PURPOSE:Patients with advanced COPD usually suffer from progressive dyspnea. Dyspnea defies conventional treatment for 50% patients. Opioids have been advocated as potential treatment for dyspnea when other therapies fail. We sought to understand attitudes to use of opioids in advanced COPD among clinicians in Eastern Canada.
METHODS:Attendees at a Medical Society Education Day in Summerside, Prince Edward Island (PEI) and at Medical Grand Rounds at McGill University, Montreal completed a questionnaire that covered practice type, years of experience, comfort with dyspnea management in advanced COPD, attitudes to use and barriers to prescriptions of opioids in COPD, from both professional and patient/ family perspectives.
RESULTS:70 clinicians responded. Most (59/70) practiced primarily in hospitals. Licensed physician respondents were mostly from Internal (22), Family (15) and Palliative Medicine (5). Most (41/42) had prescribed opioids for dyspnea in COPD and (36/41) had found them effective. For use of opioids in a terminal situation 33 were very (11) or somewhat comfortable (22) with 14 neutral, falling to 6, 9 and 17 respectively for long term opioid use with 27 stating some discomfort. Respiratory depression (39) was a more common concern than addiction (18). Fear of death (21) or of addiction (21) were top recalled patient barriers to acceptance of opioids. A starting dose of 1–2mg QID was chosen by the highest number of respondents (22), much lower than doses recommended in recent professional guidelines.
CONCLUSION:Risk of respiratory depression remains a fear for many physicians. More than 40% of respondents were comfortable or neutral concerning use of opioids for long term use in advanced COPD and most were comfortable and/or found them effective in terminal stages.
CLINICAL IMPLICATIONS:Many physicians retain an aversion to use of opioids for dyspnea in advanced COPD that is not grounded in current evidence. Educational initiative should focus on solid evidence to overcome long held biases against the use of effective low dose opioid therapy for dyspnea resistant to conventional treatment in advanced COPD.
DISCLOSURE:Graeme Rocker, None.