Fourth-line opioids (specialist use only)

(refer to hydromorphone information sheet)

• Potent opioid for specialist use only.
• Frail or elderly patients need smaller doses, less frequently with slower titration.
• Available in oral capsules and MR capsules and an unlicensed immediate release hydromorphone oral solutionⴕ. Hydromorphone can also be given by injection
• Liver impairment, reduced clearance. Start at a lower dose and closely monitor.
• Renal impairment, reduced excretion. Titrate slowly and closely monitor. Avoid in
  stage 4 and 5 Chronic Kidney Disease.
• At higher doses, consider medicines burden of breakthrough dose

(refer to methadone information sheet)

• Potent opioid for specialist use only.
• Oral methadone is used by specialists for complex pain where other opioids have inadequate efficacy.
• Available in oral tablet and liquid form. Methadone can also be given by injection.
• Dosing is difficult due to the potentially long and unpredictable half-life.
• Partial renal and biliary excretion occurs therefore dose reduction may not be required in Chronic Kidney Disease.
• Half-life is prolonged in severe liver disease.
• Conversion from other opioids to methadone is complex and inpatient admission is advised.