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Br J Clin Pharmacol. 2016 May; 81(5): 999.
Published online 2016 January 17. doi:  10.1111/bcp.12856
PMCID: PMC4834585

Opioids and COPD

The survey by Dr Vozoris et al. 1 is timely and questions too liberal use of opioids in the COPD population. An American College of Chest Physicians consensus on dyspnoea 2 stated ‘with appropriate titration opioids have not caused significant changes in survival after withdrawal of life support’, and this was recently repeated in an overview on dyspnoea 3. Such a statement has appeared widely in the medical litterature, but its applicability to clinical practice outside terminal weaning and especially in patients with COPD is questionable. Articles by Chan et al., Daly et al., Stone et al., Thorns et al. and Jenning et al. 4, 5, 6, 7, 8 have been cited in support, but one should scrutinize them. Chan et al. 4 described 75 patients (20 primarily suffered acute respiratory failure) who died in the intensive care unit after withdrawal of mechanical ventilation, and found that medium time to death was 35 min (range 1 min to 15 h). Time to death was not influenced by narcotic dose. Daly et al. 5 described 42 subjects with ‘terminal weaning’ due to various pathologies. One‐third died within 1 h, survival ranged from 1 h to 6 days, 88% received morphine and survival duration was unrelated to morhine dosage. In the hospice population studied by Stone et al. 6 without reference to COPD, mean survival was 1.3 days. Thorns et al. 7 concluded that in a terminal population on morphine ‘death was not hastened by increasing the dose in the last 24 h’. Furthermore in small populations statistics are likely to reveal no difference. The Cochrane review of Jennings et al. 8 has been withdrawn. Being near to our patients with disabling COPD we should discuss carefully with them whether they should intitiate morphine or not, titrate carefully and monitor carefully for side effects.

Competing Interests

The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organization for the submitted work.

Notes

Van Renterghem D. M. (2016) Opioids and COPD. Br J Clin Pharmacol, 81: 999. doi: 10.1111/bcp.12856.

References

1. Vozoris NT, Wang X, Fischer HD, Gershon AS, Bell CM, Gill SS, O'Donnell DE, Austin PC, Stephenson AL, Rochon PA. Incident opioid drug use among older adults with chronic obstructive pulmonary disease: a population‐based cohort study. Br J Clin Pharmacol 2016; 81: 161–70. doi:10.1111/bcp.12762. [PubMed]
2. Mahler DA, Selecky PA, Harrod CG, Benditt JO, Carrieri‐Kohlman V, Curtis JR, Manning HL, Mularski RA, Varkey B, Campbell M, Carter ER, Chiong JR, Ely EW, Hansen‐Flaschen J, O'Donnell DE, Waller A. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest 2010; 137: 674–91. [PubMed]
3. Mahler DA, O'Donell D. Recent advances in dyspnea. Chest 2015; 147: 232–41. [PubMed]
4. Chan JD, Treece PD, Engelberg RA, Crowley L, Rubenfeld GD, Steinberg KP, Curtis JR. Narcotic and benzodiazepine use after withdrawal of life support: association with time to death? Chest 2004; 1261: 286–93. [PubMed]
5. Daly BJ, Thomas D, Dyer MA. Procedures used in withdrawal of mechanical ventilation. Am J Crit Care 1996; 55: 331–8. [PubMed]
6. Stone P, Phillips C, Spruyt O, Waight C. A comparison of the use of sedatives in a hospital support team and in a hospice. Palliat Med 1997; 112: 140–4. [PubMed]
7. Thorns A, Sykes N. Opioid use in last week of life and implications for end‐of‐life decision making. Lancet 2000; 3569227: 398–9. [PubMed]
8. Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev 2001; 4: CD002066. Cochrane Database of Systematic Reviews 2012, Issue 7. Withdrawal. [PubMed]

Articles from British Journal of Clinical Pharmacology are provided here courtesy of British Pharmacological Society