Quality prescribing for chronic pain 2026-2029: consultation

19. Appendix F: Practical steps to reduce high dose opioids

1. Education: explain the importance of reducing opioids to the individual

• Find out the individuals current understanding about their chronic pain and provide chronic pain education to clarify any misunderstandings e.g. Live well with pain ten footsteps guide - footstep one- pain and the brain, NHS inform- what is chronic pain?
• Explain the lack of evidence for using opioids in chronic pain e.g. Where-do-medicines-fit-in.pdf (livewellwithpain.co.uk)
• Discuss that medication is considered effective if it reduces pain intensity by 30-50%, therefore complete elimination of pain is not guaranteed
• Discuss long term risks and side effects and provide information e.g. Live well with pain - opioid side effect lottery or information on specific medications e.g. more harm than good leaflets
• Use The Live Well With Pain Opioid Thermometer Leaflet to demonstrate the potency of the opioid that the individual is taking.
  • The Pain Management Opioid Dose Converter (paindata.org) is a tool that can be used to convert all of the different opioids that someone is taking into a morphine equivalent dose which can then be used along with the opioid thermometer to demonstrate the strength of opioids the person is taking.
• Discuss opioid induced hyperalgesia and tolerance. Increased pain and tolerance with morphine-like medicines is a useful video which explains both opioid tolerance and hyperalgesia.
• Highlight examples of individuals who have successfully reduced their opioids such as Real Stories - Painkillers Don't Exist (painkillersdontexist.com) or video versions such as True stories - Live Well with Pain and Colin's Story - three minute (youtube.com)
• Explain the pain cycle using Live Well with Pain- Understanding Pain resources and discuss the importance of self-management approaches.

2. Engagement and building rapport: give the individual as much choice as possible around how to reduce their opioids

Opioids can be reduced in different ways, as long as the overall daily dose continues to decrease over time and that there is an understanding that the opioid doses will not increase once reduced. Giving the individual choice over how this is achieved gives them more control and ownership of the process, improves their engagement and is more likely to succeed. The following are ways of engaging the individual in the process:

Assess readiness

• Reassure the individual at the outset that their medication will not stop suddenly. The plan will be to work with the individual to help them manage their pain as safely and effectively as possible
• Ensure that it is a suitable time for the individual to consider a reduction. Ensure mental health is stable and not going through a current crisis
• It is important to recognise and acknowledge that making decisions about medicines can be difficult for a person who is in distress. If a shared decision about continuing medication cannot be reached and the medicine is not in the person’s best interests, follow the advice on “handling patient requests for medicines you don’t think will benefit them” in the General Medical Council guidance: Good practice in proposing, prescribing, providing and managing medicines and devices.

Consultation

• Use consultation model/ tips from Consultation Conversations section e.g. Listen to their pain story and validate their pain experience. A useful approach is described in NHS GG&C blog on realistic medicines approach to chronic pain management
• Find out what is important or matters to them. Use tools such as Brief-Pain-Inventory.pdf (scot.nhs.uk) or The pain self efficacy questionnaire to get a better picture of how severe their pain is and how it is impacting them daily
• Listen carefully, to detect any indication of tolerance or medication not working as well as before. Use these as opportunities to highlight tolerance, especially if the individual has a high pain score despite medication. Consider discussing what would happen if they needed an operation, as high dose opioids increases anaesthetic risk and limits post-operative pain management
• Explain that reducing and stopping opioids usually makes no difference to pain but can make people feel better due to fewer side effects.
• It is essential to have an open and honest discussion with the individual about how they are currently using their medication, as their medical records may not reflect how they take it

Agree Plan

• Involve the individual in any decisions about their medication and agree any proposed reduction schedules. Consider the pattern of pain throughout the day and discuss reduction of doses to align with when pain is most manageable
• Discuss step-wise goals and plan frequency of reviews
• Reassure that once tapering has started that this can be tailored to suit the individual by slowing down or speeding up as agree
• Reassure individuals that reducing opioids will take time. It may take months or even years to stop completely especially if initially on very high doses
• Provide written tapering information such as Opioid-Medication-Leaflet-Digital..pdf (scot.nhs.uk) or National-Pain-Centre-Mcmaster-Canada-Opioid-Tapering-Patient-Information-english.pdf
• Explain that withdrawal symptoms or a change in pain may occur following each reduction but these symptoms tend to settle within a few days

3. Developing a tapering plan

Developing the plan

• It is beneficial if one healthcare professional takes responsibility for opioid prescribing for the individual and for reviewing their progress
• Consider if any other pain medication could be optimised or rationalised. For example, have they tried regular paracetamol or non-steroidal anti-inflammatory gel? Can any non-pharmacological approaches for chronic pain management be implemented?
• Calculate total oral morphine equivalence of all current opioids by any route using the opioid dose conversion chart or a dose converter tool such as Pain Management Opioid Dose Converter. Clarify with the individual what they are actually taking, to ensure the correct dose conversion. Consider reducing the dose for pharmacological variance if changing opioid.
• It is important to be aware of the potencies of the different opioids. Each 12.5microgram increment of fentanyl is equivalent to 37mg of morphine.
• Advice and support should be sought from specialist pain services in some circumstances such as high dose opioids above 90mg morphine equivalent dose (MED)16, long duration e.g. more than 10 years of opioid use or for very potent opioids such as fentanyl patches.
• Where possible, consolidate all opioids into one single modified release preparation. If an individual still requires immediate release morphine, consider converting liquids to tablets.
• Do not prescribe 'when required’ doses
• Many guidelines including The NHS GG&C opioid guideline recommend reducing opioid dose by a maximum of 10% every one to two weeks to minimise the chance of withdrawal symptoms.
• Using a fixed dose reduction of 10mg can be a pragmatic plan108. This makes dosing easier as it conforms to tablet doses. Individuals are often nervous about starting the reduction, so small decreases at the beginning should gain their confidence and give them reassurance. However, when the doses are small at the end of a taper, it is often worth discussing more gradual decreases e.g. 5mg rather than 10mg, or codeine can be considered to temper the decreases further (30mg codeine = 3mg MED).
• A slow, flexible taper where the individual feels they are in control and are being listened to will likely be more successful compared to a rigid adherence to a fixed plan108.
• Due to risk of overdose, it is important to emphasise to individuals that they should not revert to their previous dose without speaking to a healthcare professional first.
• More Harm Than Good leaflets for reductions of tramadol, codeine, co-codamol, co-dydramol and dihydrocodeine are available.

Reviewing the plan

• Review individual during taper. If experiencing withdrawal effects then rate of taper should be slowed down and go at the pace of the individual.
• Consider smaller dose reductions as the dose becomes lower. Liquid formulations may need to be considered once lower doses are achieved.

Communication

• The decision to taper/ stop opioids should be documented along with the planned taper schedule.
• Ensure that the GP practice MDT are aware of the tapering plan and that it is documented in the individual’s notes.
• The community pharmacy team can be a valuable source of support through the tapering process. Notify them to ensure that they are aware of the opioid reduction plan and can manage their stock.
• It is useful to have pharmacy text on the prescription stating that the individual is on a reducing dose so that the plan is clear to any member of the MDT issuing prescriptions.

4. Emotional impact: manage anxiety and depression

• Regular review and support from the same practitioner is important until completion of the tapering plan
• Ask about improvement in function, reduction of side effects and withdrawal effects.
• Discuss effects of tapering on mental health and ensure it is appropriate to continue tapering.
• It is helpful for the individual to be aware that anxiety is to be expected during opioid reduction and that this can be managed together. Signpost to NHS Inform: Anxiety | NHS inform.
• Consider if additional support is required e.g. psychological, addiction and alcohol support services.

5. Expectations: ensure the individual understands that this can be difficult, and that they may need support

• Discuss the possibility of withdrawal side effects, reassure that these are often transient and can be treated symptomatically. Explain that it is normal for pain to increase during the first week or two after a decrease in opioid dose – this is the body re-setting its response to the medicine and not a sign that the medicine was working. Have a plan for flare ups of pain due to withdrawal.
• Use list below to explain potential withdrawal effects and likely duration.

Opioid withdrawal symptoms

The timing and duration of these symptoms depend on the type of opioid taken. Short-acting opioids have a faster onset of symptoms compared to long acting opioids^[187]. The symptoms may present as follows^[188]:

Hours

• Anxiety
• Irritability
• Restlessness
• Muscle ache
• Increased sensitivity to pain

Days

• Nausea and vomiting
• Insomnia
• Hot and cold flushes
• Perspiration
• Watery discharge from eyes and nose
• Diarrhoea

Weeks/months

• Anxiety
• Low mood
• Insomnia.