Opioid Tapering Template

Between 2015 to 2016, approximately 2 million Ontarians filled an opioid prescription from various sources within the healthcare system. The Opioid Tapering Template is based on the best evidence available and is designed to assist family physicians and primary care nurse practitioners on evaluating opioid therapies and reducing opioid dosages in safe and effective ways.

Question #1: Most of the evidence showing benefits from opioid use for chronic non-cancer pain supports relatively low doses (less than 100MED).

Question #2: Tolerance of a previous dose of opioids is lost after how many weeks?

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Opioid Tapering Template
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Revaluating opioid therapy and discussing opioid tapering with patients can be challenging. This tool recognizes that opioid tapering is a complex process, which requires ongoing discussion and support, individualizing tapering plans and prioritizing patient safety and self efficacy. The Opioid Tapering Template is designed to assist family physicians and primary care nurse practitioners on creating tapering plans with their patients and adjusting those plans as their patients’ needs change due to pain, function and withdrawal symptoms.

The tool is divided into the following five sections to guide providers throughout the opioid tapering process:

  1. Important considerations for opioid tapering
  2. How to taper, reduce or discontinue
  3. Withdrawal symptoms & management
  4. Tapering plan
  5. Follow-up tapering visits

Throughout the tool, providers will find helpful talking points, fillable forms and links to relevant resources including those created by the CEP as part of its pain management suite of tools. These tools aim to provide primary care providers an overview of safe and effective opioid use and appropriate pain management.

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Project Overview

The Opioid Tapering Template was developed to assist providers with pain management and complements the pain management suite of tools developed by the CEP. Opioid therapy can be an effective method of pain management for many patients, but it is important for providers and their patients to jointly consider the benefits and risks of an opioid dosage and know when and how to taper opioids.

Development Process

The Opioid Tapering Template was developed using the CEP’s integrated knowledge translation approach. This approach ensures that providers are engaged throughout the development processes through the application of user-centered design methodology. Clinical leadership of the resource was provided by Dr. Arun Radhakrishnan. End-users and clinical experts were also engaged to provide feedback.

The Opioid Tapering Template is based on the 2017 Canadian Guideline for Opioids for Chronic Pain.

The Opioid Tapering Template is one of several resources developed as part of the Knowledge Translation in Primary Care Initiative. This multi-year initiative was a collaboration between the Centre for Effective Practice, Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative (KTinPC).

Meet the Team

The Centre for Effective Practice enlisted the collaboration of the following clinical leadership throughout the development of the Opioid Tapering Template:

Clinical Lead

ArunDr. Arun Radhakrishnan, MSc, MD, CM CCFP

Dr. Arun Radhakrishnan is a family physician with a focused practice in chronic pain and is the current co-chair of the Collaborative Mental Health Network and the Medical Mentoring for Addictions and Pain Network at the Ontario College of Family Physicians. He is also an adjunct assistant professor with the Department of Family and Community Medicine at the University of Toronto.

In 2013 Dr. Radhakrishnan completed a Master’s degree at the University of Toronto in Health Services Research focusing on the value of information and communication technologies to enable knowledge translation activities in the areas of pain, mental health and addictions to support community physicians. His interests also include teaching and curriculum development around the integration of technology into the clinical encounter.

Target End-User & Expert Opinion

The Centre for Effective Practice also sought target end-user and expert input to inform the content of the Opioid Tapering Template. We are grateful to these individuals for their time and expertise.

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. The CEP will make every effort to keep these links up to date.

Supporting Material

  1. Management of Chronic Non Cancer Pain – Appendices
    https://thewellhealth.ca/cncp
  2. Opioid Manager
    https://thewellhealth.ca/pain
  3. Management of Chronic Insomnia
    https://thewellhealth.ca/insomnia
  4. Naloxone and Opioid Crisis Training Resources
    https://uwaterloo.ca/pharmacy/naloxone-and-opioid-crisis-resources
  5. Ontario Naloxone Kit Access & Resources
    https://www.ontario.ca/page/get-naloxone-kits-free
  6. Buprenorphine-Assisted Treatment of Opioid Dependence: An Online Course for Front-Line Clinicians
    http://www.camh.ca/en/education/about/AZCourses/Pages/BUP.aspx
  7. Opioid Tapering- Information for Patients
    http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20Information%20(english).pdf
  8. Brief Pain Inventory (BPI)
    http://nationalpaincentre.mcmaster.ca/documents/brief_pain_ inventory.pdf
  9. PHQ Screeners. PHQ and GAD-7 screeners (available in several different languages).
    http://www.phqscreeners.com/select-screener/41

References

  1. Michael G. DeGroote National Pain Centre, McMaster University. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. 2017; [cited Jan 4, 2018]. Available from: http://nationalpaincentre.mcmaster.ca/opioid/
  2. Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guideline for opioid therapy for chronic pain. 2017 ; [cited Jan 4, 2018]. Available from: https://www.healthquality.va.gov/guidelines/pain/cot/
  3. Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain. 2016 ; [cited Jan 4, 2018]. Available from: http://www.cdc.gov/drugoverdose/prescribing/guideline.html
  4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington: American Psychiatric Association; c2013.
  5. Michael G. DeGroote National Pain Centre, McMaster University. Opioid tapering – information for patients. [cited Jan 4, 2018]. Available from: http://nationalpaincentre.mcmaster.ca/documents/Opioid%20Tapering%20Patient%20Information%20(english).pdf
  6. World Health Organization. Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. Geneva: 2009; [cited Jan 4 2018].
    Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/

Copyright & Disclaimer

The CEP fully supports the use of the Opioid Tapering Template tool by providers, educators, decision-makers and others. Please read the following information prior to use of the tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative Commons The Opioid Tapering Template is a product of the Centre for Effective Practice. Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation. Use of the Opioid Tapering Template for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected])

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool.

Please use this citation when referencing the tool: Reprinted with Permission from the Centre for Effective Practice (March 2018). Opioid Tapering Template. Toronto: Centre for Effective Practice.

Disclaimer

The Opioid Tapering Template was developed for licensed health care professionals in Canada as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using the Opioid Tapering Template. Neither the CEP, UHN, the contributors to the Opioid Tapering Template, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through the Opioid Tapering Template; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of the Opioid Tapering Template by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of the Opioid Tapering Template, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in the Opioid Tapering Template (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.

The Opioid Tapering Template (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations. These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Third Party Resource(s).