Opioid and benzodiazepine tapering: Best practices - CME Paid Option-Opioid and benzodiazepine tapering: Best practices

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Video Summary

Lecture 6 reviews best practices for tapering opioids and benzodiazepines, emphasizing that deprescribing should be a routine part of prescribing controlled substances. Tapering should be considered for all patients as an ongoing conversation, though not always pursued. Key reasons to taper include patient request, lack of meaningful improvement in pain/function (or anxiety/insomnia), adverse effects (e.g., constipation, sedation, falls, respiratory depression), high-risk comorbidities (sleep apnea, lung disease, organ dysfunction, dementia), concurrent sedatives or alcohol, and emerging misuse risk. If opioid use disorder is present, tapering is usually inappropriate; transition to medications for OUD (buprenorphine or methadone) is preferred.<br /><br />Successful tapering depends heavily on preparation: building therapeutic alliance, shared decision-making, motivational interviewing, patient education, and ensuring mental health and social supports. Slow, flexible tapers are generally safest; abrupt tapers are reserved for imminent safety threats and must never be punitive. Evidence suggests many patients maintain or improve pain, function, and quality of life during supported opioid tapering, but forced or poorly supported tapers can increase overdose/withdrawal events and mental health crises for up to 1–2 years.<br /><br />Opioid tapering guidance includes starting with small reductions (often 5–10%), typically tapering long-acting opioids first, spacing changes about monthly, slowing further near the last 20–30%, and actively treating withdrawal symptoms with non-opioid medications (e.g., clonidine, NSAIDs, antiemetics, loperamide, dicyclomine, sleep aids).<br /><br />Benzodiazepines are appropriate mainly for short-term/acute indications; long-term use often leads to tolerance, dependence, cognitive harm, and difficult, sometimes prolonged withdrawal. Taper options include tapering the same agent, switching (especially from alprazolam) to diazepam for smoother reductions, and using adjuncts (often with psychiatric input). CBT-I and SSRIs/SNRIs are emphasized as first-line treatments for insomnia/anxiety.<br /><br />Finally, the lecture describes rotating chronic opioid patients to buprenorphine for pain using standard induction (after abstinence) or micro-induction to avoid precipitated withdrawal, highlighting buprenorphine’s safety advantages and split dosing for analgesia.

Keywords

opioid tapering best practices

benzodiazepine tapering

deprescribing controlled substances

shared decision-making and motivational interviewing

opioid withdrawal symptom management

slow flexible taper schedule (5–10% reductions)

high-risk comorbidities (sleep apnea, lung disease)

buprenorphine rotation for chronic pain

opioid use disorder transition to MOUD (buprenorphine, methadone)

CBT-I and SSRIs/SNRIs for insomnia/anxiety