As I start to review patients or residents that may be affected by the de-listing of high dose opioids as discussed in another post, I begin to gather some resources to help with my practice. In addition to the Canadian Guideline for Safe and Effective Use of Opioids for  Chronic Non-Cancer Pain, here are some other useful resources that I have discovered: 

  • Opioid Withdrawal Symptoms. Rxfiles has a nice summary article here which includes a tapering protocol template to use.  I have included their table on withdrawal symptoms here as I find it very useful for assessment:withdrawal-symptoms
  • Examples of Tapering ProtocolA practical guide to tapering opioids by Mental Health Clinician has some useful resources here.  In general, the rule is to taper the opioid daily dose by ~ 10%.  This is usually feasible with morphine and hydromorphone with the availability of various dosage strengths.  However, it is difficult with Fentanyl patch which comes in increment of 25mcg/hr patch (note that 12mcg/hr patch is available but it is not covered by the Provincial drug plan).  Hence, I am particularly delighted to see they have an example to demonstrate how fentanyl patch can be tapered.  I personally like Option B more. See below:

BOX 4: Fentanyl patch taperA patient has been using 100 μg/hour fentanyl patches, changed every 72 hours. He is not certain this has been helping his pain very much, and it is quite expensive. He would like to taper off this regimen.

Option A: Reduce by 50% every 6 days:

  1. 50 μg/hour × 6 days (new patch on third day)

  2. 25 μg/hour × 6 days (new patch on third day)

  3. 12 μg/hour × 6 days (new patch on third day)a

  4. Discontinue

Option B: Reduce by 25 μg/hour (25%) every 15 days

  1. 75 μg/hour every 3 days × 15 days (1 box of 5 patches)

  2. 50 μg/hour every 3 days × 15 days (1 box of 5 patches)

  3. 25 μg/hour every 3 days × 15 days (1 box of 5 patches)

  4. 12 μg/hour every 3 days × 15 days (1 box of 5 patches)a

Consider providing an immediate-release opioid such as morphine sulfate 15 mg every 6 hours as needed for about a week to manage withdrawal symptoms.

  • Managing Symptoms of Opioids Withdrawal. As for a quick guide on managing symptoms of opioid withdrawal, the Rxfiles (as indicated above) also provides a nice section.  Here’s another one from A Practical Guide to Opioid Tapering:

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  • Resources on Naloxone.  The School of Pharmacy at the University of Waterloo has recently released a number of resources on naloxone here. I especially like the video that was developed to provide a step-by-step instruction on how to administer naloxone, written in simple language for everyone to understand.

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Hope you find this post useful in your practice setting! Good luck with all the opioid tapering that will be done in the upcoming months!

 

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