Can opioids (narcotics) exacerbate Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Yes, opiates can worsen COPD, as they can suppress respiratory drive and reduce the cough reflex, leading to increased risk of respiratory complications. According to the study by P.Z. Sobanski et al. 1, morphine should be used with caution in patients with severe COPD, and doses should be titrated to a maximum of 30 mg/24 h of oral morphine to minimize the risk of excess mortality or hospital admission. The study also notes that other opioids, such as oxycodone, have shown no benefit over placebo in managing breathlessness in people with heart failure 1.

Key Considerations

• Opiates can suppress respiratory drive, causing slower and shallower breathing, which is particularly dangerous for COPD patients who already have compromised lung function.
• Opiates can reduce the cough reflex, leading to mucus buildup and increased risk of respiratory infections.
• Non-opioid alternatives, such as acetaminophen, NSAIDs, or specialized COPD treatments like bronchodilators and inhaled corticosteroids, are generally preferred for managing pain and breathlessness in COPD patients.
• The underlying mechanism involves opioids binding to receptors in the brain's respiratory center, decreasing its sensitivity to carbon dioxide levels, which normally stimulate breathing when elevated.

Recommendations

• Healthcare providers should use the lowest effective dose of opioids, often starting with less potent options like codeine or tramadol, and closely monitor respiratory function in COPD patients who require pain management.
• COPD patients should always inform healthcare providers about their lung condition before receiving any opiate prescription.
• As noted in the study by 1, breathlessness management in people with heart failure should be pursued with caution, and non-pharmacological and pharmacological symptomatic treatment should be tailored to the individual patient's needs.

From the FDA Drug Label

Patients with Chronic Pulmonary Disease: Morphine sulfate tablets-treated patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages of morphine sulfate tablets

• Key points:
  • Morphine sulfate tablets can increase the risk of decreased respiratory drive in patients with chronic obstructive pulmonary disease (COPD)
  • Patients with COPD are at increased risk of respiratory depression, even at recommended dosages
  • COPD can be worsened by the use of morphine sulfate tablets due to the increased risk of respiratory depression and decreased respiratory drive 2

From the Research

Opiates and COPD

• Opiates can have both positive and negative effects on patients with Chronic Obstructive Pulmonary Disease (COPD) 3, 4, 5, 6, 7.
• Low-dose opioids have been shown to be effective in reducing symptoms of dyspnea in patients with severe COPD, without increasing the risk of hospital admission or death 3, 4.
• However, higher doses of opioids may increase mortality in COPD patients 3.
• The use of opioids for breathlessness in end-stage COPD is still debated, with some studies suggesting that they are underused due to fear of complications 5.
• Chronic pain is a common problem in patients with COPD, and opioids are often used to manage this pain 6.
• A literature review found that the quality of evidence for the use of opioids in COPD is low or inconclusive, and that more research is needed to determine the effectiveness and safety of opioids in this population 7.

Safety and Efficacy

• Low-dose opioids (≤30 mg oral morphine equivalents/day) have been shown to be safe and effective in reducing symptoms of dyspnea in patients with severe COPD 3, 4.
• Higher doses of opioids may increase the risk of respiratory depression and other adverse events 3.
• The use of transdermal fentanyl may have fewer side effects than morphine, but more research is needed to confirm this 7.
• A multicenter double-blind study is currently underway to investigate the effectiveness and safety of low-dose morphine and fentanyl in patients with COPD and refractory dyspnea 7.

Clinical Implications

• Clinicians should consider the use of low-dose opioids in patients with severe COPD and refractory dyspnea, but should carefully weigh the potential benefits and risks 3, 4.
• Patients with COPD should be closely monitored for signs of opioid-related adverse events, such as respiratory depression 3.
• More research is needed to determine the optimal dose and duration of opioid therapy in patients with COPD, as well as the potential benefits and risks of different opioid formulations 7.