Regular opioid therapy for chronic breathlessness in palliative care
If regular opioid therapy is appropriate for chronic breathlessness in a patient with palliative care needs (see Principles and choice of opioid therapy for chronic breathlessness in palliative care), and the patient is not already taking regular opioids, as part of a breathlessness action plan, use1:
1morphine (24-hour) modified-release 10 mg orally, once daily. Adjust dose every week according to effectiveness and tolerability, up to a maximum of 30 mg in 24 hours morphine
OR
1morphine (12-hour) modified-release 5 mg orally, twice daily. Adjust dose every week according to effectiveness and tolerability, up to a maximum of 30 mg in 24 hours. morphine
An alternative approach is to use an immediate-release formulation regularly; for example, if a patient has swallowing difficulties or only has access to an immediate-release formulation and a delay in obtaining a modified-release formulation is expected (eg in rural settings).
The ceiling effect for opioids in breathlessness is approximately 30 mg oral morphine equivalent in 24 hours; beyond this dose, adverse effects usually outweigh any additional improvement. For patients taking more than 30 mg oral morphine equivalent in 24 hours without improvement in breathlessness, review and consider withdrawing the opioid (unless it is also being used for another indication).
For management of breathlessness causing distress in the last days of life, and advice on when to consider starting a continuous subcutaneous infusion of morphine, see Breathlessness causing distress in the last days of life.