SAN DIEGO — Patients with advanced chronic obstructive pulmonary disease (COPD) may not be getting effective treatment for dyspnea toward the end of life, researchers reported here.
A retrospective review of administrative claims data showed that patients with advanced COPD were significantly less likely to receive morphine in the last three months of life than those with terminal lung cancer (OR 2.36, 95% CI 1.52 to 3.67), according to Donna Goodridge, PhD, of the University of Saskatchewan in Saskatoon.
They were also less likely to receive palliative care at home (2.8% versus 37.4%, P<0.005), and palliative care itself was associated with an increased likelihood of receiving morphine in the months before death (OR 2.64, 95% CI 1.72 to 4.06), Goodridge said at the American College of Chest Physicians meeting.
She said the findings underscore the need for further research.
“We need to explore the efficacy and safety of opioid use for relief of dyspnea at the end of life in persons with COPD,” she said. “And we also need to assess patient, family, and clinician experiences with opioid use for dyspnea at the end of life for those people dying of COPD.”
Dyspnea is the most burdensome symptom and a source of disability in end-stage COPD, Goodridge said, and it doesn’t respond to conventional therapies in 56% to 98% of patients.
Opioids are commonly used to treat dyspnea in patients with terminal cancer, but Goodridge said she was surprised to see that there wasn’t a very good management strategy in COPD.
Low doses of opioids could relieve dyspnea in COPD patients by reducing total ventilation, increasing ventilatory efficiency with exercise, reducing responses to hypoxia/hypercapnia, and reducing the drive to breathe, Joanne Young, a registered respiratory therapist at Dalhousie University in Halifax, Nova Scotia, and colleagues noted in a separate presentation at the meeting.
The drugs might also affect bronchoconstriction, they said in a poster session.
A 2002 meta-analysis in Thorax found that both oral and parenteral opioids had a positive effect on breathlessness (P=0.0008) in all patient groups, including those with COPD. But how often patients with COPD are treated with opioids has not been well studied.
So Goodridge and her colleagues examined administrative data from the Saskatchewan Health Ministry on all patients who died during 2004 of lung cancer (433 patients) or COPD (602 patients).
Patients with COPD were less likely to die in the hospital and more likely to die in a long-term care facility (P<0.05).
In the last three months of life, more patients with lung cancer received a prescription for morphine (31% versus 9%).
The strongest predictor of receiving morphine was palliative care at home, which, though more frequent in patients with lung cancer, was surprisingly underused in both groups, Goodridge said.
“This is something that I think we may need to explore further,” she said.
The study by Young and colleagues explored possible reasons at the clinical level for the infrequent use of opioids in patients with advanced COPD.
The researchers interviewed 10 family physicians and eight respiratory therapists in the province of New Brunswick about their attitudes toward prescribing the medications for the relief of dyspnea.
Although the clinicians all agreed that the control of dyspnea was the biggest challenge in treating patients with end-stage COPD, there was reluctance in using opioids unless death was imminent.
They cited concerns about respiratory depression, as well as about a lack of education and guidance from professional societies.
Two younger family physicians who received training in palliative care during their residencies expressed more comfort in using opioids for these patients.
Like Goodridge, Young and colleagues called for further research regarding the use of opioids for relieving dyspnea at the end of life in patients with COPD.
The study by Young and colleagues received funding from the Atlantic Health Sciences Corporation Health Promotion and Research Fund.
None of the authors of either of the studies reported any conflicts of interest.