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.

REFERENCE

Janssen, D. J., de Hosson, S., bij de Vaate, E., Mooren, K. J., & Baas, A. A. (2015). Attitudes toward

opioids for refractory dyspnea in COPD among Dutch chest physicians. Chronic Respiratory

Disease, 85–92. https://doi.org/10.1177/1479972315571926