Will Pain Medications Cause Respiratory Suppression?
Another common fear related to opioid use is that prescribing sufficient analgesic doses for patients with advanced illnesses could lead to toxicities, suppress their breathing, cause an overdose, or even prematurely end their lives. This scenario is often luridly presented as turning up the morphine drip. Pain management experts question the truth of this scenario, arguing that morphine often is falsely credited with deaths that result from advanced disease processes. Morphine is a common treatment for the sensation of dyspnea, while morphine-related toxicity likely will present with drowsiness, confusion, and loss of consciousness before respiratory compromise.8
A main concern of hospitalists is appreciating the need to balance pain relief with the side effects of analgesics, including opioid toxicities, which can be addressed through careful titration and frequent assessments. Respiratory suppression can be a side effect of opioids, and there are special groups of patients for whom any sedation is a major concern. An example is a lung transplant patient, for whom somnolence may suppress the important cough reflex.
Respiratory suppression from morphine is an area without a large evidence base. But a recent study of 725 patients nearing death in 13 hospice programs analyzed those who were receiving opioids and had at least one change in opioid dose prior to death to see if escalating opioid doses was associated with premature death.9 The authors conclude that “final opioid dose, but not percentage change in dose, was one of several factors associated with survival, but the association is very weak … (and explains) only a very small percentage in variation in survival.” They also found support for their conclusion that opioid use is not a major contributor to premature death in the few other published studies on the subject.
“I tell residents that the fear of respiratory suppression is overrated,” Dr. Youngwerth says. “As long as you follow World Health Organization and other recognized guidelines for dosing and titrating opioids, you can safely prescribe pain medications and control the patient’s pain. They get this fear ingrained during residency. In reality, it is not very common. I remind them that there is much more evidence of under-dosing.”
Dr. Bekanich describes a recent patient, a young woman suffering from severe abdominal pain following the birth of her baby. The pain was so difficult to manage that her hospital in rural Idaho transferred her to his medical center in Salt Lake City. She had also experienced respiratory arrest twice secondary to the application of fentanyl analgesic patches. “But she was relatively easy to manage once we tried a different drug, appropriately titrated,” he relates.
Dr. Bekanich spent two hours in the patient’s room adjusting the intravenous analgesic dose and monitoring the patient’s pulse oxygen level and neurological status. “These medicines don’t have to cause respiratory suppression, although it will happen occasionally, especially when there are multiple co-morbidities,” he says. “Hospitalists don’t realize that most of these problems can be avoided if you are meticulous in prescribing.”
Does Regulatory Scrutiny Chill Pain Treatment?
The ubiquitous fear of opioids and their potential side effects, including some unfounded or unrealistic fears, is also reflected in the regulation of controlled substances and physicians’ fears that they will be subjected to oppressive regulatory scrutiny.
Widely publicized cases of physicians being disciplined or prosecuted for over-prescribing opioids have only added to these fears, while the rare case of a physician being sued or sanctioned for under-prescribing pain medications does little to allay them.10