Junior doctors may be a little too enthusiastic about the use of opioids for the management of refractory breathlessness in patients with COPD.
According to a survey of basic trainees in Victoria, most (87%) believed that opioids have a role in the management of breathlessness and 64% would recommend it as a first line treatment.
Almost half (46%) said they had prescribed an opioid for this indication under supervision and 25% said they had initiated opioid treatment themselves.
More than one quarter (26%) of the doctors said they had no concerns prescribing an opioid for COPD patients.
The results suggest a generational change in attitudes given well-documented reluctance by doctors to prescribe opioid treatment despite the evidence base for its use.
Melbourne respiratory physician and co-author Dr Natasha Smallwood told the limbic there might be some ‘bravado’ involved with so many junior doctors reporting they had initiated opioid treatment themselves.
“Perhaps it means that senior physicians are actually coming on board and the confidence of junior doctors is mirroring a change in practice of senior general and respiratory physicians.”
She said it was exciting that junior doctors were recognising that there were additional options for symptom control beyond optimal management of the patients’ disease.
“There is recognition that low dose, extended-release morphine works and that it has an evidence base. The fact they have no concerns though is extraordinary and surprising.”
She said the fact that opioids were prescribed off-licence for the treatment of chronic breathlessness should add a layer of caution and scrutiny to the practice.
“Most senior physicians still feel uncomfortable using opioids before every other option has been offered and exhausted.”
Dr Smallwood said junior doctors did not appear to be as aware of non-pharmacological options and many (40%) said incorrectly that benzodiazepines had a role in the management of refractory breathlessness.
“Clearly there is some enthusiasm for opioids but also some knowledge gaps in suggesting benzodiazepines, long-term prednisolone and nebulisers, which are not in the guidelines and for which there is poor evidence,” she said.
The risk of respiratory depression from opioids was the major concern of junior doctors however they were less concerned about long-term side effects such as constipation, dysphoria and sedation.