Opioids for refractory dyspnea

Abstract

Refractory dyspnea is breathing difficulty that persists at rest or with minimal activity despite optimal therapy of the underlying condition. Both endogenous (β-endorphin) and exogenous (morphine) opioids modulate the perception of dyspnea by binding to opioid receptors. Proposed mechanisms whereby opioids relieve refractory dyspnea include: decreasing respiratory drive with an associated decrease in corollary discharge; altering central perception; altering activity of peripheral opioid receptors located in the lung and decreasing anxiety. As patients respond variably to opioid therapy, a low dose of an opioid should be prescribed initially to manage refractory dyspnea. The dose should be titrated to achieve the lowest effective dose based on patient ratings of breathing difficulty. Research is needed to address clinical uncertainties and to identify genetic factors to improve the use of opioids to relieve refractory dyspnea. Medscape: Continuing Medical Education OnlineThis activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Expert Reviews Ltd. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at www.medscape.org/journal/expertrespiratory; (4) view/print certificate. Learning objectivesUpon completion of this activity, participants will be able to:• Describe proposed mechanisms for the effect of systemic opioids in relieving refractory dyspnea, based on a review • Describe management of refractory dyspnea with systemic opioids, based on a review • Describe barriers to opioid use for management of refractory dyspnea and directions for future research

Exertional dyspnoea in COPD: the clinical utility of cardiopulmonary exercise testing

“…Reproduced from [37] with permission. medication [63,[130][131][132][133][134][135], which directly or indirectly reduces central respiratory drive, can ameliorate dyspnoea during physical activity and improve exercise endurance. Reduced neural drive following these interventions usually manifests as reduced breathing frequency (and increased expiratory time) often with an attendant decrease in the rate of dynamic hyperinflation [108,113,126,128,131].…”

Year in review 2016: Interstitial lung disease, pulmonary vascular disease, pulmonary function, paediatric lung disease, cystic fibrosis and sleep

“…97 Low doses of oral sustained-release morphine can be effective in managing refractory breathlessness in patients with severe respiratory disease. 99 However, clinicians appear hesitant to prescribe opioid medication in respiratory patients, possibly because of concerns about the impact on breathing. 100 In high doses, suppression of respiration, reduced arousal from sleep, lower nocturnal oxygen levels and central apnoeic events can occur.…”

Managing breathlessness in advanced disease

“…Patients with advanced cancer can develop Opioids are proposed both to reduce the spontaneous respiratory motor response to hypercapnia and hypoxia and to modulate the central processing such that perceptual sensitivity to breathlessness is diminished. 13 Important gaps remain in the knowledge base regarding variability in the degree of opioid responsiveness and tolerability between patients. Recent work suggests that younger patients and those who experience the greatest severity of breathlessness are most likely to benefit.…”

“…Opioids have been found to be signifi cantly better than oxygen in reducing breathlessness. 13 Short-burst oxygen supplementation may prevent desaturation during exercise but may not relieve breathlessness. Careful assessment of symptomatic benefi t on an individual basis is recommended.…”