Tapering principles

For prescribing clinicians

A taper and a withdrawal look similar on a chart and are different events for the person. The difference is agreement, rate, monitoring, and a way back.

Which classes require a taper

Not all of them do. The ones that do, do so for identifiable reasons, and the regulators have been explicit.

• Benzodiazepines and Z-drugs. The FDA’s September 23, 2020 class-wide boxed-warning update states that “physical dependence can occur when benzodiazepines are taken steadily for several days to weeks, even as prescribed. Stopping them abruptly or reducing the dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening.”
• Opioids. FDA-approved labeling: do not rapidly reduce or abruptly discontinue in a physically dependent patient, “because rapid reduction or abrupt discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide.”
• Antiepileptics, including gabapentinoids. Labeling: “Antiepileptic drugs should not be abruptly discontinued because of the possibility of increasing seizure frequency.”
• Antihypertensives. Several classes rebound. Blood pressure rose by a mean of 9.75 mmHg systolic after withdrawal in the pooled randomized trials, and no included trial specifically assessed adverse withdrawal reactions.
• Proton pump inhibitors. Rebound acid hypersecretion is a real randomized finding in healthy volunteers — 44% reported an acid-related symptom after withdrawal against 15% on placebo — but the deprescribing guideline states its clinical significance in long-term patients “remains unknown,” and rates the evidence that abrupt discontinuation increases relapse as very low quality. State that honestly rather than overselling the taper.

Rate — and why the published figures differ

Two authoritative sources give different opioid tapering rates, and both are correct for the population each describes. Do not average them into one number.

Source	Population	Rate
CDC 2022 Clinical Practice Guideline	On opioids for a year or longer	Approximately 10% per month or slower
CDC 2022 Clinical Practice Guideline	Shorter durations — weeks to months	About 10% of the original dose per week or slower, until roughly 30% of the original dose is reached, then about 10% of the remaining dose weekly
FDA-approved opioid labeling	Physically dependent patients generally	No greater than 10% to 25% of the total daily dose per step, every 2 to 4 weeks; faster may be tolerated after briefer treatment

Both sources say the same thing about individualization. FDA: “There are no standard opioid tapering schedules that are suitable for all patients. Good clinical practice dictates a patient-specific plan to taper the dose of the opioid gradually.” CDC adds: “At times, tapers might have to be paused and restarted again when the patient is ready.”

For benzodiazepines the FDA is equally clear that “no standard benzodiazepine tapering schedule is suitable for all patients; therefore, create a patient-specific plan to gradually reduce the dosage, and ensure ongoing monitoring and support.”

What imposed tapering does

The evidence here is unambiguous enough that it should govern practice. Among 113,618 US adults on stable long-term opioid therapy, tapering was associated with adjusted incidence rate ratios of 1.68 for overdose and 2.28 for mental health crisis — and each 10% increase in maximum monthly dose-reduction velocity raised both further. A follow-up by the same group found the elevation persisted 12 to 24 months after initiation. Among 1,394,102 Veterans Health Administration patients, hazard ratios for death from overdose or suicide after stopping rose with treatment duration to 6.77 beyond 400 days.

All three are observational and say so. The CDC drew the practice conclusion anyway, and named the mechanism: rapid tapers and abrupt discontinuation “without collaboration with patients,” rigid dosage thresholds, and “patient dismissal and abandonment” have “contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

What a collaborative taper looks like

The guidance documents are unusually consistent on this, and the language is worth using directly.

• CDC 2022: “When patients and clinicians are unable to arrive at a consensus on the assessment of benefits and risks, clinicians should acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment… Patient agreement and interest in tapering is likely to be a key component of successful tapers.”
• FDA labeling: “It is important to ensure ongoing care of the patient and to agree on an appropriate tapering schedule and follow-up plan so that patient and provider goals and expectations are clear and realistic.”
• The benzodiazepine deprescribing guideline: “Patients might be more amenable to deprescribing conversations if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice.”
• The AGS Beers Criteria: should be applied “in a manner that supports, rather than replaces, shared clinical decision-making.”

Expect withdrawal symptoms, and plan for them

In D-PRESCRIBE, 29 of 77 patients (38%) who attempted a sedative-hypnotic taper reported withdrawal symptoms — while no adverse event required hospitalization. That is the shape of the risk: common, unpleasant, manageable, and a reason for follow-up rather than for not trying.

For antipsychotics, the identifiable relapse group matters more than the average. The Cochrane withdrawal review found that in the two trials enrolling only patients who had responded to treatment for psychosis, agitation or aggression, stopping was associated with higher risk of symptomatic relapse or shorter time to it — and that people with more severe baseline symptoms may worsen. Everyone else usually comes off without rebound. Antipsychotics in dementia.

A reversal is information

A reduction that has to be undone tells you the drug was doing something, which was not knowable in advance. This only works if restarting was a planned option from the beginning, stated to the patient in those terms. A taper framed as a one-way door will be refused by the people who most need one attempted.

Back to the clinician track.

References

1. U.S. Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety Communication, September 23, 2020. fda.gov. 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class.
2. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
3. Parke-Davis, Division of Pfizer Inc. NEURONTIN (gabapentin) capsules, tablets and oral solution — FDA-approved prescribing information. DailyMed, U.S. National Library of Medicine. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee9ad9ed-6d9f-4ee1-9d7f-cfad438df388.
4. Gnjidic D, Langford AV, Jordan V, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database of Systematic Reviews. 2025;3(3):CD012572. PMID 40162571 · DOI 10.1002/14651858.CD012572.pub3.
5. Reimer C, Søndergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137(1):80–87. PMID 19362552 · DOI 10.1053/j.gastro.2009.03.058.
6. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Canadian Family Physician. 2017;63(5):354–364. PMID 28500192. No DOI is assigned to this article; cite by PMID/PMCID.
7. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411–419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
8. Fenton JJ, Magnan E, Tseregounis IE, Xing G, Agnoli AL, Tancredi DJ. Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering. JAMA Network Open. 2022;5(6):e2216726. PMID 35696163 · DOI 10.1001/jamanetworkopen.2022.16726. Same research group as Agnoli 2021 — a follow-up, not an independent replication.
9. Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283. PMID 32131996 · DOI 10.1136/bmj.m283.
10. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889–1898. PMID 30422193 · DOI 10.1001/jama.2018.16131.
11. Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician. 2018;64(5):339–351. PMID 29760253.
12. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.
13. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
14. U.S. Department of Health and Human Services. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. October 28, 2019. hhs.gov. 2019. https://nida.nih.gov/nidamed-medical-health-professionals/opioid-crisis-pain-management/hhs-guide-clinicians-appropriate-dosage-reduction-or-discontinuation-long-term-opioid.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed August 21, 2026. This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.