ResearchCMAJ OPEN C hronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally by 2020.1 Recent Canadian data suggest that about 1 in 4 adults 35 years or older can expect to develop COPD. 2 Dyspnea is the predominant symptom, and up to 50% of patients with advanced COPD have dyspnea (persistent, episodic or both) that is refractory to conventional treatment.3 Dyspnea "crises" often trigger intense feelings of helplessness that can overwhelm patients' and caregivers' abilities to cope. 4 More than 20 years have passed since morphine was found to be associated with a reduction in dyspnea in patients with COPD.5 Despite the systematic review of a decade ago, 6 experience with using opioids in this clinical context remains limited. Subsequent evidence focuses on, or extrapolates from, short-term effects over hours 7,8 or days. 9 Longer-term clinical use over months has received relatively little attention or support until recently. 10,11 The dearth of quality evidence relating to the longer-term effects of opioids prompted our study.Building on our previous research in this area, 12,13 we designed a multicentre mixed-methods study (a) to understand further the experiences of patients living with advanced Background: Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients' experiences when opioids are added to optimized conventional treatments for advanced COPD.Methods: A total of 44 patients (median age 74, range 51-89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid "helpfulness" and adverse effects before, at 2 months and at 4-6 months after opioids were started. Results:Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients' overall positive experiences: small gains have big impact; realign hopes with reality; and "try it." Significant improvements were observed in median (interquartile range) scores between baseline and 4-6 months' assessment for health-related quality of life Interpretation: Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting. Trial registration: ClinicalTrial.gov, no. NCT00982891Competing interests: Available at the en...
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