapering you can share the plan with a trusted family member or friend so that they can better support you.
Click here to download the worksheet
Consider these possible next steps:
1) Share your taper plan with a close friend or family member to get their thoughts and input
2) Share your taper plan with your doctor or another member of your health care team and ask for helping filling in the plan in places that you might have questions about what help is available from your health care organization
3) Explore how you might fill in any gaps in your taper plan or have questions any outstanding questions answered about the taper process or managing your pain after tapering
4) Revisit any modules in this guide that you think might be helpful
Alana, age 48, rheumatoid arthritis
““I walked in and I was like ‘I’m done, all the pills are gone, I didn’t do any refills, and you were right, this worked, this totally worked.’ What I discovered … is this greater pain didn’t come. The same level of pain I was trying to treat while I was on medicine, whether it was the most ever and I needed to have Narcan in my freaking night drawer in case my husband noticed my breathing stopping ... it didn’t change when I was on half of that, a fourth of that, none of that. The same level I was trying to treat with pain medication is what I deal with as a chronic pain sufferer, from arthritis.””
Resources
Example tapering plan
Lowering Your Opioid Dose (from Australia): https://www.nps.org.au/assets/NPS-MedicineWise-Lowering-your-opioid-dose.pdf