Opioid Benzos Tapering Flowchart

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TAPERING FLOWCHART START HERE BENZODIAZEPINE TAPER Consider opioid taper for patients with opioid MED > 120/methadone > 40, Basic principle: Expect anxiety, insomnia, aberrant behaviors, significant behavioral/physical risks, lack of improvement in and resistance. Patient education and pain and function. support very important. Risk of seizures with abrupt withdrawal increases with higher Consider benzodiazepine taper for patients with aberrant behaviors, behavioral doses. The slower the taper, the better risk factors, impairment, or concurrent opioid use. tolerated. 1 Explain to the patient the reason for the taper: “I am concerned…” 2 Determine rate of taper based on degree of risk. 1 Slow taper: Calculate total daily dose. Switch from short acting 3 If multiple drugs involved, taper one at a time (e.g., start with benzos, follow agent (alprazolam, lorazepam) to with opioids). longer acting agent (diazepam, clonazepam). Upon initiation of 4 Set a date to begin, provide information to the patient, and set up behavioral taper reduce the calculated dose supports, prior to instituting the taper. See page 26 of OPG guidelines. by 25–50% to adjust for possible metabolic variance. 2 First follow up visit 2–4 days after initiating taper to determine need OPIOID TAPER to adjust initial calculated dose. 3 Reduce the total daily dose by Opioids (not methadone) Methadone 5–10% per week in divided doses. Basic principle: For longer acting Basic principle: Very long half life drugs and a more stable patient, use may necessitate a more protracted 4 After ¼ to ½ of the dose has been slower taper. For shorter acting drugs, tapering process. Otherwise follow reached, with cooperative patient, less stable patient, use faster taper. opioid principles. you can slow the taper. MED for Selected Opioids 5 Consider adjunctive agents to 1 Utilize the drug the patient is taking help with symptoms: trazodone, as the tapering medication. If you Approximate buspirone, hydroxyzine, clonidine, Equianalgesic switch medications, follow MED antidepressants, neuroleptics, and Dose (oral and equivalency chart and then reduce alpha blocking agents. the dose by 25–50% as starting Opioid transdermal) dose. Metabolic variability can be Morphine (reference) 30mg quite significant. Utilize a 90% dose Codeine 200mg reduction if switching to methadone. 1 Rapid taper: See the tapering guidelines Fentanyl transdermal 12.5mcg/hr See dose calculator link below. on page 28 of the OPG guidance Hydrocodone 30mg documents. 2 Decrease total daily starting dose by Hydromorphone 7.5mg 5–15% per week in divided doses. Methadone Chronic: 4mg† Oxycodone 20mg Benzodiazepine Equivalency Chart See patient frequently during Half-life Dose 3 Oxymorphone 10mg process and stress behavioral Drug (hrs) Equivalent supports. Consider UDS, pill counts, Chlordiazepoxide 5–30 h 25mg and PDMP to help determine (Librium) adherence. Link to Morphine Equivalent Diazepam (Valium) 20–50 h 10mg Dosing (MED) Calculator Alprazolam (Xanax) 6–20 h 0.5mg 4 After ¼ to ½ of the dose has been agencymeddirectors.wa.gov/mobile.html reached, with cooperative patient, Clonazepam (Klonopin) 18–39 h 0.5mg you can slow the process down. Lorazepam (Ativan) 10–20 h 1mg Oxazepam (Serax) 3–21 h 15mg 5 Consider adjuvant medications: Triazolam (Halcion) 1.6–5.5 h 0.5mg antidepressants, NSAIDs, clonidine, anti-nausea, anti-diarrhea agents. www.oregonpainguidance.com.

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