Associate Professor Natasha Smallwood
Low-dose opioids benefited two out of three patients with chronic breathlessness from non-malignant advanced lung disease, according to the first study to examine the long-term impact of the treatment.
The research, published this week in the Internal Medicine Journal, found the extended use of oral opioids had a subjective benefit to a majority of patients, importantly, with no accidental overdoses, incidents of sedation or other events requiring hospitalisation, or death.
“The cohort included patients with poor respiratory function and multiple medical and psychological comorbidities, which is a group that is generally at increased risk from opioid-associated adverse events,” the researchers from Monash University, Melbourne, concluded.
“Our study demonstrated that patients were willing to accept and compliant with low-dose opioid treatment for breathlessness, experienced subjective symptom improvement, and there were no serious adverse events.”
Study author Associate Professor Natasha Smallwood, a respiratory physician, said the research confirmed previous studies about the potential benefit of low-dose opioids for a specific group of patients.
“If you are careful about selecting the right person to give an opioid, and consider the risks and benefits, and identify a safe group then you can see beneficial effects,” she told the limbic.
“An opioid is tolerated well and is safe, if you select the right group.”
Palliative care
The study was conducted on a group of 109 patients who attended the Royal Melbourne Hospital’s integrated respiratory and palliative care service from 2013 to 2020.
All experienced breathlessness, a common, under-treated and debilitating symptom of patients with chronic obstructive lung disease and interstitial lung disease. Nearly all (104) were also seeing a palliative care clinician during the course of the research, and 81 died over the study.
Patients were provided with education and screened for their clinical and social capacity to comply with the opioid treatments. This included checking for kidney and liver function, as well as cognitive capacity and social supports to ensure safe treatment.
“It’s unclear what are the characteristics of the group that will most benefit from an opioid,” Associate Professor Smallwood said.
“We really need take the time to inform patients about opioids, individualise how we prescribe them, and give them very specific plans for medication use.”
“The challenge is really making that time. We need to think about how we can support respiratory clinicians … and also people in primary care to have time to support patients who may benefit from an opioid.”
About two out of three (65.1%) reported a subjective improvement in their breathlessness but the clinical indicator, the mean mMRC dyspnoea score, did not show a significant change.
Associate Professor Smallwood said the mMRC did not have the precision to respond well to changes over time, as a unidimensional assessment of breathlessness.
Most patients (33.9%) were prescribed an extended-release preparation (such as MS Contin or Kapanol) together with an immediate-release preparation as needed at a median dose of 12mg oral morphine equivalents per day.
Half the group reported no side effects, but 16 stopped either due to side effects (12 patients) or a lack of efficacy (four).
“Further research is needed to determine the long-term effects of opioids on quality of life and lung function parameters in this patient population,” the study said.
“Ensuring patients receive individualised care, opioid education, support and follow-up is important to mitigate risks in this older patient group, who are more vulnerable to adverse events.”
Associate Professor Smallwood’s research team will later this week launch a website with educational resources for patients, caregivers and clinicians regarding non-pharmacological treatments for breathlessness. These include breathing exercises, postures, pacing and fan therapy.