ABSTRACT
This chapter presents a case study of Linda, who is a 43-year-old lady with myeloma. Despite some poor renal function initially, she did well with chemotherapy. Two months ago she relapsed and developed lytic bone lesions. While she was waiting for the treatment to take effect she was started on morphine for pain. Hydromorphone has fewer renally excreted active metabolites than morphine and may be safe in mild to moderate renal impairment, but in severe renal failure fentanyl is the opioid of choice. Diamorphine is converted to morphine, and apart from greater solubility for injection it has no advantages. Morphine, diamorphine and hydromorphone have renally excreted metabolites, methadone and fentanyl do not. The pin-point pupils and the circumstances of her illness suggest the last cause. One of the active metabolites of morphine is morphine-6-glucuronide which is water soluble and excreted by the kidneys.
