Jill Stein

September 14, 2009

September 14, 2009 (Vienna, Austria) — Opioids are underprescribed in patients with chronic obstructive pulmonary disease (COPD) and refractory dyspnea who are nearing death, despite increasing evidence that supports the use of opioids in this population, investigators reported here at the European Respiratory Society (ERS) 19th Annual Congress.

In fact, the data reveal that patients with advanced COPD are much less likely to be prescribed opioids in the community than patients with advanced lung cancer, even though dyspnea is significantly more common in advanced COPD than in advanced lung cancer.

"We estimate that about 50% of patients with advanced COPD and dyspnea are refractory to conventional dyspnea treatment involving bronchodilators, steroids, and oxygen, although we still need to establish the prevalence and correlates of refractory dyspnea in this population," Donna Goodridge, RN, PhD, associate professor of nursing at the University of Saskatchewan in Saskatoon, told Medscape Pulmonary Medicine. "Given the known efficacy of opioids in these patients, we believe there is a potential role for carefully initiated and titrated opioids."

Dr. Goodridge noted that her colleague, Graeme Rocker, MD, who is head of the Division of Respirology at Dalhousie University in Halifax, Nova Scotia, recently proposed the use of a "dyspnea ladder" for the management of breathlessness. Similar to the World Health Organization pain ladder, the first step incorporates conventional approaches to dyspnea management, with supplementation by nonpharmacological approaches in step 2. These approaches include pulmonary rehabilitation, cognitive behavioral therapy, and self-management. Opioids, she added, may be helpful at step 3, when dyspnea persists at a high level despite optimal conventional therapies. A low-dose (perhaps 0.5 mg of oral morphine twice a day), measured approach to initiating opioids is important in this population, and opioid titration can occur weekly, depending on the patient's response.

Dr. Goodridge's group compared the frequency of opioid prescriptions for patients with COPD or lung cancer in the last 3 months of life using administrative data for 1035 Saskatchewan residents: 433 lung cancer patients and 602 COPD patients.

"Depending on the series, between 32% and 79% of lung cancer patients and 56% and 95% of COPD patients complain of dyspnea in the last days or weeks of life," Dr. Goodridge observed.

"While dyspnea is frequently refractory to optimized medical therapy in patients with late-stage COPD, a large body of evidence has shown significant improvement in dyspnea in this difficult-to-treat population," she said. Benefits are most pronounced with oral or parenteral opioids.

However, despite compelling data, "deeply embedded" concerns among both doctors and patients thwart the widespread use of opioids in patients with advanced COPD, she continued. It is often incorrectly assumed that opioid use will precipitate respiratory depression, and careful titration will prevent this complication. Both the American Academy of Pain Medicine and the American Pain Society have stated that denying patients appropriate opioids on the basis of respiratory concerns is unwarranted.

Opioids, however, are frequently used to control symptoms, including pain and dyspnea, in patients with advanced cancer.

In this study, Dr. Goodridge and colleagues examined predictors of opioid use in the last year of life and described differences in the opioid prescriptions between patients who died from lung cancer and those who died from COPD.

Study outcomes included community prescriptions for the oral and nonoral forms of selected strong opioids (morphine, hydromorphone, and transdermal fentanyl).

The data showed that in the last 3 months of life, nearly half (47.6%) of lung cancer patients, but only 15.6% of COPD patients, received at least 1 prescription for any form of morphine, hydromorphone, or fentanyl (P < .001).

After adjustment for age, sex, residence, palliative-care consultation, comorbidities, and place of death, patients with lung cancer were more likely than those with COPD to be prescribed any opioid (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.80 - 3.80); oral morphine (OR, 2.36; 95% CI, 1.52 - 3.67); oral hydromorphone (OR, 2.69; 95% CI, 1.53 - 4.72), or transdermal fentanyl (OR, 2.25; 95% CI, 1.28 - 3.98) in the last 3 months of life (P < .005 for all).

The findings were maintained whether patients died in the hospital, at home, or at a long-term care institution.

Dr. Goodridge said that her group was surprised at the discrepancy in opioid use between the 2 patient groups, "especially since we know that symptom burden at the end of life is similar." However, she was quick to add that her group's observation that only 2.8% of the individuals who died from COPD received formal palliative-care services in the community might reflect the need for an increased focus on symptom management in this patient population.

"As with pain in COPD patients, we have good evidence that opioids may help, and it is true that opioids are used less often for dyspnea than they are for pain relief," Leonardo Fabbri, MD, professor of respiratory medicine at the University of Modena, in Italy, and past president of the ERS, told Medscape Pulmonary Medicine. "So this study provides a very important message: Please read the literature supporting the use of opioids to relieve dyspnea in end-of-life COPD patients."

The study was funded by the Saskatchewan Health Research Foundation. Dr. Goodridge and Dr. Fabbri have disclosed no relevant financial relationships.

European Respiratory Society (ERS) 19th Annual Congress: Abstract E442. Presented September 13, 2009.

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