5 Aug 2016
Initiation of opioid use in elderly patients with chronic obstructive pulmonary disease (COPD) more than doubled the risk of death from respiratory-related complications compared with non-opioid users, according to a retrospective population-based cohort study in Canada.
“The fact that incident opioids are frequently initiated in older adults with COPD makes these results particularly worrisome,” the researchers said. “Our findings suggest that a careful, individualized approach needs to be taken when administering opioids to older adults with COPD, given the potential for adverse respiratory outcomes.”
“These data raise concerns regarding the degree and manner with which opioids are used among vulnerable older adults with COPD,” said study authors Dr. Nicholas Vozoris from the Division of Respirology at the Department of Medicine of St. Michael’s Hospital in Ontario, Canada, and Dr. Denis O’Donnell of the Department of Medicine at Queen’s University in Ontario, Canada.
These findings showed that adverse outcomes could also develop in new lower-dose opioid users (≤30 mg morphine equivalents per day) and not limited to higher-dose opioid users as suggested in previous studies, the authors added.
When comparing the subgroup of patients using opioid-only medication with controls, new opioid users had a higher risk of outpatient exacerbations (p<0.0001).
The subgroup of new opioid-only users were also more likely to visit the emergency department or be hospitalized for COPD or pneumonia, or die from COPD or pneumonia or any other cause compared with controls (all p<0.0001).
Opioid-only agents usually contain more potent opioids like codeine and were indicated at a higher dose than opioid/non-opioid combination therapy, which might explain the difference in exacerbation risk in the subgroup analysis, the authors said.
“I almost never use opioids for my COPD patients. I would think that opioid-containing medication may be used to suppress cough or try to relieve the sensation of dyspnoea in these patients [in the study],” said Dr. Ong Kian Chung, a consultant respiratory specialist from the KC Ong Chest & Medical Clinic at Mount Elizabeth Medical Centre, Singapore, who was unaffiliated with the study.
“I would be cautious if the patients are very frail, elderly, already requiring oxygen supplementation and/or non-invasive ventilatory support,” he said.
For such vulnerable groups of patients, antihistamines, mucolytics or dextromethophan can be used to manage cough, while long-acting bronchodilators such as methylxanthines can be used for chronic dyspnoea, and steroids for COPD exacerbation, suggested Ong.