Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them

Marc Ginsburg, RN, MScN, NP; Shawna Silver, MD, PEng; Hershl Berman, MD, FRCPC


Geriatrics and Aging. 2009;12(1):48-52. 

In This Article

Choosing Opioids for Use in Older Adults

When choosing an opioid, the World Health Organization recommends using a systematic and graduated approach, the "analgaesic ladder," starting with non-narcotics, then changing to weak opioids and nonsteroidal anti-inflammatory drugs (NSAIDs), and subsequently progressing to stronger medications as needed, depending on side-effects or inefficacy (Figure 1).[4] However, many older adults have contraindications to NSAIDs and may have comorbidities precluding them from adhering to this approach.

Figure 1.

The World Health Organization's "Analgesic Ladder"

There are two factors that must be taken into account when prescribing and switching opioids in older adults. First, it is important to ensure that the patient is able to comprehend the instructions given. Cognitive deficits may lead to confusion, and hearing difficulties may interfere with comprehension.[5] In the case of conversion from one drug to another, it is vital that the patient understands that the old drug is not to be used anymore and must be disposed of appropriately.

Second, as people age, their creatinine clearance may become reduced, even if their creatinine is within the normal range.[6] The choice of opioids should take this into account. In general, most of the metabolism of opioids occurs in the liver.[7] The kidney is an important site for excretion. Some medications, such as morphine, should be used with caution among older adults, particularly in those with poor renal function, because of a tendency for renally accumulated metabolites to cause adverse effects. Others, such as meperidine, should not be used at all.


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