Methods for tapering long-term prescription opioids in outpatient settings

Evidence is needed on the effectiveness of various methods for tapering long-term prescription opioids in outpatient settings. National best practice guidelines in the United States, Australia, Canada and the United Kingdom recommend that appropriate candidates receive opioid tapering using flexible, patient-centred methods, but all of these guidelines note that stronger tapering evidence is needed. To delve further into this issue, US researchers compared the effectiveness of three opioid tapering and pain control strategies from July 2018 to November 2023.The randomized controlled trial (called EMPOWER—Effective Management of Pain and Opioid-Free Ways to Enhance Relief) study was conducted across five US states and involved 11 primary care and pain clinics. The trial enrolled adults (age 18–85) with any type of pain for at least six months. All patients were receiving a morphine equivalent daily dose of 10 or higher for at least three months, and did not have moderate or severe opioid use disorder.All participants received an individualized, patient-centred opioid tapering plan co-created with their prescribing clinician(s). The goal was to help participants achieve their lowest comfortable opioid dose over 12 months. Participants could control the pace of their taper and pause their taper if they wished, with opioid dose increases allowed during the study if their clinician deemed it appropriate. Small dose reductions (e.g., 5%) were recommended to start, with one dose reduction monthly until the patient was stable and without distress. Recommended subsequent reductions were at most 10% per month. Recommendations included tapering one opioid at a time and avoiding concurrent tapering of other medications.Patients were randomized into one of three study groups: taper only (without additional support), taper plus cognitive behavioural therapy for chronic pain (pain-CBT, which included 8 weekly sessions of CBT), or taper plus a chronic pain self-management program (which included six 2.5-hr weekly sessions of a group, peer-led chronic pain self-management program).Taper success (the primary outcome) was either a morphine equivalent daily dose decrease of at least 50% with no increase in pain, or no morphine equivalent daily dose increase with a decrease in pain intensity.Key results:A total of 562 participants were randomly assigned (191 taper only, 203 taper plus pain-CBT, 168 taper plus chronic pain self-management program). The taper success rate was:50.9% (95% confidence interval [CI], 42.9%–58.9%) for taper only48.6% (CI, 41.0%–56.2%) for taper plus pain-CBT, and 44.5% (CI, 36.0%–53.3%) for taper plus chronic pain self-management program. Tapering with pain-CBT or a chronic pain self-management program provided no benefit in taper success over taper only:taper plus pain-CBT vs. taper only, −2.4 percentage points [CI, −11.9 to 7.2 percentage points]taper plus chronic pain self-management program vs. taper only, −5.2 percentage points [CI, −15.3 to 4.8 percentage points]). Study-related adverse event risk (including opioid withdrawal symptoms) was highest in the taper only group (66%) compared with taper plus pain-CBT (54%) and taper plus chronic pain self-management program (64%).The authors conclude that adding CBT or self-management to patient-centred opioid tapering did not improve tapering success at 12 months. However, the addition of CBT to patient-centred opioid tapering may reduce adverse effects, including opioid withdrawal symptoms. The authors believe that the results of this study provide evidence to inform approaches for tapering opioids in a population without moderate or severe opioid use disorder who are interested in opioid tapering.Reference1. Darnall BD, Perez L, Kao MC, et al. Patient-centered prescription opioid tapering methods: a randomized clinical trial. Ann Intern Med 2026; published online July 7, 2026. https://www.acpjournals.org/doi/10.7326/ANNALS-25-04784 (accessed August 11, 2026).

Methods for tapering long-term prescription opioids in outpatient settings

Register for free access or login.

Related Topics