Hospitalized patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD) are not frequently prescribed opioids for severe breathlessness, and those who are prescribed opioids for breathlessness do not receive timely follow-up to assess their treatment outcomes after discharge, according to study results published in the Journal of Pain and Symptom Management.
This retrospective cohort study included patients with COPD or ILD who were hospitalized at the Royal Melbourne Hospital in Australia with an acute exacerbation or breathlessness crisis between 2016 and 2018 (N=412). Investigators examined patients’ electronic medical records to collect data regarding demographics, comorbidities, functional capacity, and disease severity. Additional data collected for the study included the prescribing rates for opioids during admission or on discharge.
Overall, participants underwent 700 hospital admissions and presented with severely impaired respiratory function (median forced expiratory volume in 1 second, 48% predicted), significant hypoxemia (median arterial blood gas partial pressure of oxygen, 57.2 mm Hg), and several comorbidities (n=4). A total of 44 (10.7%) patients were newly prescribed an opioid medication, whereas 10 (2.4%) patients had their preexisting opioid prescription dose increased during hospitalization to treat breathlessness. Patients underwent a median of 2 respiratory admissions in the previous 2 years.
Approximately 6.3% of the patients who were newly prescribed an opioid or had their preexisting opioid dose increased also continued their new opioid regimen on discharge. These patients demonstrated significantly worse diffusion capacity vs patients not treated with opioids (P =.026). Approximately one-third (33.3%) of patients who were newly prescribed opioids or had increased opioid doses received nonpharmacologic breathlessness management education delivered by physiotherapists or nurses. Only 5.6% of patients had documentation that the new opioid prescription or dose alteration was discussed during admission.
Morphine was the most commonly prescribed opioid on discharge for the management of breathlessness (n=18). The median morphine dose prescribed was 20 mg oral morphine equivalents per day. Patients with COPD were prescribed a higher median daily dose compared with patients with ILD (24 mg vs 15.5 mg, respectively). Follow-up arrangements were made at discharge for 83.3% (n=45) of the 54 patients who were newly prescribed opioids or had their opioids altered. The median requested time interval between discharge and outpatient appointment was 28 days, whereas the actual median time interval between discharge and outpatient appointment was 42 days.
Limitations of this study included its retrospective design as well as the inclusion of patients from a single center.
Given these findings, the researchers suggested that there exists “an urgent need for clinical research to identify new, effective strategies to address severe breathlessness in both inpatients and outpatients with advanced chronic respiratory diseases.”
Chen X, Treanor D, Le B, Smallwood N. Gaps in opioid prescription for severe breathlessness in hospitalised patients with chronic obstructive pulmonary disease or interstitial lung disease [published online May 20, 2020]. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2020.05.017