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Opioids in special circumstances 

Opioids in special circumstances
Chapter:
Opioids in special circumstances
Author(s):

Fliss Murtagh

, Polly Edmonds

, and Chris Farnham

DOI:
10.1093/med/9780199218806.003.0017
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date: 28 May 2020

Regarding opioids in renal disease, the degree of renal impairment should be established where possible, using estimated glomerular filtration rate. Choice of opioid is important. In severe renal impairment avoid repeated administration of opioids with known toxic metabolites (such as codeine, dihydrocodeine, morphine and diamorphine), and avoid modified release preparations. Use preferred opioids (buprenorphine, fentanyl and alfentanil) carefully, start at very low doses, with increased dose interval, and titrate against clinical response.

Regarding opioids in liver disease, many patients with hepatic dysfunction have pain requiring opioid analgesics. The liver dysfunction needs to be severe for clinical issues around prescribing in palliative care to become relevant. Avoid opioids with long half lives and modified release preparations; if toxicity develops, it will be prolonged. Opioids should be used with caution eg low starting doses, increased dose interval and careful monitoring. Alternative opioids do not have any specific advantages. Regarding opioids in respiratory disease, opioids are known to have respiratory depressant side effects. Clinicians may be anxious about prescribing opioids in patients with chronic lung disease. In practice, patients seem to develop tolerance to the respiratory depressant side effects. Careful titration with normal release opioids and regular clinical review means these drugs can be used in patients with respiratory disease. Regarding prescribing opioids in patients with a history of drug misuse, patients with a history of substance misuse develop pain. Substance misuse can be a barrier to adequate pain management. Effective pain control requires good communication, boundary setting and team working. British Pain Society guidance should guide practice.

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