Chronic pain in COPD: prevalence and longitudinal associations with multimorbidity, breathlessness, emotional distress, and adverse clinical outcomes

Background Chronic pain is common in patients with chronic obstructive pulmonary disease (COPD) and is linked to adverse clinical outcomes, multimorbidity and COPD symptoms, but the exact associations remain unclear. Importantly, chronic pain is underrepresented in most current clinical management guidelines. This study aimed to describe chronic pain prevalence in patients with COPD across 16 years, and its longitudinal association with mortality and respiratory-related hospital visits, multimorbidity, and COPD-related symptoms. Methods This study included patients with COPD, with survey data sweeps in 2005 and 2012, and Swedish national register data from 2005 to 2021. The prevalence of chronic pain and mortality were described in the patients. Repeated dispensed physician-prescribed pain medication defined chronic pain. Survival analyses were used to investigate longitudinal associations among chronic pain, multimorbidity, breathlessness, emotional distress, all-cause mortality, and respiratory-related hospital visits. Results Chronic pain prevalence among 1071 COPD patients was 27% in 2005, 37% in 2012, and 38% in 2021. Initially, chronic pain was associated with all-cause mortality with a 72% higher hazard, compared to patients without pain. Adjustment for sociodemographic factors, breathlessness severity and multimorbidity attenuated this association to 19% (adjusted hazard ratio (adjHR) 1.19, 95% CI 1.01–1.40), although only partially. Chronic pain, breathlessness (adjHR 1.33, 95% CI 1.24–1.43), and multimorbidity (adjHR 1.44, 95% CI 1.36–1.54) were associated with all-cause mortality in fully adjusted models, and emotional distress (adjHR 1.29, 95% CI 1.20–1.38), breathlessness (adjHR 1.41, 95% CI 1.32–1.51), and multimorbidity (adjHR 1.07, 95% CI 1.01–1.13) were associated with recurrence of respiratory-related hospital visits. Conclusions Chronic pain was common and strongly associated with mortality in COPD patients and highlights the importance of considering chronic pain in patients with COPD. Emotional distress was associated with increased respiratory-related hospital visits but not with mortality. This emphasises the relevance of prioritising somatic COPD symptoms, more than subjective distress, in clinical decision-making. Chronic pain should be considered in COPD assessment and management, as it is associated with adverse outcomes and mortality risk in these patients.