Predictors of Opioid-related Adverse Pulmonary Events among Older Adults with Chronic Obstructive Pulmonary Disease

Rationale: Although opioids are frequently prescribed in chronic obstructive pulmonary disease (COPD), there is poor understanding regarding which individuals will experience pulmonary harm upon exposure.Objectives: We sought to identify patient characteristics and opioid drug properties predictive of opioid-related adverse pulmonary events among older adults with chronic COPD.Methods: A retrospective, population-based, cohort study design was used, analyzing Ontario heath administrative data. Individuals aged 66 years and older, with validated, physician-diagnosed COPD receiving a new opioid drug were included. Adverse pulmonary events (defined as an emergency room visit, hospitalization, or death related to either COPD or pneumonia) occurring within 30 days following new opioid receipt were considered. Multivariable-adjusted, cause-specific hazard modeling was used to identify predictors of adverse pulmonary events.Results: Out of 169,517 older adults with COPD receiving a new opioid, 4,861 (2.9%) experienced an adverse pulmonary event within 30 days. Factors independently predisposing to adverse pulmonary events included older age (≥85 yr old: hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.26-1.49), long-term-care home residence (HR, 1.32; 95% CI, 1.21-1.44), severe COPD exacerbation within the preceding year (HR, 2.96; 95% CI, 2.77-3.17), comorbidities (including non-COPD lung disease [HR, 1.16; 95% CI, 1.09-1.23], congestive heart failure [HR, 1.22; 95% CI, 1.14-1.30], sleep disorder [HR, 1.22; 95% CI, 1.15-1.30], and dementia [HR, 1.14; 95% CI, 1.05-1.24]); other psychoactive medication receipt, including benzodiazepines (HR, 1.27; 95% CI, 1.19-1.35) and serotonergic antidepressants (HR, 1.10; 95% CI, 1.03-1.19), and receipt of an opioid-only agent (HR, 1.35; 95% CI, 1.26-1.46). Factors that independently protected from adverse pulmonary events included female sex (HR, 0.78; 95% CI, 0.73-0.82), surgery within the preceding year (HR, 0.70; 95% CI, 0.64-0.77), and musculoskeletal disease (HR, 0.75; 95% CI, 0.70-0.80). No significant associations were observed between adverse pulmonary events and opioid half-life duration or opioid daily dosage.Conclusions: Patient and opioid drug factors predictive of opioid-related adverse pulmonary events among older adults with COPD were identified, which may assist with safer opioid prescribing.

Prevalence of Pain in COPD Patients and Associated Factors: Report From a Population-based Study

OBJECTIVES

To assess the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and migraine among Spanish adults with chronic obstructive pulmonary disease (COPD) compared with non-COPD patients matched by age and sex; and to identify predictors for each of these types of pains among COPD sufferers.

MATERIALS AND METHODS

A cross-sectional study conducted with data collected from the European Health Interview Surveys for Spain (EHSS) conducted in years 2009/2010 (n=22,188) and 2014 (n=22,842). Data were analyzed using multivariable logistic models.

RESULTS

The prevalence of COPD among patients aged 35 years or above were 7.6% (n=1328) for the EHSS 2009 and 5.4% (n=1008) for the EHSS 2014. We matched 2251 COPD patients with age and sex controls. The prevalence of all types of pain were significantly higher among those suffering COPD than those without COPD. For CNP the figures were 40.5% versus 26.1%, for CLBP 44.8% versus 28.4%, and for migraine 22.5% versus 13.2%. Multivariable analysis showed that COPD was associated to a 1.21 (95% confidence interval [CI], 1.02-1.45) higher risk of CNP, 1.38 (95% CI, 1.16-1.64) of CLBP, and 1.36 (95% CI, 1.12-1.65) of migraine. Associated factors with the presence of these types of pain among COPD patients included younger age (not for CLBP), female sex (not for CLBP), "fair/poor/very poor" self-rated health (not for migraine), high blood pressure (not for CNP), mental disorders, obesity (not for migraine), and use of pain medication.

DISCUSSION

The prevalence of CNP, CLBP, and migraine was significantly higher among COPD patients in comparison with controls. Associated factors to suffering these types of pain in patients with COPD included age, sex, self-rated health, certain comorbidities including mental disorders, obesity, and using pain medication.

Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.