Opioid Safety in Patients With Renal or Hepatic Dysfunction

It has been estimated that up to one-third of patients with renal dysfunction (defined as creatinine clearance [CrCl] < 50 mL/min) also receive opioids to relieve pain [Davison 2003]. Use of opioids in these patients can present a challenge because adequate pain control is necessary while balancing the risk of overdose due to altered drug clearance and accumulation of the opioid parent drug and/or metabolites in the presence of renal dysfunction. During dialysis, properties of the parent opioid drug and its metabolites, as well as physical properties of the dialysis equipment (eg, filter pore size), flow rate, the efficiency of the technique used, and dialysis method (intermittent versus continuous dialysis), must be considered to achieve effective pain relief without adverse effects. Similar problems exist for patients with hepatic dysfunction because the liver is responsible for metabolism of the parent opioid drug to active and inactive metabolites.