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Tapering and discontinuing opioid use


A taper is a reduction in daily opioid dosage done to improve a patient’s safety profile or quality of life. A successful taper reflects shared decision making and can result in either a lower daily dose, or discontinuation of opioid therapy, dependent on the patient’s goals and risk profile. A taper should only be undertaken when it improves the patient’s risk benefit profile, or when it is requested by the patient.

In order to determine whether a taper is indicated, providers must complete and document a thorough, thoughtful risk benefit analysis (RBA) of continuing opioid therapy at the current dose. A thorough RBA requires a depth of knowledge about the patient’s circumstances, which is why tapers should occur within a strong, therapeutic alliance. This may not be possible in every situation, e.g., a patient presenting to an Emergency Department with a life-threatening opioid related harm. But a thoughtful RBA provides the foundation for decision-making for most outpatient opioid therapy tapers. The general sequence of events that occur when considering a taper are:

Thoughtful risk benefit analysis » Patient engagement through shared decision making » Formulating a patient-centered taper plan based on reassessment of pain and function » Ongoing patient support

Concern about the safety and efficacy of opioid therapy for chronic pain has led to increased numbers of patients being considered for dose reductions. Clinicians should be aware that not every risk benefit analysis will indicate a taper is needed to improve the patient’s risk profile. In addition, for some patients long-term opioid therapy may be a useful component of multidisciplinary care, e.g., some cases of sickle cell disease, hospice, palliative care, and pain management for certain cancers.  Non-voluntary tapers raise significant ethical and clinical issues, and are generally not recommended.
At its best, tapering opioids slowly to a most comfortable, most functional and safest dose possible is an opportunity to improve health, to improve patient engagement in one’s health, and to strengthen the patient-provider relationship. It is normal for patients to express apprehension, but over time, patients often experience a sense of empowerment as their opioids are tapered successfully and they become less reliant on the health care system. However, when done poorly, tapering opioids is unsafe, stigmatizing, and may estrange a patient from their providers. Tapering opioids should never increase stigma or be accompanied by negative judgement or impatience on the part of the provider. Tapering opioids well requires time, compassion, empathy, education and support for patients.
This guidance, as well as the US Health and Human Services’ guidance, the Veterans Affairs Taper Decision tool and various state-level recommendations on tapering recommend including behavioral health providers on the treatment team (HHS, 2019; VA Taper Decision Tool, BRAVO guidance).  While anyone can develop long-term opioid use for chronic pain, those with anxiety, depression, or a history of trauma or substance use disorders are at higher risk (Halbert, 2016; Edlund, 2010; Sullivan, 2014, Hooten, 2015). Opioids can mask underlying, comorbid mental health condition, and a taper can reveal or exacerbate those conditions. Assessment and treatment of these conditions prior to and during a taper is necessary. The presence of these conditions should not be stigmatized; rather, it is reason to provide additional support and behavioral health care during a taper.

Clinical Recommendations

The following recommendations focus on opioid tapers that occur in an outpatient setting, and are guided by the clinician who provides the patient’s pain management.

  • Perform and document a thorough risk benefit analysis of initiating an opioid taper when the risk of ongoing opioid therapy at the current dose outweighs the benefit of continued use.
  • Reduce opioid dosage only when it improves the patients risk profile or quality of life, engaging the patient in shared decision making to the extent possible. Providers should not taper a patient for their own convenience or solely to comply with a pharmacy benefit manager, health insurance company, health system or state policy.
  • Use motivational interviewing (MI) techniques to discuss tapering opioids. This may help the patient identify a willingness to change their opioid treatment regimen. Patient voluntariness and understanding should be the goal (but not an absolute requirement) prior to initiating a taper. Engage the patient in shared decision making to establish a patient-centered plan.
  • Evaluate patients for opioid use disorder (OUD) and depression or suicidal thoughts prior to a taper, and throughout the taper process. Treat or refer patients to treatment of OUD or any active mental health crisis if present.
  • Urgently refer patients to an addiction medicine specialist if they are at imminent risk for an overdose, or experience a non-fatal overdose. This must be a warm hand-off from clinician to clinician.

Patients who are willing to attempt a taper 

  • Develop a taper plan using shared-decision making that focuses on making incremental changes informed by reassessment of pain, function and safety, rather than a plan with a predetermined timeline and specific target dose.
  • Consider consulting with a pharmacist to understand available medication formulations to optimize increments of dosage change.
  • Increase the frequency of clinic visits or remote visits during dose reductions. Encourage the patient to contact the clinic if problems arise during dose reductions.
  • Support the patient throughout the taper, and especially during dose reductions. Patient support may include any or all of the following: withdrawal symptom education and management; non-opioid and non-pharmacological pain management; and behavioral health therapy. Patients will likely benefit from enhanced behavioral health treatment during the taper process [assist the patient in locating these resources].
  • Ensure that a patient’s pain remains well-controlled during a taper, a referral for OUD treatment, and in cases of proven diversion. Take extreme caution to ensure dose reductions are not accompanied by increased pain, reductions in activities of daily living, or other adverse effects.
  • Educate patients on the increased risk of overdose when tapering, supply a naloxone prescription, and encourage the patient to ask family and friends to become educated about rescue use. Naloxone training is available in clinic settings, at pharmacies and through online education.

Patients who are not willing to taper

  • Do not abruptly discontinue chronic opioid analgesic therapy, unless there is proven diversion confirmed by a urine drug screen.
  • Clinical conditions that may warrant a dramatic dose reduction (~50%) include acute encephalopathy, acute respiratory failure, or a sudden change in medication clearance resulting in medication build-up. These conditions are likely to be treated in an inpatient setting, where clinicians can closely monitor the patient and the opioid dose taper.
  • Clinicians who determine continuing opioid therapy at the current dose is unsafe and a dose reduction is the appropriate clinical course of action--yet are unable develop the patient’s willingness to attempt a taper after multiple discussions--may consider a very modest dose reduction with extremely close follow-up. The intent of this dose reduction is to develop the patient’s confidence to attempt reducing their dosage, while very gradually moving towards a safer dosage. Encourage the patient to contact the clinic if there are problems, ensure that the patient has a naloxone prescription, and schedule a follow-up visit in the near future.


There are three reasons to taper chronic opioid analgesic therapy: 1) the patient requests a taper and the taper is safe; 2) the patient’s medical risks of continuing opioid therapy at the current dose outweigh the benefits of continued use; and 3) there is a lack of demonstrated benefit at the current dose and the taper is safe. Patient-requested opioid tapers are less common than clinician-led tapers, but the taper approach remains the same.

The discussion addresses the following core components of an opioid taper: 1) risk benefit analysis of continuing opioid therapy at the current dose and of a taper; 2) patient engagement; 3) the taper plan; and 4) patient support during the taper.  

Risk benefit assessment of an opioid taper

The harms associated with long-term opioid therapy require clinicians to actively assess the risks and benefits of continued use. See Section IV. Prescribing opioid therapy for chronic pain. If the risks appear to outweigh the benefits, clinicians should undertake a thorough risk benefit analysis in order to understand if a taper is indicated and if it is safe.

Indicators for a risk benefit assessment

  • Increasing pain in the absence of any degradation of the underlying pathophysiology associated with the pain;
  • Falls at home;
  • Recent pneumonia, worsening chronic obstructive pulmonary disease (COPD) status, worsening obstructive sleep apnea (OSA);
  • Observed or reported somnolence or over sedation;
  • Change in renal or liver function;
  • Episodes of bowel obstruction or significant constipation;
  • Additional new medications (anticholinergics, benzodiazepines) causing interactions with opioids, such as sedation or delirium, in the patient;
  • Accidental, non-fatal overdose;
  • Suicidal intent or action;
  • Urine toxicology indicative of other substance use not prescribed to the patient;
  • Ongoing use despite resolution or healing of a painful condition;
  • The condition being treated is contraindicated for opioid therapy, e.g. migraine or fibromyalgia;
  • Adverse effects of opioid therapy are not tolerated or are unmanageable;
  • Unwillingness to pursue therapies that have a reasonable chance of benefit to the patient; or
  • Development of the belief that it is impossible to manage pain well without opioids.

The presence of risk alone is not an indicator for a taper; the risk must also outweigh the benefit of continued use. If the risk outweighs the benefit, the severity and predictable onset of the harm should inform patient engagement strategies and the taper plan. For example, if the risk of harm is low, but there is no benefit to continued use, patient engagement and the taper timing can be very slow. On the other hand, if a patient experiences a life-threatening event, the severity of the risk requires a faster response.

Evaluation and treatment of comorbidities and barriers to a taper

Medical and psychological factors that may predict difficulties with a taper should be addressed as part of the risk benefit assessment. These factors include: certain medical conditions; depressive symptoms; anxiety; high pain scores; past failed taper; and high opioid dose. Patients with depressive symptoms at initiation of an opioid taper are more likely to drop-out of the taper and return to opioid use (Berna, 2015). Therefore, it is important to stabilize mental health to the extent possible or ensure adequate treatment of underlying metal health conditions prior to initiating a taper. Ensure that screening and treatment is offered for the following conditions before engaging with a patient about a taper:

  • Mental health conditions, including depression and anxiety
  • Opioid Use Disorder and other substance use disorders
  • Medical complications such as lung disease, hepatic disease, renal disease and fall risk
  • Sleep disorders, including sleep apnea

Opioid Use Disorder

The lifetime prevalence for OUD among patients receiving long-term opioid therapy is estimated to be 41.3%. (Boscarino, 2015) This includes 28.1% for mild symptoms, 9.7% for moderate symptoms, and 3.5% for severe symptoms. Clinicians should evaluate patients for OUD prior to initiating a taper using the DSM-5 criteria, and treat patients with OUD using an evidence-based treatment approach or refer the patient to a provider who offers medications for OUD, such as methadone or buprenorphine. Patients on long-term opioid therapy with untreated OUD who are tapered off opioids are at risk for harm unless referred to treatment.

During the course of an opioid taper, symptoms of OUD may be revealed or exacerbated. Clinicians should remain vigilant for signs and symptoms of OUD during the taper process. If an OUD is present, patients need both treatment of OUD using an evidence-based treatment, and on-going pain management support.

Situations when the patient is not currently a good taper candidate

Not all patients on COAT are good candidates for an opioid taper. Circumstances in which a taper may not be appropriate in the near term include:

  • The risks of continued opioid therapy do not outweigh the benefit of continued use;
  • Patients in an active mental health crisis, without suicidal intent or indications for psychiatric hospitalization;
  • Recently inherited patients on long-term opioid therapy prior to developing a strong, therapeutic alliance
  • Patients with cognitive impairments who are on very low daily doses, e.g., patient receives 30 MME/day or less in a controlled environment.

If a patient is not presently a good candidate for a taper, providers should continue to monitor the patient’s risk profile. Avoid insisting on opioid tapering or discontinuation when opioid use may be warranted (e.g., treatment of cancer pain, patients with a terminal illness, pain at the end of life, or other circumstances in which benefits outweigh risks of opioid therapy) (HHS, 2019a).

Patient engagement

Successful taper programs actively engage the patient from the outset by discussing the patient’s risk profile, developing motivation to change, setting goals, developing priorities, and monitoring the taper progress. Depending on the patient’s readiness for change, providers may spend a significant amount of time developing the patient’s motivation to change, addressing barriers to tapering, or planning the taper. Providers should be aware that many patients have prior experience with tapering, which may not have been positive. Patients may equate an opioid taper with judgement, stigma and detoxification period or immediate cessation of therapy. (Henry, 2019)

Planning taper conversations

Consider the timing of taper discussions in relation to other events in the patient’s life, and the primary purpose of the clinic visit. Consider scheduling a separate patient visit or extending the length of an existing appointment to discuss a taper. It may be counter-productive to introduce tapering when a patient is in the clinic for a refill.

Assure patients that the clinical relationship will not be harmed if they are not ready to taper.

Focus on the patient’s safety when initiating conversations about opioid therapy. Below are examples of ways to initiate the conversation:

  • I am concerned about your safety if we continue your opioids at the current dose.
  • I believe the risks of continuing your opioid therapy are now greater than the benefits you receive. Given this medication’s risks, I’m worried about your continued use of these drugs at your current dose. Can I explain in general what a taper is, and then we can identify how we can work on this together?
  • My responsibility is to provide you with the most effective and safest pain control I can. My medical opinion is that your current medicine is no longer the safest or most effective option.

Motivational interviewing (MI) and shared decision making

The first step towards initiating a taper is to discuss with the patient their understanding and perceived risks and benefits of continued opioid therapy. Motivational interviewing strategies may be employed to discuss ongoing opioid therapy in a collaborative manner, and to assess the patient’s readiness for change (Crawley, 2018). Patient voluntariness and shared understanding should be the goal for each patient (but not an absolute requirement depending on the patient’s risk profile) prior to initiating a taper.

See Appendix E. Motivational interviewing techniques

Tapering opioid therapy often elicits fear and anxiety for patients as they consider ongoing pain management, ability to function and potential disruptions to daily life (Henry, 2019). Providers should be aware that fears of addiction and overdose may be less common. It is important that a patient’s concerns and fears are addressed prior to initiating a taper and throughout the taper process. Using a shared-decision making strategy about the taper process may help reduce some of that anxiety. Providers should also consider collaborating with mental health providers and with other specialists as needed to optimize psychosocial support for anxiety related to the taper (Dowell, 2016).

Shared decision making is a process in which clinicians and patients work together to make decisions and select treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values (, 2013). Patient involvement in developing the taper plan, when appropriate, is an important part of the patient provider communication and tapering success (Dowell, 2017; Lembke, 2018). The Agency for Healthcare Research and Quality’s SHARE model identifies the five essential steps of shared decision making (The SHARE Approach, 2018).

  1. Seek your patient’s participation. Inviting patients to participate lets them know that they have options and that their goals and concerns are part of the decision making process.
  2. Help your patient explore and compare treatment options. Patients need to know the available options. Provide balanced information based on the best available scientific evidence. Check back with patients to be sure they understand.
  3. Assess your patient’s values and preferences. Assist patients in evaluating options based on their goals and concerns.
  4. Reach a decision with your patient. Ask the patient if he or she is ready to make a decision, or needs additional information or tools. Patients may also need time to consider the options or discuss them with family members, friends or caregivers.
  5. Evaluate your patient’s decision. Make plans to review the decision in the future, and monitor the extent to which the decision is being implemented. If barriers exist, assist the patient with navigating those issues.

Remember that tapering often requires substantial effort across multiple domains of a patient’s everyday life. For example, patients may have to time when they take their medication based on daily activities or limit contact with individuals who do not support their taper. Patients’ social relationships can facilitate or impede the taper, yet this is not often discussed with providers. (Henry, 2019) However, incorporating these considerations into the shared-decision making process and ongoing support may reduce barriers or facilitate success.

Patient education

  • Patient education about the taper is an important elements of the shared decision making process.
  • Educate patients about different approaches to the taper. Discuss different approaches to reducing dosage and the timing of the taper. Providing options around timing and dosage may reduce fear and anxiety by giving the patient control over elements of the process.
  • Educate patients about expected withdrawal symptoms and pain outcomes prior to initiating the taper and throughout the process. 
  • Discuss with patients that their physical pain may get worse each time the dose is decreased, but that with time the body will adjust to the new lower dose (4 weeks), the pain level will return to baseline. The increased pain patients experience after dosage decrease does not indicate progression of their underlying pain condition. Rather, the pain represents time-limited, opioid withdrawal-mediated pain (Lembke, 2020).
  • Discuss the differences between opioid dependence and addiction. Discuss the fact that tapers sometimes reveal an OUD. If an OUD is detected, assure the patient that it is a common side effect of long term opioid use and not something to be ashamed of. Reassure the patient that the OUD will be treated in addition to treating pain, and that you will support them through the process.
  • While acknowledging initial skepticism and fear are common, describe to your patient what people are like after a successful taper:
    • They have successfully learned to self-manage pain
    • They have “taken back control of their pain”
    • They no longer struggle with shame and stigma, rather they are empowered
    • They commonly report the same or less pain, improved functioning and less depression.
  • Continue to revisit the goals and process of an opioid taper. Clinicians should provide continued reassurance that they will support the patient through the taper process.

Reduce the risk of an overdose during a taper

  • Provide opioid overdose education, and prescribe naloxone to patients when initiating a taper.
  • Strongly caution patients that it takes as little as a week to lose their tolerance and that they are at risk of an overdose if they resume their original dose.
  • Educate the patient that pharmaceuticals obtained from friends or acquaintances are frequently adulterated with highly potent and lethal doses of fentanyl even if these pills look exactly like the medication they normally took. “Counterfeit” pharmaceuticals have led to many deaths during dosage reductions.

Taper plan

A common mistake made with tapering opioid therapy is going too fast. A retrospective analysis of Vermont Medicaid data between 2013 and 2017 found that among long-term opioid recipients undergoing a taper, the median length of time to discontinuation was 1 day. Almost half of patient undergoing a taper had an opioid-related hospitalization or emergency room visit after the stopped treatment (Mark, 2019).

Flexible taper plans focused on sustained, gradual reductions, rather than a predetermined reduction rate, are often more successful. The taper approach should incorporate patient preferences, and be individualized based on the patient’s risk profile, goals and concerns. Consider the following when developing a taper plan:

  • A successful initial decrease is important. The success of the initial dose reduction is more important than achieving a specific dose decrease.
  • The dose and the interval between doses are two different variables in a taper. One or both may be adjusted at each dose decrease, depending on patient preference and the opioid dosing availability.
  • Go slowly. Patients may tolerate larger dose reductions in the beginning of the taper and then require smaller dose reductions as daily MME is decreased.
    • A slower taper is a 5-10% dose reduction per month. This rate serves as a starting point, but patients may require a dose reduction rate of less than 5% a month of a 5-10% dose reduction over the course of 2-3 months. Slower tapers are often better tolerated than more rapid tapers, especially following opioid use of more than a year. Slower tapers may take several months to years to complete.
    • A faster taper involves a decrease of 10% of the original dose per week or longer. Faster tapers are not preferred, but may be needed for patient safety when the risks of continuing opioid therapy outweigh the risks of a rapid taper or when patients have been on COAT for a short period of time.
  • Sudden large dosage decreases may be necessary if the patient experiences encephalopathy, has a change in renal or pulmonary status or has a new medication that interacts with opioids. When continuing the current opioid dose poses an imminent medical risk, but discontinuation of the opioid is not appropriate (such as a patient with cancer or sickle cell disease who develops renal failure) a dose decrease of 30-50% followed by close monitoring may be appropriate.
  • Changing the formulation of a given opioid (e.g., long-acting to short-acting formulations or strengths of the same formulation) may facilitate the dose reduction process, but confuse the patient. Do not change or “rotate” types of opioids prior to the taper unless you have expertise in doing so. Provide clear communication to the patient on any changes in the medication formulation.
  • Maintain the same dosing schedule when possible, especially at the beginning the taper. Patients may be accustomed to taking pain medication at a certain time each day, or before certain activities. Discuss whether the proposed schedule aligns with the patient’s daily roles and responsibilities.
  • Provide patients with the option to pause the taper and restart again when ready. Pauses give patient time to acquire new skills for management of pain and emotional distress, introduction of other medications, or initiation of other treatments, while allowing for physical adjustment to a new dosage (VA, 2019; VA 2017). This may reduce the risk of a failed taper.
  • Tapers should be considered successful as long as the patient is making gentle progress at reducing opioid dosage.
  • Discuss living arrangements, daily responsibilities, and social support networks with the patient. Incorporate strategies to help the patient fulfill their daily roles and responsibilities during the taper.  

Document the taper plan in the medical record and in patient materials, including prescription instructions. As the taper progresses or if conditions change, providers should update patient records with any changes to the plan. A case-control study in a large urban primary care setting found that taper plans documented in health records and prescription instructions were associated with an increased likelihood of sustained opioid taper (Sullivan, 2020).

Patient support during a taper

Patient support

  • All patients undergoing a taper are likely to benefit from increased support during the process. Ask patients how you and the clinic can support them during the taper process.
  • Effort must be made to ensure the patient can self-report problems with the taper and other issues without fear of judgment, and providers must be willing to halt or discontinue the taper depending on the patient’s circumstances.
  • Continually provide patients reassurance and convey your confidence in their ability to achieve their goals. Make yourself or a team member available to the patient to provide support, if needed (VA Opioid Decision Taper Tool, 2019).
  • Reassess the patient’s medical and psychological conditions—including their support network and living conditions—throughout the taper. In general, frequency of reassessment and evaluation should be determined by the patient’s risk level.
  • Follow up frequently. Successful tapering studies have used at least weekly follow up (Frank, 2017).

Multi-disciplinary teams can help support the patient during the taper process, and may be required depending on the patient’s needs. They can also support increased safety, quality, efficiency and outcomes during a taper, as well as share the responsibility of supporting the patient with the prescribing clinician. Consider involving the following providers in the taper plan and process: primary care providers, mental health providers, pharmacists, physical therapists, addiction specialists.

Behavioral health therapy

All patients undergoing a taper are likely to benefit from enhanced mental health care. Mental health should be stabilized prior to starting the taper, but it is critically important that patients with underlying mental health conditions receive enhanced care during the taper. For patients without mental health comorbidities at the outset of the taper, providers should monitor the patient for signs of anxiety, depression, suicidal ideation, and opioid use disorder throughout the taper. The taper may reveal underlying mental health conditions that were previously masked by opioid therapy, or the taper itself may illicit depression and anxiety which needs to be addressed.

Research examining the use of behavioral health care during a taper suggest that integrating therapies before and during a taper can help manage pain and improve the likelihood of tapering success. (Frank, 2017) Access to behavioral health therapy is a challenge, especially in rural areas. When access to in-person behavioral health care is limited, providers should explore alternate options with patients. Evidence-based, low-cost approaches delivered through telehealth and the internet provide an alternative to in-person care. (Darnall, 2014; Kearns, 2018) Research suggests that brief telehealth and digitally delivered treatments allow for broad patient access and yield outcomes similar to in-person psychological interventions for chronic pain. (Heapy, 2017)

Pain management during a taper

Ongoing pain management of the underlying conditions is an important part of the taper plan. Providers should recognize that social and emotional factors are dynamic, and may influence the patient’s pain and perceived need for pain relief on a daily basis. (Henry, 2019) Optimize non-opioid and non-pharmacologic treatment modalities for pain during the taper process. This includes:

  • Pain education
  • Good sleep hygiene
  • Physical activities, as tolerated
  • Good nutrition
  • Non-opioid pain medications
  • Behavioral health therapy. Most patients will benefit from CBT during the opioid taper.

See Section C. Non-opioid and non-pharmacologic treatment modalities

Address symptoms of opioid withdrawal

  • If tapering is done gradually, withdrawal symptoms should be minimized and manageable.
  • Expectation management is an important aspect of counseling patients through withdrawal.
  • Consider assessing the patient’s withdrawal symptoms with a brief, validated screening such as the patient self-rated Subjective Opiate Withdrawal Scale or the practitioner assessment Clinical Opiate Withdrawal Scale (Handelsman, 1987; Wesson, 2003).
  • Significant opioid withdrawal symptoms may indicate a need to pause or slow the taper rate, or discontinue the taper if benefits of the taper no longer outweigh the risks to the patient.
  • Onset of withdrawal symptoms depends on the duration of action of the opioid medication used by the patient. Symptoms can begin as early as a few hours after the last medication dose or as long as a few days, depending on the duration of action (Berna, 2015).
  • Early withdrawal symptoms (e.g., anxiety, restlessness, sweating, yawning, muscle aches, diarrhea and cramping) usually resolve after 5-10 days but can take longer (VA Opioid Decision Taper Tool, 2019).
  • Some symptoms (e.g., dysphoria, insomnia, irritability) can take weeks to months to resolve (VA Opioid Decision Taper Tool, 2019).
  • Consider using non-addictive medications to help mitigate withdrawal symptoms. If the taper is slow enough, withdrawal symptoms should be minimal and tolerated.
    • Short-term oral medications can help manage withdrawal symptoms, especially when prescribing faster tapers (VA Opioid Decision Taper Tool, 2019). These include alpha-2 agonists for the management of autonomic signs and symptoms (sweating, tachycardia), and symptomatic medications for muscle aches, insomnia, nausea, abdominal cramping, or diarrhea

Concomitant opioids and benzodiazepines

Consider sequential tapers for patients concomitantly on COAT and sedative hypnotics. There is a paucity of evidence related to which medication should be tapered first, therefore the approach should be individualized. The 2016 CDC Chronic Pain Prescribing Guidelines suggest tapering the opioid first, given the greater risks of benzodiazepine withdrawal relative to opioid withdrawal and the possibility of increased anxiety related to the opioid taper (CDC, 2016). However, concurrent use of benzodiazepines and opioids multiplies the risk of opioid-related harm. Given that benzodiazepines are risk multipliers, tapering the benzodiazepine first may be appropriate. Patients receiving high daily MME and intermittent benzodiazepines may be able to successfully taper the benzodiazepine first. For patients who receive therapies from two different clinicians, care must be coordinated between the prescribers.

Special populations: Pregnant women

Special consideration must be given to pregnant women on COAT who request a taper, or when a taper is indicated. Maternal opioid use is associated with pregnancy-related maternal and fetal morbidity and mortality. Babies exposed to opioids in utero are likely to develop symptoms of Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). NAS or NOWS are terms used to represent the pattern of clinical findings typically associated with opioid withdrawal in newborns. While the possibility of NAS or NOWS is a significant concern, opioid withdrawal during pregnancy may lead to spontaneous abortion or premature labor (CDC, 2016). Providers managing long-term opioid therapy in pregnant women should consult with relevant experts prior to initiating a taper, including maternal-fetal medicine, and addiction medicine specialists.

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