Opioid and benzodiazepine tapering: Best practices - FREE No CME-Opioid and benzodiazepine tapering: Best practices

Video Transcription

Video Summary

Lecture 6 reviews best practices for tapering opioids and benzodiazepines, emphasizing that deprescribing should be a routine part of prescribing. Clinicians should consider tapering conversations with all patients on controlled substances, though tapering is not always appropriate. Key reasons to consider tapering include patient request; lack of meaningful improvement in pain/function (or anxiety/insomnia with benzodiazepines); adverse effects (e.g., constipation, sedation, falls, cognitive impairment); high-risk comorbidities (sleep apnea, lung disease, organ dysfunction, dementia); and dangerous co-use with other sedatives (benzodiazepines, alcohol, carisoprodol). If opioid use disorder is present, tapering is usually ineffective and treatment with buprenorphine or methadone is preferred.<br /><br />Successful tapers rely on therapeutic alliance, shared decision-making, motivational interviewing, and careful timing (avoid stressful life periods). Slow, gradual reductions (often 5–10% initially) are generally best; abrupt tapers should be rare, safety-driven, and delivered empathetically, sometimes requiring higher levels of care (especially for rapid benzodiazepine tapers). Evidence suggests many patients maintain or improve pain, function, and quality of life during voluntary opioid tapers, but forced or poorly supported tapers can increase overdose/withdrawal events and mental health crises for up to 1–2 years afterward.<br /><br />Opioid tapering requires optimizing non-opioid “altos,” tracking function, and actively managing withdrawal (e.g., clonidine, hydroxyzine, NSAIDs, trazodone, loperamide). Benzodiazepine tapering highlights limited long-term indications, frequent dependence, complex withdrawal, and benefits of switching short-acting agents (especially alprazolam) to longer-acting diazepam. CBT (including CBT-I) and SSRIs/SNRIs are first-line for anxiety/insomnia.<br /><br />Finally, the lecture outlines transitioning chronic opioid therapy to buprenorphine for pain via standard rotation (after abstinence) or micro-induction (overlapping opioids to avoid precipitated withdrawal), noting buprenorphine’s improved safety profile and split dosing for analgesia.

Keywords

opioid tapering

benzodiazepine tapering

deprescribing controlled substances

shared decision-making

motivational interviewing

withdrawal symptom management

opioid use disorder treatment

buprenorphine micro-induction

diazepam substitution

CBT-I for insomnia