Opioids in Special Populations
Renal impairment
Impaired renal function avoid morphine (can be used at lower doses, less frequently), caution with oxycodone or hydromorphone. Recommended opioids are fentanyl, buprenorphine or methadone
Hepatic impairment
Caution with oxycodone/naloxone controlled release
Elderly
Morphine tends to be poorly tolerated in the elderly (probably as a reflection of impaired renal function). Buprenorphine patches (Norspan®) give a continuous infusion of low-dose opioid.
Possible effects/characteristics:
- Confusion.
- Increased plasma free drug concentration related to reduced metabolism and distribution volume in the elderly.
- Reduced clearance of opioids related to reduced hepatic blood flow (up to 40-50% by age 75).
Children
Contact the Paediatric Palliative Care team at Queensland Children’s Hospital 07 3068 1111.
Opioid dependence
Patients with a history of abuse of opioid analgesics should not be denied opioid analgesics for management of pain. Their care may need to involve a health professional with expertise in addiction therapy.
Such patients may require higher than usual opioid doses to control pain
See Therapeutic Guidelines: Palliative Care, 'Managing Pain in Patients with Substance Use Disorders', pp 226-7.
Terminally ill
Although patients may be unable to respond when close to death, there is no evidence to suggest sensation is reduced at this time. There should be no reduction in analgesia unless a judgment is made by a palliative care clinician that the patient is over-sedated or narcotised.