Pain Medication Taper Regimen Time frame to taper off days

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Cecil Briggs
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1 Pain Medication Taper Regimen Time frame to taper off days Medication to taper Taper Regimen Comments Methadone Taper by no more than 25% Morphine Taper by no more than 25% Tramadol Taper by no more than 25% Hydrocodone/APAP Taper by no more than 25% Oxycodone Taper by no more than 25% Fentanyl Taper by no more than 25% Hydromorphone Taper by no more than 25% Methadone: For long-term users, see taper option below No Real taper needed but is a good adjunct or alternative when tapering Discontinuing long-term use of methadone may require a more gradual taper with a 5-10mg decrease per week until the patient is maintained on 20mg per day. At this point the taper should average 1-2mg reductions per day. For practical reasons, this may have to be done in 2.5mg increments due to product availability (examples in tables below). This part of the taper may require close patient monitoring, since the final 2 to 3 weeks of taper are most frequently associated with relapse. Methadone 14-Day Taper Dose(mg) # of 5mg Days Tablets Methadone 21-Day Taper Dose(mg) # of 5mg Days Tablets

see taper option below No Real taper needed but is a good adjunct or alternative when tapering Discontinuing long-term use of methadone may require a more gradual taper with a 5-10mg decrease per

2 Adjunct Therapy Dosing Regimen Ibuprofen 400mg q 4-6hr prn Mild to moderate pain adult dose Naproxen BID prn Mild to moderate pain adult APAP 325 to 650 mg every 4 to 6 Adult Dosage hours, or 1 g 3 to 4 times a day. Do not exceed 4 g/day Cycobenzaprine 5-10mg tid prn Adult dosage, For short periods of use up to 2-3 weeks Methocarbamol 500 mg tablets: initial: 3 tablets 4 times a day maintenance: 2 tablets 4 times a day. 750 mg tablets: initial: 2 tablets 4 times a day maintenance: 1 tablet every 4 hours, or 2 tablets 3 times a day. Adult dosage A dosage of 6 g/day is recommended for the first 48 to 72 hours of treatment.(for severe conditions 8 g/day may be administered). Thereafter, the dosage can usually be reduced to approximately 4 g/day Clonidine 0.1mg 0.3mg BID Help with opioid withdrawl Methadone/opiate detoxification: 15 to 16 mcg/kg/day If tapering off a medication without switching to another pain medication (ie Methadone to Morphine) then taper by no more than 25%. If switching to another pain med you can be a little more aggressive because pt will not have withdrawal symptoms. Adjunct therapy can also be used, like NSAIDS, muscle relaxers, and clonidine 0.1mg- 0.3mg twice daily to help with opioid withdrawal.

Do not exceed 4 g/day Cycobenzaprine 5-10mg tid prn Adult dosage, For short periods of use up to 2-3 weeks Methocarbamol 500 mg tablets: initial: 3 tablets 4 times a day maintenance: 2 tablets 4

3 Benzodiazepine Discontinuation Taper Recommendations for Outpatient Pharmacy Before a taper schedule can be initiated, several things must be considered Indication Depending on the disease state being treated, different approaches may need to be considered. For example, patients with panic disorder will probably require longer taper schedules (max 10% of the dose weekly). This can become difficult with product availability, but can certainly be accomplished with dose-rounding and creative scheduling. Most other indications may be responsive to a slightly more rapid taper (below) Specific benzodiazepines Alprazolam use may require longer taper schedules due to increased incidence of euphoria and more significant withdrawal symptoms compared to other benzodiazepines. The manufacturer recommends no more than a 0.5mg decrease every 3 days, and longer tapers for patients who don t tolerate this taper. Tapering should be an active process. Even the most gradual tapers should have pointed goals so that discontinuation remains a viable endpoint in the patient s mind. Too gradual of a taper may make the withdrawal symptoms a miserable focus-point in the patient s mind. The target time for discontinuation of the medication should be 8-12 weeks from the start of the taper. The more intense withdrawal symptoms tend to occur in the latter part of the taper schedule. Therefore the second half of the taper should take longer than the first half. Strategies Somewhat aggressive approach: the total dose of drug can be decreased by as much as 50% in the first two weeks, then 10% every week as tolerated. More conservative approach: taper by 10% every one or two weeks until 20% of original dose is reached, then taper by 5% every 2 to 4 weeks. Switching to longer acting benzodiazepines may allow for more rapid tapers and fewer side effects for patients taking high doses or prolonged (>3 months) use. Diazepam has been studied for this strategy. Switch to diazepam (multiply triazolam dose by 20, alprazolam dose by 10, and lorazepam dose by 5 to get the approximate equivalent dose of diazepam) then choose from the following o Decrease dose by 25% the first week, 25% the second week, then 12.5% every 7 days o Start with 50% of diazepam equivalent dose, then reduce by 10 to 20% daily o Decrease diazepam equivalent by 2mg every 1 to 2 weeks until half of initial dose reached, then by 1mg every 1 to 2 weeks.

This can become difficult with product availability, but can certainly be accomplished with dose-rounding and creative scheduling.

4 Counseling Points Keep in mind that studies have shown that both anxiety and depression are often decreased after the taper has been completed for patients on long-term benzodiazepine therapy. Common withdrawal symptoms to be aware of include rebound anxiety, agitation, hallucinations seizures, tremor, sweating, and tachycardia. Since withdrawal symptoms can be fairly severe and have an abrupt onset (including seizures), the patient should not be driving or operating heavy machinery during the taper. Although these symptoms are very uncomfortable and disturbing, withdrawal from benzodiazepines alone is very rarely fatal. Adjunctive Therapy For anxiety and panic disorders, alternatives to benzodiazepines can be employed. SSRIs (1st line therapy for generalized anxiety disorder) should of course be considered if not in use already. Cognitive Behavioral Therapy has also been used successfully. Other options include: Carbamazapine ( mg/day) has been studies as adjunctive therapy to decrease the severity of benzodiazepine withdrawal as well as assist in keeping patients from needing benzodiazepine therapy in the future. Trials are limited, but evidence does support this adjunct therapy. Hydroxyzine has been shown to decrease severity of benzodiazepine withdrawal with a minimum of 50mg as a PRN dose Propranolol may be useful as a replacement for benzodiazepines for situational anxiety, but is not likely helpful for use during benzodiazepine withdrawal Buspirone has been shown definitively to not be helpful during a benzodiazepine taper and withdrawal, and is thus not recommended. It may maintain utility, however, as maintenance therapy for anxiety disorders after the benzodiazepine has been successfully discontinued.

Since withdrawal symptoms can be fairly severe and have an abrupt onset (including seizures), the patient should not be driving or operating heavy machinery during the taper.

5 References 1. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder. 2nd edition. January ideline.pdf. (Accessed January 10, 2012) 2. Benzodiazepine toolkit. Pharmacist s Letter/Prescriber s Letter 2011;27(4): Chang F. Strategies for benzodiazepine withdrawal in seniors. CPJ 2005;138(8): Denis C, Fatseas M, Lavie E, Auriacombe M. Pharmacological interventions for benzodiazepine monodependence management in outpatient settings (Review). Cochrane Database of Systematic Reviews. CD005194;2006(3) 5. Lader M, Tylee A, Donoghue J. Withdrawing Benzodiazepines in Primary Care. CNS Drugs 2009;23(1): Rickels K, DeMartinis N, Rynn M, Mandos L. Pharmacologic Strategies for Discontinuing Benzodiazepine Treatment. J Clin Psychopharmacol 1999;19(6 Suppl 2):12S-16S. 7. Rickels K, Rynn M. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry 2002;63 (Suppl 14):27-33.

Strategies for benzodiazepine withdrawal in seniors. CPJ 2005;138(8):38-40 4. Denis C, Fatseas M, Lavie E, Auriacombe M.

Benzodiazepines: A Model for Central Nervous System (CNS) Depressants

Benzodiazepines: A Model for Central Nervous System (CNS) Depressants Objectives Summarize the basic mechanism by which benzodiazepines work in the brain. Describe two strategies for reducing and/or eliminating