Patients with advanced chronic obstructive pulmonary disease (COPD) and shortness of breath found that opioids provided relief and improved their quality of life, states an article in CMAJ (Canadian Medical Association Journal). However, physicians are reluctant to prescribe opioids for this condition, meaning many people will not benefit from this treatment.
The prevalence of COPD in Canada is increasing, and shortness of breath (dyspnea) is a major symptom that is difficult to treat and can result in fear, anxiety and a decreased quality of life. Although opioids are often used to treat pain and dyspnea associated with malignant diseases, they are underused in COPD treatment. The Canadian Thoracic Society released a clinical practice guideline recommending the use of opioids for shortness of breath in patients with advanced COPD that doesn't respond to conventional treatment.
Researchers sought to understand physician attitudes toward this treatment and to understand the perspective of patients and their caregivers about the use of opioids for severe shortness of breath, known clinically as refractory dyspnea, that cannot be alleviated through other treatments. They interviewed 8 patients, 12 caregivers and 28 physicians in Nova Scotia, Canada. Patients had shortness of breath so severe that they could not leave their homes, or were breathless dressing or undressing, were on recommended therapies for COPD and long-term oxygen, and had been using opioids for dyspnea for five weeks to four years.
"All patients reported that opioids provided significant improvements to their quality of life, relief of dyspnea, or both, and cited this as their main reason to continue taking opioids over the longer term," write Dr. Graeme Rocker, Dalhousie University, Halifax, Nova Scotia, with coauthors.
Caregivers reported improvements in their family members' quality of life and stress levels for themselves as well.
"Many physicians indicated uncertainty and discomfort about prescribing opioids to patients with COPD," state the authors. "Lack of guidance, confidence and experience, a fear of respiratory suppression, and concern about censure were key factors limiting their willingness to prescribe opioids in this context. However, most acknowledged that dyspnea is difficult and frustrating to manage and thus were willing to consider opioids for this purpose."
"Discrepancies between the positive experiences of patients and family caregivers and the reluctance of physicians to prescribe opioids for refractory dyspnea constitute an important gap in care," write the authors. "Bridging this gap will likely require innovative educational initiatives to improve the uptake of guidelines and confidence in prescribing opioids for refractory dyspnea."
"Evidence is accumulating to suggest that soon the appropriate question will no longer be if we should prescribe opioids to help palliate refractory dyspnea in patients living with advanced COPD, but rather how to do this competently and when," conclude the authors.
Paper online: www.cmaj.ca/lookup/doi/10.1503/cmaj.111758