Intended for healthcare professionals

Practice Uncertainties

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

BMJ 2018; 362 doi: (Published 27 September 2018) Cite this as: BMJ 2018;362:k2990


Diagnosing opioid addiction in people with chronic pain

  1. H Sandhu, associate professor and consultant, health psychologist in pain management1,
  2. M Underwood, professor, primary care research1,
  3. AD Furlan, associate professor of medicine2,
  4. J Noyes, speciality trainee anaesthetics and pain research fellow3,
  5. S Eldabe, professor, consultant in pain medicine3
  1. 1Warwick Clinical Trials Unit, Warwick Medical School, UK
  2. 2Department of Medicine, University of Toronto, Canada
  3. 3The James Cook University Hospital, Middlesbrough, UK
  1. Correspondence to H Sandhu harbinder.k.sandhu{at}

What you need to know

  • For people with chronic pain and who do not have cancer, the benefits of long term opioids are outweighed by the issues of tolerance, dependence, and the requirement for higher doses

  • Tapering is the gradual reduction of opioids with the aim of limiting withdrawal symptoms; it may target complete discontinuation of the opioid, or on occasion a reduction of the dose

  • It is not clear how best to support people to taper their opioids; whether it is best done by interdisciplinary pain management programmes, buprenorphine substitution, or behavioural interventions

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

Fig 1

Long term use of opioids leads to tolerance and increased levels of pain

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 …

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