Opioids for breathlessness: a narrative review

Abstract

<jats:p>Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10–30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world’s therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data.</jats:p>

Wahrnehmungen zum Umgang mit Opioiden: Fokus COVID-19

“…Die Wirksamkeit von Opioiden bei Dyspnoe wurde insbesondere bei Patient:innen mit COPD, aber auch bei Herzversagen und Krebserkrankungen gezeigt [ 17 , 21 ]: Hui und Bruera untersuchten in ihrem „evidenzbasiertem Review“ die pharmakologische Wirksamkeit speziell kurz wirksamer Opioide für die Linderung von „breathlessness“ [ 17 ]: Auf der Basis von 28 randomisierten klinischen Studien beurteilten sie die Evidenz insbesondere als gut, wenn kurz wirksame Opioide als Einzeldosis vor körperlicher Anstrengung verabreicht wurden. Johnson und Currow bestätigten retardierten Opioiden eine „moderate 1a-Evidenz“ [ 21 ]. Sie identifizierten die beste Evidenz für 10–30 mg retardiertes Morphin täglich „de novo“ bei opioidnaiven Patient:innen.…”

“…In Studien zur Sicherheit identifizierte Vozoris bei COPD-Patient:innen sogar „ein erhöhtes Risiko von respiratorisch-bedingten Exazerbationen, Hospitalisation und Tod in Verbindung mit Opioidgebrauch“ [ 34 ], während Johnson und Currow morphinbezogene Nebenwirkungen lediglich als „meist mild und selbstlimitierend, sobald die Substanz abgesetzt wird“ beschrieben [ 21 ]. Sie verglichen die Häufigkeit von ernsten Nebenwirkungen mit denen von Placebo.…”

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

“…8 Following independent review of all clinical study data one jurisdiction (Australia) has now authorised an extended license for a sustained release morphine formulation for use in chronic breathlessness. 10 However, clinical use and acceptance of morphine for use in chronic breathlessness has been limited, 11 with implementation in clinical practice varying in relation to (i) whether clinicians will prescribe opioids; 12 and if so, (ii) the formulations and treatment regimens used and (iii) whether patients adhere to, and family members support, prescribed treatment for chronic breathlessness.…”

Assisting People With Their Living, Not Their Dying: Health Professionals’ Perspectives of Palliative Care and Opioids in ILD

“…25 Oral opioids may relieve breathlessness in some people with advanced respiratory or malignant illnesses. [26][27][28][29][30][31] Currently, very few people with ILD access opioids to treat severe, chronic breathlessness, 13,32,33 which may relate to the lack of evidence for the efficacy of opioids in ILD, inadequate symptom screening or delayed referral to palliative care services. 15,17,34 Clinician factors have also been recognized as important.…”