Judicious use of opioids justified in COPD: expert

There is an urgent need to dispel myths about the risks of using regular low-dose opioids in patients with COPD, according to Adelaide palliative care physician Professor David Currow and his colleagues.

Writing to the British Journal of Clinical Pharmacology in response to a Canadian study that claimed to identify safety concerns from over-prescribing, Professor Currow said the judicious use of opioids is justified.

“To preclude their use would continue to condemn a large population to poor symptom control,” he said.

The Canadian study analysed an Ontario database and found that 68% of community-dwelling patients with COPD had been treated with opioids during the 10-year observation period.

The figure was 54% in long-term care residents, who also received multiple dispensing (9%), dispensing for more than 30 days duration (up to 20%) and early refills (24%).

The Canadian researchers acknowledged that opioids could reduce dyspnoea in advanced COPD but said they could also predispose to negative respiratory outcomes and were associated with well-known side effects including falls and fractures, dizziness, delirium, somnolence, constipation, nausea and vomiting.

“The authors imply in this paper that disasters await clinicians who prescribe opioids in people with COPD for symptom relief,” Professor Currow said.

“The paper refers to ‘significant risks’ when the data presented and references cited are non-randomised studies that describe observed ‘associations’ only.

“The data presented…do not support the authors’ conclusion that ‘potential safety concerns are raised by the degree and pattern of new opioid use’ in people with COPD.”

There was no discussion in the paper of the potential costs of avoiding opioids, such as increased exacerbations and more ED presentations.

“More than 90% of people with advanced COPD have breathlessness at rest or on minimal exertion and between one-third and two-thirds have pain,” Professor Currow said.

“Symptom control is necessary in order to avoid a range of morbidities. Having long term, uncontrolled pain or breathlessness is a cause of significant suffering, and is intolerable when, for example, evidence supports the effective and safe use of regular low dose sustained release morphine for chronic refractory breathlessness.”

More work is needed to define who will benefit most, and safely, from opioids in COPD and to ensure that it becomes a registered treatment for chronic refractory breathlessness, he concluded.

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