Although there are many exceptions, the following information describes drugs and medication-delivery routes that should be avoided in hospice and palliative care settings.
Drug: Meperidine
Very low potency when give orally. Active metabolite, normeperidine, accumlates in diminished renal function. May precipitate seizures, confusion, and tremors.
Drug: Mixed agonist-antagonist (e.g., pentazocine)
No more potent than codeine. High incidence of hallucinations and agitation (30% in cancer patients). Inhibits analgesia of morphine.
Propoxyphene
No more potent than acetaminophen. Active metabolites, norpropoxyphene, accumulates in diminished renal function. May precipitate seizures, confusion, dizziness, cardiotoxicity, and respiratory depression.
Routes: IM Injections
Morphine, 30mg, PO is as potent as 10mg IM/SC. Avoid the pain and expense of IM injections with PO or SL morphine. If a patient cannot tolerate anything PO, start an SC infusion or give slow-release morphine tablets rectally.