What is the relationship between Chronic Obstructive Pulmonary Disease (COPD) exacerbation and opioid use?

From the Guidelines

Opioids should be used cautiously in COPD exacerbations, but they can be appropriate for managing dyspnea in severe cases when benefits outweigh risks, as stated in the most recent guideline from 2023 1.

Key Considerations

• Low-dose opioids such as morphine (2.5-5mg orally every 4 hours), hydromorphone (0.5-1mg orally every 4 hours), or fentanyl (12.5-25mcg transdermal) may be considered for patients with refractory breathlessness despite optimal bronchodilator therapy.
• Start with the lowest possible dose and titrate slowly while monitoring respiratory rate, oxygen saturation, and level of consciousness.
• Immediate-release formulations are preferred initially over extended-release options.
• Patients should be closely monitored for respiratory depression, especially those with hypercapnia, as opioids can suppress respiratory drive.

Non-Opioid Approaches

• Non-opioid approaches should be maximized first, including:
  • Optimal bronchodilator therapy (short-acting beta-agonists like albuterol and anticholinergics like ipratropium)
  • Corticosteroids
  • Oxygen therapy if indicated
  • Non-pharmacological interventions such as positioning, breathing techniques, and anxiety management

Mechanism of Opioid Effectiveness

• The mechanism behind opioid effectiveness in dyspnea involves reducing respiratory drive, decreasing oxygen consumption, blunting the perception of breathlessness, and reducing anxiety.

Ongoing Opioid Therapy

• For patients requiring ongoing opioid therapy, regular reassessment of benefit versus risk is essential, with dose reduction or discontinuation if adverse effects occur or when the exacerbation resolves, as recommended by the 2017 global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 1.

Prevention of Exacerbations

• Prevention of exacerbations is a key objective in COPD management, and treatments that effectively reduce the frequency and/or severity of exacerbations may have an impact on quality of life, the progression, and ultimately the prognosis of COPD, as stated in the 2017 European Respiratory Society/American Thoracic Society guideline on prevention of COPD exacerbations 1.

From the Research

COPD Exacerbation and Opioid Use

• COPD exacerbations can cause significant morbidity and mortality, and effective management is crucial for patient care 2.
• The use of opioids for managing refractory dyspnea in COPD is a topic of interest, with some studies suggesting a small improvement in dyspnea, but also an increased risk of respiratory-related exacerbation, hospitalization, and death 3.
• Current guidelines recommend inhaled pharmacologic therapy as the preferred route of administration for treating COPD, with bronchodilators being the mainstay of pharmacologic therapy 4.
• The American Thoracic Society clinical practice guideline recommends a conditional approach to opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy 5.
• Barriers to prescribing opioids for managing chronic breathlessness in COPD include a lack of training, education, inadequate guidelines, and concerns surrounding respiratory depression and other side effects 6.

Opioid Use in COPD Management

• Opioid efficacy trials demonstrate at best a small improvement in dyspnea in limited numbers of individuals with COPD, whereas safety trials consistently show an increased risk of respiratory-related exacerbation, hospitalization, and death in association with opioid use 3.
• The current body of evidence does not support the wide application of opioids to manage refractory dyspnea among individuals with COPD, but instead, a highly selective and careful approach 3.
• Opioid use for refractory breathlessness in COPD is likely under-prescribed by healthcare professionals working in areas other than palliative care 6.

Guidelines and Recommendations

• The American Thoracic Society clinical practice guideline provides recommendations for the pharmacologic treatment of COPD, including a conditional recommendation for opioid-based therapy in patients with advanced refractory dyspnea 5.
• Guidelines should offer further advice on when to start opioids and which patients would benefit most from opioids 6.