Attitudes toward opioids for refractory dyspnea in COPD among

Dutch chest physicians

ABSTRACT

Dyspnea is the most frequently reported symptom of outpatients with advanced chronic

obstructive pulmonary disease (COPD). Opioids are an effective treatment for dyspnea.

Nevertheless, the prescription of opioids to patients with advanced COPD seems limited. The aims

of this study are to explore the attitudes of Dutch chest physicians toward prescription of opioids

for refractory dyspnea to outpatients with advanced COPD and to investigate the barriers

experienced by chest physicians toward opioid prescription in these patients. All chest physicians

(n = 492) and residents in respiratory medicine (n = 158) in the Netherlands were invited by e-mail

to complete an online survey. A total of 146 physicians (response rate 22.5%) completed the online

survey. Fifty percent of the physicians reported to prescribe opioids for refractory dyspnea in 20%

or less of their outpatients with advanced COPD and 18.5% reported never to prescribe opioids in

these patients. The most frequently reported barriers toward prescription of opioids were resistance

of the patient, fear of possible adverse effects, and fear of respiratory depression. To conclude,

Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory

dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of

the patient and fear of adverse effects, including respiratory adverse effects.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a chronic, incurable, and often progressive

disease and is nowadays the third leading cause of death. In the last decade, the needs for palliative care for

patients with COPD have been recognized. Cornerstone of palliative care is optimal symptom management.
Symptom burden of patients with advanced COPD is at least comparable to symptom burden of patients

with cancer. Dyspnea is the most frequently reported symptom of patients with advanced COPD. Dyspnea

has significant impact on the patient as well as the family caregiver and is a major determinant of health

status.

Previous studies have shown that opioids can relieve dyspnea. Therefore, international statements

recommend the use of opioids to treat refractory dyspnea in patients with COPD. Nevertheless, the

prescription of opioids in patients with advanced COPD seems limited. In fact, only one-fourth of the

patients with COPD received opioids in their last 6 months of life, while half of the patients with lung

cancer received opioids. Moreover, while 94% of the clinically stable outpatients with advanced COPD

reported moderate to severe dyspnea, only 2% used opioids, such as morphine. Exploring the attitudes of

chest physicians toward prescription of opioids to patients with advanced COPD is needed to understand

why implementation of guidelines concerning the use of opioids for refractory dyspnea in daily practice is

limited.

CONCLUSION

Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory

dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of the

patient and fear of adverse effects, including respiratory adverse effects. In addition, predicting which

patients are likely to respond to opioids remains difficult. To facilitate implementation of current guidelines

about opioid prescription for dyspnea, these barriers need to be addressed. Therefore, future studies should

explore the perceived resistance of patients, the occurrence of adverse (respiratory) effects of opioids in

COPD, and how to select which patients are likely to respond to opioids. Guidelines about the use of opioids

for dyspnea should include prevention and management of adverse effects. Finally, adequately powered

randomized controlled trials are needed to explore the effect of different opioids and different

administration routes on dyspnea, including episodic dyspnea.