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Case Studies: Principles in Practice: Ralph

Ralph: Transitioning a Patient From Opioid to Nonopioid Therapy

Ralph is a 55-year-old graphic artist with a history of severe, posttraumatic osteoarthritis and persistent right knee pain. He underwent a total replacement of the right knee 6 months ago and received a prescription for a low-dose of an immediate-release opioid postoperatively. After 2 months of daily treatment, the prescription was changed by his primary care physician to an extended-release (ER) formulation.

Now Ralph presents to a new health care provider after relocating for his job. Until his recent move, he continued to actively participate in physical therapy for postoperative rehabilitation. He has continued to take the prescribed ER opioid on a regular basis.

Note: Representative case example. This case is not based on an actual patient.

Ralph: Transitioning a Patient From Opioid to Nonopioid Therapy

“Why I Don’t Think You Need Opioid Medication”


Ralph’s new health care provider, a nurse practitioner, administers the Brief Pain Inventory to assess Ralph’s knee pain and its impact on his daily functioning (see video).The results reveal little to no pain and no interference with daily activities. When asked why he did not request that his primary care physician taper him off the opioid medication, Ralph reveals that he has been afraid to discontinue it given that he has been increasing his physical activity.

The nurse practitioner explains that there are other, nonopioid pain medications that Ralph can use instead, if the pain flares up. She also explains the risks associated with long-term use of prescription opioids. Ralph agrees to tapering and discontinuation of the opioid medication.

Ralph: Transitioning a Patient From Opioid to Nonopioid Therapy

“I’d Like to Start Taking You Off the Opioid Medication”


The nurse practitioner prescribes a nonsteroidal anti-inflammatory drug for Ralph to use as needed. She then provides Ralph with a new dosing schedule for the low-dose ER opioid based on a 20% tapering of the original dose each week for the next 8 weeks (see video).1,2 She explains that this slow tapering is necessary to help minimize potential withdrawal effects.

The nurse practitioner encourages Ralph to continue his physical therapy. She notes that her office will be contacting him in a few weeks to review his progress, and asks Ralph to let her know if he experiences any negative effects or unrelieved pain in the interim.

As a final note, the nurse practitioner mentions to Ralph that any opioid medication left unused at the end of the tapering period should be flushed down the toilet.3


  1. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. Accessed November 6, 2017.
  2. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. Accessed November 6, 2017.
  3. US Food and Drug Administration. New safety measures announced for extended-release and long-acting opioids: ER/LA opioid analgesic class labeling changes and postmarket requirements [letter to ER/LA opioid application holders]. September 10, 2013. Accessed November 6, 2017.