The clinical utility of most analgesic drugs is altered in the presence of patients with impaired renal function, not simply because of altered clearance of the parent drug, but also through production and accumulation of toxic or therapeutically active metabolites. The author reviews the literature pertaining to the metabolism of several of the commonly used opioids, and the known activity of their metabolites. The effect of renal failure on the pharmacokinetics of these drugs and metabolites is then reviewed. Based on the review, it is recommended that morphine and codeine are avoided in renal failure/dialysis patients; hydromorphone or oxycodone are used with caution and close monitoring; and that methadone and fentanyl/sufentanil appear to be safe to use. Besides, it's also recommended morphine dosage reduction for renal failure patients, and based on patient's GFR (glomerular filtration rate) to modify the morphine dosage. Extra dosing of morphine is also needed during or after dialysis to achieve ideal pain control. The least dialyzable opioids seems to be comparative safe drug for renal failure or dialysis patients.