COPD patients who use opioids at risk from respiratory complications

Older patients with chronic obstructive pulmonary disease (COPD) who take opioids to relieve their symptoms increase their risk of dying from a respiratory-related complication compared with non-opioid users, according to new research.

Nicholas Vozoris, a respirologist at St Michael’s Hospital in Toronto, Canada, and colleagues found that the use of combination products, which tend to contain less potent opioids, such as codeine with caffeine, and which are traditionally believed to be safer for COPD patients, also increased mortality risk.

The findings, reported in the European Respiratory Journal
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(online, 14 July 2016), are based on an analysis of 130,000 records of COPD patients aged over 65 years who were on the Institute for Clinical Evaluative Sciences database in Canada. Of those patients, 68% were new opioid users.

The researchers found that risk of COPD or pneumonia-related mortality increased when COPD patients started combination opioids/non-opioid agents compared with COPD patients who did not use opioids (hazard ratio [HR] 1.58, 95% confidence interval [CI] 1.16-2.14).

In users taking products that contained a single opioid, such as hydromorphone or levorphanol, rather than a combination product, the risk of dying from COPD or pneumonia was almost five times higher than for non-opioid users (HR 4.76, 95% CI 3.40-6.66).

The results also showed that new opioid users were more likely to visit emergency departments for COPD or pneumonia compared with non-users (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.00–1.29; P=0.04).

However, outpatient exacerbation risk was lower among opioid users (HR 0.88, 95% CI 0.83–0.94); and there were no significant associations linked to hospitalisations, or intensive care unit admissions during hospitalisations, for COPD or pneumonia among these patients.

“Previous research has shown about three-quarters of older adults with COPD have been prescribed opioids, which is an incredibly high rate of new use in a population that is potentially more sensitive to narcotics,” says Vozoris. “Our new findings show there are not only increased risks for respiratory-related death associated with new opioid use, but also increased risk of visits to emergency rooms, hospitalisations and needing antibiotics or steroid pills.”

Analysis of the data suggested that use of combination opioid/non-opioid drugs, which are generally less potent, could be associated with less respiratory risk among older adults living in the community. But frailer, older adults who live in long-term residential care homes showed more vulnerability for several serious adverse respiratory outcomes with use of these agents.

“The fact that incident opioids are frequently initiated in older adults with COPD makes these results particularly worrisome,” the authors say. “Our findings suggest that a careful, individualised approach needs to be taken when administering opioids to older adults with COPD, given the potential for adverse respiratory outcomes.”

Richard Russell, honorary medical adviser for the British Lung Foundation, warns that the findings must be interpreted cautiously. “These data suggest associations but cannot define causality. This is important. What if the people taking opiates all had cancer? You would then expect them to die more and they would die more of respiratory disease.”

Russell also points out that people with severe COPD often have pneumonias and attacks of acute lung disease. “It may well be that the opiates are very important for symptom control. If they are relieving breathlessness then this may be more valuable to an individual patient than perhaps their overall length of life,” he says.