Breathlessness, Benzodiazepines, and Opioids: Options for COPD Patients

A study evaluating the safety of benzodiazepines and opioids in chronic obstructive pulmonary disease patients finds that low-dose opioids may be safe for treating breathlessness in patients with severe cases.

Anyone who has ever had the wind knocked out of them has experienced the anxiety of struggling to take a breath. For those with chronic obstructive pulmonary disease (COPD), breathlessness is a frequent if not chronic fact of life. As the disease progresses and as COPD patients age, breathlessness often worsens, leading to chronic anxiety and concern. Almost all end-stage COPD patients experience long periods of dyspnea after minimal exertion. These patients often suffer when at rest, even if they are adequately treated with long-term oxygen therapy (LTOT).

Some research has suggested that oral sustained-release morphine can help patients who are breathless. Benzodiazepines, which are effective at relieving anxiety, may also help, but little research has been conducted to evaluate their safety in COPD patients. Now an international team of researchers has undertaken a population-based longitudinal consecutive cohort study of options to relieve breathlessness and associated anxiety. Their results were published in the January 30, 2014, issue of BMJ.

The study included 2249 patients in Sweden identified using the national Swedevox register and deemed eligible if they started LTOT for COPD between 2005 and 2009. Outcome measures were hospital admission rates and mortality. The researchers adjusted for age, sex, arterial blood gas tension, body mass index (BMI), World Health Organization performance status, previous admissions, comorbidities, and concurrent drugs.

In the study population, 1681 (76%) patients had hospital admissions after a median of 76 days of follow-up and 1129 (50%) died over a median follow-up period of 1.1 years. No patients were lost to follow-up. COPD patients receiving LTOT who were taking benzodiazepines or low-dose opioids (≤30 mg oral morphine equivalent per day) did not have significantly different hospital admission or mortality rates. This was true in patients who were opioid-naïve, concurrently using benzodiazepines, or who had hypercapnia. Patients taking concurrent benzodiazepines and opioids did not have increased risk for hospital admission.

Benzodiazepines and opioids were associated with a modest increase in mortality, with risk increasing along with dose. Low-dose opioids were not associated with increased mortality, but high-dose opioids (>30 mg oral morphine equivalent per day) were.

“Sustained release morphine should be considered as a first line treatment and should be initiated at a low dose regularly and titrated upward over days and weeks, balancing beneficial and adverse effects,” the researchers write. “Titration up to 30 mg morphine daily might safely improve breathlessness in over 60% of patients, with a mean decrease of 35% in the intensity of breathlessness from the person’s own baseline.”

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.