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

Authors and Disclosures

Marc Ginsburg, RN, MScN, NP, Medical Student, University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles.

Shawna Silver, MD, PEng, Resident, Department of Pediatrics, Hospital for Sick Children, University of Toronto,Toronto, ON.

Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network; Associated Medical Services Fellow in End-of-Life Care Education, University of Toronto; Centre for Innovation In Complex Care, University Health Network, Toronto, ON.

Disclosure: No competing financial interests declared.

Key Points

• Older adults can take opioids but may need to be started at lower dosages and titrated up more slowly.

• Creatinine clearance is a key consideration in the choice of which opioid to use.

• Meperidine should never be used for pain in older adults.

• When converting between opioids, attention must be paid to the potential for incomplete cross-tolerance.

• Close monitoring is essential after any change in opioid prescription.

Clinical Pearls

Because creatinine clearance can be significantly decreased in older adults, opioids with few or no renally cleared metabolites, such as hydromorphone or oxycodone, are preferred choices. When converting from one opioid to another, a stable dosage should be established using an immediate-release formulation before switching to a sustained-release formulation.