Tapering and stopping analgesics for acute pain

Acute pain is usually of limited duration and there is an expectation of recovery and return to usual function. Prescribers should always document an analgesic tapering and stopping plan for patients receiving analgesics for acute pain. This should include the anticipated duration of therapy, when to start tapering doses (eg after major surgery or trauma, opioid doses usually start to decrease after 1 to 2 days) and how to taper doses safely.

An analgesic tapering and stopping plan is particularly important for patients prescribed opioids because long-term opioid use often starts with the use of opioids for acute pain. Ideally, the opioid is stopped within a few days of reducing the dose1. For patients in hospital for more than a couple of days, tapering opioids should start before discharge. The discharge opioid prescription should take into account the amount of opioid the patient has required 24 to 48 hours prior to leaving hospital. In general, taper and stop fentanyl, morphine and oxycodone before tramadol and tapentadol; paracetamol and NSAIDs should be the last drugs discontinued. For detail on the role of analgesics commonly used for acute pain, see Role of analgesics commonly used to manage acute pain .

See Example of tapering and stopping acute pain analgesia for an example of tapering and stopping acute pain analgesia.

The patient’s general practitioner must be involved to ensure appropriate follow-up and regular analgesic review. Patients, carers and/or family should receive education regarding analgesic use and discontinuation before they leave the hospital. Education should include written and verbal advice about pain management, expectations of pain control, expected duration of analgesic use, tapering and stopping analgesics, and potential adverse effects. For advice on the use of opioids in the community, see here.

Seek specialist advice if a patient’s opioid requirements are not decreasing after an acute presentation.

Prolonged opioid use after an acute pain presentation may be associated with:

  • postoperative or posttrauma complications
  • preadmission use of opioids, benzodiazepines or antidepressants
  • substance-use disorder
  • depression, anxiety and other psychiatric disorders.
Figure 1. Example of tapering and stopping acute pain analgesia

Presentation

A 35-year-old male was admitted after a motor vehicle accident in which he sustained six fractured ribs on his right side and some lung contusion. He had no other injuries or comorbid conditions.

Initial analgesia in hospital

  • paracetamol 1 g orally, four times daily
  • celecoxib 200 mg orally, twice daily
  • fentanyl administered by patient-controlled analgesia (PCA)

Maintenance analgesia in hospital

Day 2

  • tramadol 50 mg, orally, 6-hourly was added, and increased to tramadol 100 mg, orally, 6-hourly later the same day

Day 3

  • fentanyl was stopped
  • oxycodone 10 to 15 mg orally, every 2 hours as required (based on his PCA fentanyl use) was added

In the 24 hours before discharge, he used oxycodone 60 mg in addition to his other drugs.

Discharge prescription

Day 4

  • paracetamol 1 g orally, four times daily
  • celecoxib 200 mg orally, twice daily
  • tramadol 100 mg orally, four times daily
  • oxycodone 5 to 10 mg orally, 4-hourly as required

Patient advice

Take paracetamol, celecoxib and tramadol regularly.

Reduce the dose of oxycodone a little each day according to pain requirements. Use for as short a time as needed.

Once you have stopped taking oxycodone, reduce tramadol to take as needed and stop after a few days.

Continue paracetamol and celecoxib until no longer needed for pain relief. Stop celecoxib before paracetamol.

If your pain continues or is not controlled, contact your general practitioner.

1 A slower approach is required if the patient has been taking the opioid for more than 7 days, because opioid-tolerance may have developed.Return