Affiliation:
1. Leiden University Medical Center, Department of Anesthesiology, Leiden, Netherlands
Abstract
Background: Opioids may induce life-threatening respiratory depression, but limited
knowledge is available on factors that contribute to opioid-induced respiratory depression
(OIRD). This is especially true for patients with chronic pain on prolonged opioid therapy.
There are no good quality case control studies or randomized controlled trials available on this
topic. Here we present and analyze all case series since 1980 on OIRD in chronic pain patients
extracted from PubMed.
Objective: To describe and understand clinically identified factors involved in life-threatening
OIRD in patients receiving opioids for chronic pain relief.
Study Design: A literature search was performed for all relevant case reports on OIRD in
chronic pain.
Methods: We searched PubMed (www.ncbi.nlm.nih.gov) for all available case reports/series
on OIRD in adolescent (12 years and older) and adult patients treated with opioids for chronic
pain, from which we identified specific commonalities that contributed to OIRD (akin to closed
claims analyses). The dataset was post-hoc divided into 2 distinct categories: cases published
from 1980 to 1999 and those from 2000 to 2012.
Results: Thirty-four reports describing 42 chronic pain patients experiencing OIRD were
retrieved. Cases published before the year 2000 (pre-2000) predominantly involved morphine
in cancer patients, whereas cases since 2000 (post-2000) predominantly involved methadone
or transdermal fentanyl in non-cancer pain patients. Specific factors that contributed to OIRD
were elevated opioid plasma levels due to renal impairment and sensory deafferentiation in
pre-2000 cases, and elevated plasma levels due to drug interactions on the cytochrome P450
in post-2000 cases.
Limitations: The case series analysis of published case reports imposes limitations in terms of
the types of cases presented (only severe cases are published or cases with specific precipitating
factors), the journal-related publication strategy, and changes in clinical practice.
Conclusions: Our case review confirms that life-threatening OIRD in chronic pain patients
involves a series of complex often-interacting factors. In spite of the factors identified in this
cases series, OIRD remains unpredictable and safe opioid prescribing requires careful titration
of opioid dosages and continuous monitoring to prevent life-threatening OIRD.
Key words: Opioids, opioid-induced respiratory depression, toxicity, pain, chronic pain, case
series
Publisher
American Society of Interventional Pain Physicians
Subject
Anesthesiology and Pain Medicine
Cited by
16 articles.
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