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Physicians hesitant to prescribe opioids for advanced COPD

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Despite a guideline in Canada recommending the use of opioids to relieve refractory dyspnea in COPD patients, physicians there are reluctant to do so.

“Bridging this gap will require initiatives to improve the uptake of practice guidelines and to increase confidence in prescribing opioids for dyspnea refractory to conventional treatment,” conclude the authors of the report in the Canadian Medical Association Journal issued April 23 online.

Dr. Graeme Rocker, at Dalhousie University in Halifax, Nova Scotia, and colleagues explain that a recent national guideline from the Canadian Thoracic Society recommends the use of opioids for refractory dyspnea in patients with advanced COPD. However, long-standing practice may inhibit the uptake of this recommendation.

To increase understanding of the issues, the team conducted a qualitative study with eight patients with advanced COPD taking morphine or fentanyl for severe dyspneic episodes, 12 caregivers, and 28 physicians.

All patients reported that opioids improved their quality of life, relieved their dyspnea, or both. The caregivers saw the benefit as substantial and did not feel adverse effects were much of a concern, the authors report.

The physicians interviewed practiced family medicine (n = 10), respiratory medicine (n = 6), internal medicine (n = 6) and palliative medicine (n = 6). “They expressed various levels of comfort with prescribing and administering opioids in hospital settings; most were uncomfortable with prescribing opioids in home or community settings,” the investigators found.

For many of the physicians, the risk of respiratory depression, lack of knowledge about opioids, and the possibility of censure for prescribing opioids in this setting were a concern.

“From a medical perspective, a shroud of uncertainty and disquiet continues to surround the use and prescription of opioids for patients with COPD,” Dr. Rocker and colleagues write.

Still, they conclude, “Evidence is accumulating to suggest that soon the appropriate question will no longer be if we should prescribe opioids to help palliate refractory dyspnea in patients living with advanced COPD, but rather how to do this competently and when.”


Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease

CMAJ 2012.