Abstract
The use of opioids to treat refractory breathlessness requires careful evaluation of risks and benefits http://ow.ly/ylHT30bPzfu
From the authors:
We thank N.T. Vozoris for his comments and interest in the case report that we presented in the European Respiratory Journal of a patient with chronic obstructive pulmonary disease (COPD) who experienced respiratory depression after inadvertent opioid overdose while using opioids to manage refractory breathlessness [1].
As N.T. Vozoris notes, the case patient was first prescribed opioids for refractory breathlessness during a hospital admission with an infective exacerbation; however, the episode of respiratory depression only occurred after discharge from hospital, when the patient was recovering from the exacerbation and thus becoming more “stable”. Whilst the initiation of opioids for refractory breathlessness has only been evaluated in clinical trials of stable outpatients [2, 3], observational data suggest that opioids are started in up to 18% of COPD patients around the time of hospital presentations for exacerbations [4]. It seems likely that for some of those patients (including our case patient), opioids were commenced for symptom palliation, when it was unknown if the patient would survive or die during the exacerbation. Similarly, in such settings, when the absolute focus of care is to reduce the distress of a patient who appears to be actively dying from respiratory failure, the opioid regimen recommended by either the respiratory team or palliative care team (as in our case report) may differ from the regimens used in clinical trials or suggested by guidelines.
The issue then arises of how to manage opioid therapy prescribed for breathlessness palliation during a near fatal exacerbation when the patient with end-stage disease does survive and is ready to be discharged home. Should the opioid be ceased or continued? If the opioid is ceased, how will the patient and family feel about this? Will there be concerns that the patient will not cope at home without symptom palliation? However, if the opioid is continued, then the questions remain regarding what regimen and what dose should be given, as it seems likely that the dosing requirements will reduce as the acute exacerbation resolves. Such questions as these are commonly faced by clinicians and highlight the challenges that arise in translating evidence into real-world medicine, particularly when prescribing palliative treatments to patients with an unpredictable disease.
We agree with N.T. Vozoris that whilst opioids have an important role in managing refractory breathlessness in patients with advanced lung disease, the needs, comorbidities and abilities of the patient must be included in the careful evaluation of the risks and benefits of any opioid treatment regimen. Significant adverse events, including inadvertent overdose, may occur at any time; therefore, close supervision and support in the community, coupled with individualised, patient-focussed care, are essential to ensure both effective and safe, optimal management of distressing breathlessness.
Footnotes
Conflict of interest: None declared
- Received April 2, 2017.
- Accepted April 3, 2017.
- Copyright ©ERS 2017