3 major barriers to use of low-dose opioids for breathlessness: what patients think

Lack of knowledge, misinformation, and social stigma about opioids are some of the major barriers to their effective use in managing severe chronic breathlessness, Australian research shows.

An analysis of  interviews with 24 outpatients with chronic breathlessness due to COPD or chronic heart failure revealed four themes around the use of low-dose opioids: stigmatised attitudes and beliefs, limited knowledge and information-seeking behaviour, relationships with health professionals and continuity of care, and past experience with opioids.

The qualitative study found patients from both opioid-naive and opioid-experienced groups had common concerns and negative attitudes such as fear of addiction, fatalistic beliefs and a fear of overdosing.

“Opioid-naïve participants largely believed that opioids should be reserved only once people reached a ‘desperate’ end stage of the illness. These beliefs were also shared by opioid-experienced participants prior to commencing treatment,” the study authors said.

The Melbourne study, published in BMJ Supportive & Palliative Care, found there was a need for more knowledge in opioid-naive patients while others described feeling exhausted from information overload. Some harboured passivity and resignation towards their treatment.

However patients generally reported a good relationship with health professionals.

“These participants reported trust and confidence in their doctors, good communication, continuity of care and being shown kindness. Additionally, these participants described a preference for discussing medical treatments (such as opioids) with trusted health professionals as opposed to receiving written educational information.”

Most patients had some prior experience of opioids therapy, either personally or via friends and family. Unfortunately these were mostly negative experiences including addiction, death of a loved one, and adverse effects.

Opioid-experienced participants, however, also described benefits from treatment for their breathlessness such as improved mobility, eating habits and personal care, participation in activities and independence.

“These findings highlight the immense stigma and objections participants held towards opioids, as well as the need for regular, repeated conversations regarding symptom palliation earlier in the illness course so that patients become familiar with the benefits of concurrent disease-directed and symptom-focused treatment approaches and to gradually break down barriers,” the study said.

The investigators, including Professor Jennifer Philip and Associate Professor Natasha Smallwood, said underappreciation of patient-related barriers contributes to low prescription rates of opioids to people with advanced cardiorespiratory diseases.

“It is likely that early integration of palliative services provides both the education and relationships needed to help support the use of stigmatised interventions, such as opioid therapy.”

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