Which opioid is considered the best choice for a 76-year-old female with renal insufficiency experiencing severe pain from a compression fracture?

For a 76-year-old female with renal insufficiency experiencing severe pain, the best choice among the opioids listed is hydrocodone/acetaminophen. This combination medication is often utilized for its effectiveness in managing moderate to severe pain while also being safer for patients with compromised renal function.

In renal insufficiency, some opioids rely heavily on the kidneys for elimination, which can lead to toxic accumulation and increased side effects. Hydrocodone primarily undergoes hepatic metabolism and therefore may have a more predictable safety profile in patients with renal impairment, particularly when used in combination with acetaminophen for enhanced analgesia.

The other options present varying degrees of risk in the context of renal insufficiency. Meperidine is not recommended in patients with renal impairment due to its neurotoxic metabolite, normeperidine, which can accumulate and lead to seizures. Fentanyl, while safer than some other opioids due to its minimal renal metabolism, still poses risks of sedation and respiratory depression, especially in the elderly or those with comorbidities. Morphine, although effective, is largely cleared by the kidneys; thus, it can lead to increased side effects or toxicity in a patient with renal dysfunction, making it less than ideal.