New study examines use of opioids for chronic cough
Cough is one of the most common reasons adults seek medical care
Regenstrief Institute
INDIANAPOLIS – Chronic cough, with symptoms lasting more than eight weeks, affects approximately one in 10 adults. Cough is among the most common reasons for seeking medical care in the United States, yet chronic cough is difficult to treat. One of the largest studies of chronic cough and one of the first to explore the use of opioids, which are known to suppress cough, to treat these patients, has found that 20 percent of patients with chronic cough received a prescription for a cough suppressant containing an opioid.
With the goals of estimating opioid prescription in the chronic cough population and of informing alternative treatment strategies, a research team led by Michael Weiner, M.D., MPH, of Regenstrief Institute and the Indiana University School of Medicine, found that the odds of an opioid being prescribed were twice as great for chronic cough as for non-chronic cough.
Chronic cough is a symptom, a condition that can have a variety of causes including asthma, acid reflux, “postnasal drip”, neurological issues or a reaction to a drug.
“The magnitude of use and prescription of opioids for chronic cough is really very high. As we learned from our study, some subgroups were especially likely to be prescribed these drugs. Patients who had Medicaid insurance -- typically low-income individuals -- were more likely to be prescribed these drugs. Older patients were more likely to be prescribed these drugs than younger patients,” said Dr. Weiner. “Although over one-third of patients with chronic cough had at least three prescriptions for cough suppressants containing opioids, more than 10 prescriptions for these drugs were ordered for only half a percent of patients with chronic cough. This indicates that opioids, which play an important role in chronic cough care, are not used as long-term therapy in most cases.”
Opioid-containing cough suppressants were defined as drugs with codeine, dihydrocodeine, or hydrocodone. All opioids carry a risk of addiction.
The researchers studied the electronic health records of 23,210 patients seen by clinicians for cough at least three times over a period of about two to four months and 229,538 patients with non-chronic cough, ages 18 to 85. The deidentified data were obtained from the Indiana Network for Patient Care (INPC), one of the nation’s first and largest clinical data repositories. It was created by Regenstrief Institute and is managed by the Indiana Health Information Exchange (IHIE). Regenstrief Data Services is the custodian of data for research purposes.
Chronic cough does not have a diagnostic code, which has made it difficult to track the condition at both the individual and population levels.
“With our decades of experience with electronic health records, we were well aware that symptoms, such as cough – both chronic and non-chronic – are hard to identify. But using a natural language processing method that we developed and tested in a previous study of chronic cough, helped us identify these cases of chronic cough in the clinical notes,” said study co-author Regenstrief Institute Research Scientist Paul Dexter, M.D., a biomedical informatician who has conducted multiple prior studies using natural language processing.
“Chronic cough is a significant problem -- at home, at work and when out in the community -- for a very large number of patients and warrants not only better diagnosis plans and management pathways, but also a larger array of treatment options so that we don't have to rely on opioids to such a great extent,” added Dr. Weiner, who studies the effects of health information and information technology on physician practice and patient outcomes. “We may, for example, discover chemical compounds with new mechanisms of action to suppress cough or attack its root causes. There are drugs already in the pipeline that may be less addictive, more effective or safer with fewer side effects and complications than opioids. I'm optimistic that the future of treating patients with chronic cough will be brighter than it has been in the past.”
“Prescriptions of opioid-containing drugs in patients with chronic cough” is published in the peer-reviewed journal Therapeutic Advances in Respiratory Disease. This research was supported by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
Study authors and affiliations:
Michael Weiner1,2,3, Ziyue Liu2, Jonathan Schelfhout4, Paul Dexter2,5,6, Anna R Roberts7, Ashley Griffith5, Vishal Bali4, Jessica Weaver4.
- 1Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., 1101 West 10th Street, Indianapolis, IN 46202-4800, USA.
- 2School of Medicine, Indiana University, Indianapolis, IN, USA.
- 3Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Systems Research CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- 4Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ, USA.
- 5Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, IN, USA.
- 6Eskenazi Health, Indianapolis, IN, USA.
- 7Regenstrief Data Services, Regenstrief Institute, Inc., Indianapolis, IN, USA.
Michael Weiner, M.D., MPH
In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Michael Weiner, M.D., MPH, is a research health scientist at the VA Health Systems Research Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, and a professor of medicine at the Indiana University School of Medicine.
Paul R. Dexter, M.D.
In addition to his role as a research scientist with the Clem McDonald Center for Biomedical Informatics at Regenstrief Institute, Paul R. Dexter, M.D., is an associate professor of clinical medicine at the Indiana University School of Medicine.
Journal
Therapeutic Advances in Respiratory Disease
Article Title
Prescriptions of opioid-containing drugs in patients with chronic cough
Chronic cough may be hereditary
Uppsala University
image:
Össur Ingi Emilsson, Docent in Lung, Allergy and Sleep Research at the Department of Medical Sciences, Uppsala University.
Photographer: Emil Össurarson
Credit: Emil Össurarson
Chronic cough is among the most common reasons for seeking medical care, with middle-aged women the group most affected. New studies at Uppsala University also show that this condition appears to be a hereditary phenomenon. The studies have been published in ERJ Open Research and PLOS ONE.
“More than 10% of the population has a chronic cough, which has been shown to entail several negative consequences: reduced quality of life, reduced ability to work and voice problems. At present, we have insufficient knowledge about what causes coughing and how best to treat it,” notes Össur Ingi Emilsson, Docent in Lung, Allergy and Sleep Research at the Department of Medical Sciences at Uppsala University.
Two recently published studies from the department have investigated both how cough is currently managed in Swedish healthcare, and whether chronic cough can be hereditary.
One of the studies, based on data from the Swedish healthcare register, showed that one to two percent of the entire Swedish population sought care for chronic cough between 2016 and 2018, usually in primary care. Of those who sought care, the majority appear to have had a long-standing cough. The prevalence is highest among women between the ages of 40 and 60, with around 21,000 women seeking treatment for cough in these three years.
“Women generally seem to have a slightly more sensitive cough reflex, so the threshold for abnormal coughing is lower in women than in men. For me, it was unexpected that only one to two percent of patients seek help for a troublesome cough when over ten percent are affected. This can be partly explained by the lack of effective treatments. There also appeared to be some differences in care between different parts of the country, suggesting that better guidelines are needed for investigating and treating chronic cough,” continues Emilsson.
Another study by the same research team has provided a clue as to why some individuals develop chronic cough. Cough appears to be a hereditary phenomenon. In a large population study in northern Europe of 7,155 parents and their 8,176 adult children aged 20 years and over, it was found that if one parent has had chronic dry cough, their offspring were over 50% more likely to have chronic dry cough. This link was independent of confounding factors such as asthma, biological sex and smoking.
“A similar relationship was seen for productive cough, but in those cases smoking had a greater impact on prevalence. These results suggest that there is a genetic link to chronic cough,” adds Emilsson.
The research team has already begun a treatment study into chronic cough. Based on these new findings, the group is now moving forward with studies on genetic variants in collaboration with the Icelandic company deCODE genetics, which analyses the human genome. The aim is to identify which genetic variants are linked to chronic cough.
“This could provide a better understanding of the occurrence of chronic cough, which may ultimately result in better treatments for this difficult-to-treat condition,” explains Emilsson.
Journal
ERJ Open Research
Method of Research
Observational study
Subject of Research
People
Article Title
Heritability of cough across two generations: the RHINESSA study
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