Opiate Tapering

Opioid abuse kills 115 people every day in the United States, according to the U.S. Centers for Disease Control and Prevention (CDC). This deadly epidemic of substance abuse began around 1999, and it has worsened every year since then.

Now that illicitly produced fentanyl has entered the supply of opioids in this country, the rate of overdose deaths has skyrocketed. 

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This drug is often sold as mixed into heroin or in place of heroin or other narcotics. It is between 50 to 100 times more potent than morphine and roughly 80 times more potent than heroin. If you do not know that fentanyl is in a drug you take, you are very likely to overdose on it and die.

Abusing opioids is still very dangerous, even if you do not accidentally consume fentanyl. Many people who struggle with opioid addiction want to quit and try to stop taking the drugs without help. Cold-turkey quitting is risky – not because opioid withdrawal symptoms are dangerous, but cravings for the substance and the discomfort of the symptoms are likely to lead to relapse. A relapse increases the risk of overdose.

Getting help to overcome opioid addiction through evidence-based treatment is the best way to end an addiction to opioids. There are several approaches to medically supervised detox for opioid addiction, most of which involve receiving a prescription for a medication like buprenorphine or methadone and then slowly tapering off that drug until the body no longer needs opioids to feel normal.

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What is Tapering, and How Does It Work?

Tapering opioid consumption with a doctor’s supervision is the safest method to quit using them. This is true even if you take an opioid painkiller as prescribed. You may develop a physical dependence on these drugs even if you are not addicted to them. When you’re ready to quit taking an opioid painkiller, your doctor will work with you to taper the use of the medication.

The CDC’s Guidelines for Prescribing Opioids for Chronic Pain state that a doctor and patient should taper the drug when:

  • Patient requests a dose reduction/stop taking it
  • There is no clinically meaningful pain reduction
  • When the patient is on a high dose of opioids
  • Combining the painkiller with benzodiazepines
  • The patient suffers an overdose
  • The patient shows signs of overdose risk
  • The patient shows signs of addiction

The tapering process is very individual. It can depend on age, gender, body weight, how much of the opioid has been consumed, how long the drug has been consumed, and what type of opioid was consumed. The CDC recommends four basic steps to clinicians to help them understand the tapering process.

Decreasing the original dose by 10 percent to start can help a doctor determine how serious their patient’s opioid withdrawal symptoms may be. The patient may need a slower taper, but many patients benefit from speeding up the process. Raising the dose of opioids to manage withdrawal symptoms is inappropriate; however, pausing the taper process while managing withdrawal symptoms can be significant.

Getting addiction specialists and counselors involved in the process is essential, especially for high-risk patients who show signs of addiction or for patients who are pregnant.

Psychosocial support is very important during this time because stress can trigger addictive behaviors. The patient is also likely afraid of being in pain without help. Assure them that they are being observed and treated as an individual; get counselors involved if necessary.

Most people who take opioid painkillers as prescribed do not experience increased pain after they are done with the drug. They also have better functioning in their daily lives because they suffer fewer side effects.

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Medication Maintenance and Tapering for Opioid Detox

The CDC guidelines hint at what the medication-assisted treatment (MAT) process looks like.

However, instead of working with the original opioid medication, an addiction specialist at a detox program may prescribe a long-lasting medication that manages withdrawal symptoms, which can be tapered slowly over time.

If your doctor determines that you need a medication to ease withdrawal symptoms, you may receive either buprenorphine or methadone.

These medications both bind to the opioid receptors in the brain, although buprenorphine is a partial opioid agonist, meaning it does not elicit the same level of intoxication as methadone or opioid drugs. Methadone is a long-lasting full opioid agonist, but for people who have abused large doses of narcotics for a long time, it is a great approach to treating addiction to other substances.

Methadone is a full opioid agonist that binds for at least 24 hours to the brain’s opioid receptors. This means it is useful for people who experience severe withdrawal symptoms, including cravings, because it can stabilize brain chemistry. However, methadone is only available at licensed methadone clinics or inpatient treatment facilities, which will monitor the tapering process. This process can take several weeks, perhaps even months.

There is a general recommended tapering schedule for methadone.

  • Week 1: 30 mg of methadone three times per day
  • Week 2: 20 mg three times per day
  • Week 3: 15 mg three times per day
  • Week 4: 10 mg three times per day
  • Week 5: 10 mg every day in the morning, 5 mg around noon, and 10 mg in the evening
  • Week 6: 5 mg in the morning and at noon, then 10 mg at night
  • Week 7: 5 mg three times a day
  • Week 8: 5 mg in the morning and evening, 2.5 mg at noon
  • Week 9: 2.5 mg in the morning and at noon, 5 mg in the evening
  • Week 10: 2.5 mg three times a day
  • Week 11: 2.5 mg twice per day
  • Week 12: 2.5 mg daily
  • Week 13: discontinue entirely

Some people struggle with opioid abuse for so long that they require a longer taper – sometimes this can last for a year. It is important to note that methadone tapering is no longer the preferred method of opioid detox, so it is not appropriate for most patients.

Like methadone, the specific amount of buprenorphine your physician starts with can vary, depending on how serious withdrawal symptoms are and how large the dose of opioids abused was. The standard recommended taper includes a starting dose and then a daily decrease.

  • A starting point of 4 mg of Suboxone or similar buprenorphine medication is often recommended. If possible, observe the patient for one or two hours, and administer an additional 4 mg of buprenorphine if needed.
  • If the person still suffers withdrawal symptoms after a day or two, raise the dose of buprenorphine by 2 mg; otherwise, keep it stable for the next dose.
  • After hitting 16 mg of Suboxone, or after three days, keep the dose stable.
  • After no more than seven days of steady dosing, begin to decrease the dose by 2 mg at a time – typically daily – until the individual no longer experiences withdrawal or is not taking buprenorphine anymore.

The process of tapering off buprenorphine medications like Suboxone can take several weeks, but it involves less time than methadone tapering. If the individual does not respond well to buprenorphine and continues to experience withdrawal symptoms, they may benefit more from longer-lasting methadone treatment; however, this is rare.

The Importance of Addiction Specialists

A doctor can determine if you need medications like buprenorphine or methadone and how rapidly these can be tapered. Often, mild withdrawal symptoms are managed with over-the-counter drugs or symptom-specific drugs, and many people who have moderate withdrawal symptoms can go without replacement medications. Severe withdrawal symptoms should be managed in a clinical setting, usually a form of inpatient detox, so the person can be monitored three or four times a day for symptom severity.

There is no safe way to detox at home. The risk of relapse is too high, and it will likely lead to an overdose. Get medical help to overcome physical dependence on opioids and then follow the other recommended steps to overcome addiction. Enter a rehabilitation program for behavioral treatment and create an aftercare plan to stay sober.

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SOURCES

(August 30, 2017). Opioid Overdose: Understanding the Epidemic. Centers for Disease Control and Prevention (CDC). Retrieved October 2018 from https://www.cdc.gov/drugoverdose/epidemic/index.html.

(June 2016). What is fentanyl? National Institute on Drug Abuse (NIDA). Retrieved October 2018 from https://www.drugabuse.gov/publications/drugfacts/fentanyl.

(April 20, 2016). Opiate and opioid withdrawal. Medline Plus. Retrieved October 2018 from https://medlineplus.gov/ency/article/000949.htm.

(August 19, 2018). Treating Opioid Use Disorder With Medications. WedMD. Retrieved October 2018 from https://www.webmd.com/mental-health/addiction/breaking-an-addiction-to-painkillers-treatment-overvew#1.

Pocket Guide: Tapering Opioids for Chronic Pain. Guideline for Prescribing Opioids for Chronic Pain. Centers for Disease Control and Prevention (CDC). Retrieved October 2018 from https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf.

(September 28, 2015). Medication and Counseling Treatment. Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved October 2018 from https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat.

(May 2015). A practical guide to tapering opioids. The Mental Health Clinician (MHC). Retrieved October 2018 from http://mhc.cpnp.org/doi/full/10.9740/mhc.2015.05.102?code=cpnp-site.

Dosing Guide: For Optimal Management of Opioid Dependence. The National Alliance of Advocates for Buprenorphine Treatment (NAABT). Retrieved October 2018 from http://www.naabt.org/documents/Suboxone_Dosing_guide.pdf.