The Longitudinal Pattern of Response When Morphine Is Used To Treat Chronic Refractory Dyspnea

Abstract

Background: While evidence supports using sustained release morphine for chronic refractory breathlessness, little is known about the longitudinal pattern of breathlessness intensity as people achieve symptomatic benefit. The aim of this study is to describe this pattern.Methods: This secondary analysis used breathlessness intensity scores (100 mm visual analogue scale (VAS)) from a prospective, dose increment study of once daily (morning) sustained release morphine for chronic refractory breathlessness. Participants who achieved < 10% improvement over their own baseline at one week (10 mg) were titrated to 20 mg and if no response, another week later to 30 mg for one week. Time was standardized at the first day of the week in which participants responded generating twice daily data one week either side of symptomatic benefit. Analysis used random effect mixed modeling. Results: Of the 83 participants, 17/52 responders required > 10 mg: 13 participants (20 mg) and 4 (30 mg), contributing 634 VAS observations. In the week leading to a response, average VAS scores worsened by 0.3 mm/ day ( p = 0.16); the average improvement in the first 24 hours of response was 10.9 mm (7.0 to 14.7; p < 0.0001), with continued improvement of 2.2 mm/day ( p < 0.001) for six more days. Conclusion: When treating chronic refractory breathlessness with once daily sustained release morphine, titrate to effect, since inadequate dose may generate no response; and following an initial response, further dose increases should not occur for at least one week. Whether further benefit would be derived beyond day six on the dose to which people respond, and what net effect a further dose increase would have are questions yet to be answered.

Prescription of opioids for breathlessness in end-stage COPD: a national population-based study

“…This evidence consists of a Cochrane meta-analysis,12 a systematic review,24 a randomized trial,10 and several studies 16,22. Sustained-release morphine should be considered as a first line treatment and should be initiated at a low dose regularly and titrated upward over days and weeks, balancing beneficial and adverse effects 25,26. All treatments assume adequate follow-up of the patient’s clinical condition and symptoms, including proper prophylaxis and treatment for expected effects such as opioid-related constipation 10,25.…”

Epidemiology and Characteristics of Episodic Breathlessness in Advanced Cancer Patients: An Observational Study

“…It has been suggested that opioid-na€ ıve patients could be slowly titrated because inadequate dosing may generate no response. 23 In this study, 40% of patients with episodic breathlessness were receiving a pharmacological treatment for it, and about 80% of them were receiving oral opioids. Oral opioids do not fit the temporal characteristics of episodic breathlessness, as their effect starts about 30 minutes after administration.…”

Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis

“…Chronic refractory breathlessness [7][8][9] Chronic breathlessness that is refractory to treatments for the underlying condition Episodic breathlessness [10][11][12][13][14] Severe worsening of breathlessness intensity or unpleasantness beyond usual fluctuations [13][14][15] Breathlessness can be very frightening for patients and families 25,26,28-31 and can have a devastating impact on their lives, severely limiting well-being and quality of life (QoL). 2,[32][33][34] It is associated with considerable anxiety, depression, fear, social isolation, deconditioning and disability, 21,28,29,31,35,36 and shortened life expectancy.…”

“…Complete a needs assessment around breathlessness, map it to current service provision and consider areas for service improvement (P1) 8 (7)(8)(9) Prioritise supporting development of breathlessness-triggered services, which span all stages of multiple diseases and conditions (P2) 8 (7-9)…”

“…Increase public awareness and/or education around breathlessness (e.g. as a sign of disease vs. normal exertional symptom) (P6) 8 (7)(8)(9) Provide all health and social care staff with education around breathlessness and its management, ideally starting during vocational and/or undergraduate training and continuing throughout professional lives (P8) 8 (7-9)…”