A Proposed Opioid Tapering Tool

• Electronic Health Records
• Opioids
• Pain Management
• Patient-Centered Care
• Pilot Studies
• Primary Health Care
• Software

Despite increasing attention to the opioid epidemic, many primary care providers lack confidence in prescribing opioids.^1–2 Evidence regarding the efficacy and safety of chronic opioid therapy (COT) for chronic noncancer pain (CNCP) and the optimal strategy for opioid tapering is limited.³ The US Department of Health and Human Services (HHS) recently published guidelines intended to assist providers in tapering opioids.⁴ These guidelines highlight the need for individualizing tapers—noting that some patients may require a slower taper to minimize withdrawal symptoms and increasing success of tapering.

In light of these recommendations, our group has developed an opioid tapering software to assist clinicians in managing patients on COT deemed appropriate for tapering. The software is designed to reduce a patient’s prescribed chronic opioids by 5% to 10% every month (rounded based on available tablet strength), or 5 morphine milligram equivalents per day (MMED), whichever is the greatest, in line with HHS guidelines. The program, however, allows users to adjust the rate of taper; it also accounts for patients taking multiple opioids, including combinations of long- and short-acting opioids (including those combined with acetaminophen). The software will generate a tapering schedule based on a patient’s initial daily opioid dose, frequency of dosing, and available medication dosage formulation. The software utilizes the following rules to generate a taper:

• - When multiple opioids are used, 1 medication will be tapered to 0 mg before initiating the taper of the next medication.

• - The tool will identify and initiate taper of extended-release medications before immediate-release medications.

• - If there are multiple extended-release or immediate-release medications for a given patient, the tool will use the following tapering hierarchy based on estimated risk of harm (higher risk of harm tapered earlier): oxycodone > hydromorphone > morphine > hydrocodone > codeine > tramadol. We chose to taper tramadol last due to its weaker opioid effect and possibly lower abuse potential compared with other opioids.⁵

• - If there are multiple daily doses for a single medication, all doses will be concurrently lowered rather than tapering 1 dose at a time—as long as the taper adheres to our tapering rules (ie, 5% to 10% per month, or 5 MMED, whichever is greater). If concurrent tapering of multiple doses of a single medication cannot be achieved due to tapering rules, then episodes earlier in the day will be discontinued before episodes later in the day.

We are currently using RedCap for the application programming interface in the initial iteration of this software (https://www.project-redcap.org/). RedCap is a Web-based application used to develop and manage surveys and databases; information collected and stored in this environment is secure and HIPAA compliant. Our group intends to use this software in an upcoming pilot study to taper patients on COT for CNCP.

We realize that the initial iteration of our software does have some limitations. For example, this tool does not provide tapering schedules for patients on some opioid formulations, including fentanyl and methadone. Our tool also does not account for concurrent chronic benzodiazepine use when generating tapering schedules. Moreover, our tapering hierarchy has limited support in the literature.

We are exploring the possibility of transitioning our software into other available application programming interfaces (eg, App Orchard in Epic) with the goal of integrating this software into major electronic health record systems. We invite readers with experience using RedCap in research or clinical settings to provide recommendations on incorporating these additional features into our tool, making it more robust and applicable in diverse clinical scenarios.

Our group envisions that our software will provide clinicians an additional tool within a patient-centered, multimodal framework in managing patients on COT for CNCP.

• Received for publication February 19, 2020.
• Revision received May 2, 2020.
• Accepted for publication May 18, 2020.