What interventions are effective to taper opioids in patients with chronic pain?

Opioids are commonly prescribed for short term pain relief in people with chronic pain (not caused by cancer). If they are used long term, most patients develop tolerance, their pain increases, and clinicians gradually escalate the dose (fig 1). Sales of prescribed opioids in the USA quadrupled between 2000 and 2010.1 Media have reported the harms of dependence23 and the increasing number of deaths from accidental overdose.45678910 Other long term harms include immune suppression, hormonal imbalance, falls and fractures, acute myocardial infarction, addiction, sedation, and cognitive impairment.11

There is very little guidance on withdrawing or tapering opioids in chronic pain (not caused by cancer). People can fear pain, withdrawal symptoms, a lack of social and healthcare support, and they may also distrust non-opioid methods of pain management.12 People may experience flu like symptoms, irritability, anxiety, nausea, diarrhoea, shivering, yawning, sweating, and altered sleep, generalised aches and pains, and abdominal cramps when they stop opioids.13 It is important to distinguish physical dependence on opioids (the physiological responses and symptoms above) from addiction (a compulsive need to take opioids for pleasure).14 Fewer than one in 30 …