The New “Opioid Crisis”: Scientific Bias, Media Attention, and Potential Harms for Patients with Refractory Dyspnea

Rocker, Graeme; Bourbeau, Jean; Downar, James

doi:10.1089/jpm.2017.0619

Cited by 9 publications

(9 citation statements)

References 30 publications

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“…Nevertheless, there are still some positive aspects to opioid use other than dyspnea alleviation. Lower hospital admission rates for congestive heart failure were found in new opioid users in patients with COPD in the community setting, with no additional cardiac-related mortality causes 12…”

Section: Discussionmentioning

confidence: 84%

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Management of Breathlessness in Palliative Care: Inhalers and Dyspnea—A Literature Review

Senderovich

Yendamuri

2019

Rambam Maimonides Med J

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IntroductionDyspnea is prominently observed in palliative care (PC). Dyspnea can be multifactorial, primarily caused by obstructive or restrictive lung diseases or secondarily induced by various comorbidities. Numerous interventions exist, with route of administration and efficacy requiring further discussion. Despite opioids being the first line of treatment, their adverse effects lead to reluctance on the side of patients to take them, creating limitations in patient management planning.ObjectivesThis paper reviews and highlights the role of inhalers for dyspnea management in PC.MethodsThe CINAHL, CENTRAL, and OVID databases were searched for scholarly articles on the role of inhalers in dyspnea management from 1998 to the present. A grey literature Internet search was also performed via Google, the World Health Organization, and CareSearch. Twenty-five articles relevant to the subject at hand were located and summarized. The Cochrane Systematic Reviews of Health Promotion and Public Health Interventions Handbook was consulted for structuring.ResultIsolated bronchodilators can be effective in dyspnea management. However, combination with opioids leads to a 52% reduction of dyspnea, demonstrating efficacy of their combined use. There is a role for conventional inhalers not only in patients afflicted with chronic obstructive pulmonary disease, but also in those where obstruction is reversible, and in cases of dyspnea not yet diagnosed.ConclusionInhalers can be utilized as adjuvant therapy to opioids, to limit opioid use, augment responses to dyspnea, and/or minimize opioid side effects, especially in opioid-naïve patients. Correct administration can increase the efficacy of short-acting beta-agonists, long-acting beta-agonists, short- and long-acting anticholinergic agents, and inhaled corticosteroids, achieving reduction and alleviation of dyspnea.

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Section: Discussionmentioning

confidence: 84%

“…Statistically significant differences were found ( P <0.001) between Groups 1 and 2 compared to Groups 3 and 4 11. One article supported the idea of combination therapy, stating that there was an increased risk of cardiovascular events in those not combining an opioid with a non-opioid intervention 12…”

Section: Discussionmentioning

confidence: 99%

Management of Breathlessness in Palliative Care: Inhalers and Dyspnea—A Literature Review

Senderovich

Yendamuri

2019

Rambam Maimonides Med J

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“…In this study, we purposely excluded patients given opioids for palliative purposes because we thought that this would mask any pejorative effect of opioids used as treatment rather than as a palliative. Some authors speak of "confounding by indication" in pharmacological studies, including COPD 28 . In the case of COPD patients consulting an ED for trauma, the risk of a limitation of care order is unlikely, and the use of opioids appeared safe.…”

Section: Discussionmentioning

confidence: 99%

Opioid drug use in emergency and adverse outcomes among patients with chronic obstructive pulmonary disease: a multicenter observational study

Viglino

Daoust

Bailly

et al. 2020

Sci Rep

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there is still debate as to the safety of non-palliative opioid administration to chronic obstructive pulmonary disease (COPD) patients punctually treated for an acute complaint. All patients over 40 presenting at two university hospital emergency departments (Montréal Qc, Grenoble Fr) from March 2008 to September 2014 with dyspnea, abdominal pain or trauma were retrieved, and COPD patients were selected. our primary endpoint was a composite criterion including invasive ventilation and death. comparisons between visits in which opioid drugs were prescribed and those without opioids were performed using an inverse probability of treatment and censoring weight (iptcW) estimator to adjust for baseline confounders. A survival weighted Cox model was used. 7799 visits by COPD patients were identified, corresponding to 4173 unique patients. Opioid drug prescription was reported in 1317 (16.9%) visits. After applying IPCTW weighting, opioid prescription was found to be associated with the composite criterion of poor clinical outcomes (HR = 4.73 (2.94; 7.61), p < 0.01). When taken separately, this association remained significant for invasive ventilation and death, but not for NIV. All sensitivity analyses confirmed the association, except for patients with trauma or abdominal pain as the main complaint. This excess risk is observed whatever the route of administration. MethodsStudy design and setting. Data were extracted from the databases of two university hospital ED with more than 50,000 patient visits per year (Sacré-Coeur de Montréal Hospital, Quebec, Canada and Grenoble Alpes University Hospital, France). Both are level 1 trauma centers and are local reference centers for chest and respiratory diseases. The databases consist of detailed electronic medical records of patients attending the ED including demographic data, medical records with timestamped treatments, final diagnosis and outcomes such as ICU admission, and in-hospital death. Institutional review board approval was obtained by each center (University of Montreal, Quebec, Canada; and CECIC Rhône-Alpes-Auvergne, Clermont-Ferrand, France IRB N°5891). Methods and data collection were conducted in accordance with guidelines for retrospective research. Scientific RepoRtS |(2020) 10:5038 | https://doi.

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“…3,[62][63][64][65][66][67] Orally administered opioids have been found to be beneficial in the treatment of breathlessness in patients with advanced disease, but the effects are modest or small 61,62 and there are concerns regarding adverse cardiac and respiratory effects of long-term use, especially in older people with chronic obstructive pulmonary disease (COPD). [68][69][70][71] Oxygen has a clear and accepted role in treating mildly hypoxic patients. [72][73][74] However, the benefit derived from oxygen in mildly or non-hypoxaemic breathless patients is similar to medical air, and there are limitations to its use (e.g.…”

Section: Current Treatment and Service Provisionmentioning

confidence: 99%

Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis

Maddocks

Brighton

Farquhar

et al. 2019

Health Serv Deliv Res

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Background Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress. Objectives The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research. Design The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities. Results Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers. Limitations The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity. Conclusions Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers. Future work Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested. Study registration This study is registered as PROSPERO CRD42017057508. Funding The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.

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The New “Opioid Crisis”: Scientific Bias, Media Attention, and Potential Harms for Patients with Refractory Dyspnea

Cited by 9 publications

References 30 publications

Management of Breathlessness in Palliative Care: Inhalers and Dyspnea—A Literature Review

Management of Breathlessness in Palliative Care: Inhalers and Dyspnea—A Literature Review

Opioid drug use in emergency and adverse outcomes among patients with chronic obstructive pulmonary disease: a multicenter observational study

Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis

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