Attitudes of patients with chronic breathlessness towards treatment with opioids

Abstract

Breathlessness is the most common symptom in advanced chronic lung disease or chronic heart failure (CHF) [1]. Opioids are recommended for palliative treatment of breathlessness persisting despite optimal pharmacological and non-pharmacological treatment [2, 3]. However, physicians don't always consider opioids for chronic breathlessness [4,5] and experience barriers when considering opioids, such as resistance of patients [6]. This can limit effective palliative treatment. Qualitative studies in patients with COPD and CHF revealed fear of dependence and fear of imminent death as the most important barriers to opioid use. The reason to start treatment was to do as much as possible [7][8][9]. These qualitative studies were only conducted in small patient populations. Therefore, our aims were to assess the willingness of patients with chronic lung disease or CHF to use opioids for breathlessness, irrespective of a current indication for opioid treatment; and to assess their barriers towards opioid use and reasons to use opioids. Finally, we aimed to compare willingness differences according to sex, age, educational level, diagnosis and breathlessness severity.An exploratory convenience sample of 175 patients referred for a baseline assessment prior to pulmonary or heart failure rehabilitation was recruited, independent of their level of breathlessness. Patients were excluded if they could not read or write, had not mastered Dutch, were aged <18 years or were unable to give informed consent. The Maastricht University Medical Centre (MUMC+, Maastricht, the Netherlands) medical ethical committee, reviewed the study protocol and concluded that the study didn't fall under the Medical Research Involving Human Subjects Act (METC 2018-0790). Patients completed a survey including demographic characteristics, educational level, previous and current opioid use (opioid, dosage and reason for prescription) and willingness to use opioids for breathlessness. Patients willing to use opioids and patients who had experience with opioids were asked to indicate their reasons to use opioids; patients unwilling to use opioids were asked to indicate their barriers. Patients who were indecisive were asked to indicate their barriers against and the reasons to use opioids. In addition, patients were invited to report reasons other than those predefined using a free-text field. The predefined reasons were selected based on previous research [7][8][9], expert opinion of the project group and experience from patient inclusion for an opioid trial (MORDYC) [10]. Disease characteristics (diagnosis, disease history, lung function, 6-min walk distance (6MWD) [11]) and breathlessness severity (modified Medical Research Council (mMRC) scale) [12] were recorded using chart review. Data were described using mean±SD or median (interquartile range (IQR)) for continuous variables and n (%) for categorical variables. We compared the willingness to use opioids between sexes, age (<65 years or ⩾65 years), educational level (lower education, defined as having...

Professionals’, patients’ and families’ views on the use of opioids for chronic breathlessness: A systematic review using the framework method and pillar process

“…Effective communication of potential benefits and harms of opioids for breathlessness was important 32 and found to improve patient trust in clinicians and patient approval of clinician recommendation of opioids for breathlessness. 39 Poor communication about the use of opioids and potential harms was found to reduce patient willingness and confidence in using opioids to reduce symptomatic chronic breathlessness. 39 Furthermore, a poor relationship between a clinician and the patient’s family was shown to be a potential barrier when there were cultural differences between the clinician and the patient/family.…”

“…Clinician 37 However, older patients were less willing and less confident about using opioids for breathlessness than younger patients, although reasons for this were not explored. 39 Furthermore, the study which highlighted this age difference only received an MMAT total of 2 and was found to have little justification for survey questions as well as limited inclusion and exclusion criteria. This may impact the weighting of the relevance of patient age on opioid use.…”

“…One study found a large variation of opinions across patients, likely resulting from inconsistent information sharing from clinicians to patients about opioid treatment. 39 This study had limitations in that not all included patients had an indication for opioid treatment as the study has a convenience sampling strategy.…”

“…This theme was a major finding across the studies suggesting significant clinician and patient fears relating to opioid use. 25,32,39,41 Clinicians' fears included opioid-related patient harms, particularly respiratory depression and a concern that opioid use would result in hastening patients' deaths. Fears of opioid use stemmed from previous medical training, as they had been taught that opioids would hasten death in people with respiratory disease: 'I mean when I went to medical school, we were taught to never consider opioids in people with COPD.…”

“…A study found that patient fears related to being unfamiliar with opioids, worries about 'getting high' and fear of weight gain. 39 Patients also perceived clinician reluctance in one study, in turn increasing patient fear of opioids, and causing a reluctance to use opioids even when prescribed them: Regulatory issues. There was a perceived lack of support from regulatory agencies by clinicians, particularly due to delays and concerns about potential censure if adverse effects were caused by opioids.…”