Principles and choice of opioid therapy for chronic breathlessness in palliative care
If breathlessness remains problematic despite the use of general measures (including optimising management of the causative disease and comorbidities), consider an opioid in combination with nonpharmacological therapy and a breathlessness action plan.
Evidence to support opioid use for chronic breathlessness is limited and is primarily from patients with COPDBarnes, 2016Ekström, 2022van Dijk, 2021 (with a small amount of data from patients with advanced cancer, heart failure or interstitial lung disease). Despite the limited evidence, opioids remain the main drug class used for breathlessness in patients with palliative care needsBruera, 1993Cherny NI, 2021.
Opioid therapy for chronic breathlessness is usually started in stable patients in an outpatient setting because this is the group of patients in whom opioid therapy has been studied.
Do not use nebulised opioids to treat breathlessness—there is no evidence of benefitBarnes, 2016.
Opioids are used in a variety of ways to manage breathlessness, tailored to the needs of the patient. Approaches include:
- as a pre-emptive measure before an activity known to cause breathlessness (eg showering)
- when required to manage acute-on-chronic breathlessness
- regular therapy (eg for patients who are continually breathless at rest, or on minimal exertion).
Evidence to support one approach to starting opioid therapy over another for chronic breathlessness in palliative care is lacking; in practice, dose regimens vary based on the needs of the patient, clinician preference and location of care. Some clinicians prescribe an immediate-release opioid for use before exertion, while others reserve its use for management of acute-on-chronic breathlessness. The role for routine use of regular modified-release opioids in chronic breathlessness is unclearEkström, 2022. Some patients may find therapy with a regular modified-release opioid beneficial (eg those with breathlessness at rest). For examples of different clinical scenarios in which opioids may be started, see Examples of clinical scenarios in which an opioid may be started for chronic breathlessness (including breathlessness on exertion and acute-on-chronic breathlessness).
Monitor for adverse effects when starting and titrating opioids (eg drowsiness, constipation, nausea and vomiting). For information on prevention and management strategies for opioid adverse effects, see Opioid adverse effects in palliative care.
For management of breathlessness in the last days of life, see Breathlessness causing distress in the last days of life.
A scenario in which an opioid may be started for breathlessness on exertion
An older patient with severe COPD experiences breathlessness while showering. The patient can usually manage their breathlessness with nonpharmacological measures outlined in the breathlessness action plan, but daily morning showering remains stressful.
Consider introducing a pre-emptive dose of immediate-release oral opioid 15 to 45 minutes before showering.
A scenario in which an opioid may be started for acute-on-chronic breathlessness
A patient with severe COPD manages their chronic breathlessness day-to-day with a breathlessness action plan. When the patient becomes unwell with a COPD exacerbation, the COPD action plan is followed to manage the exacerbation; however, the breathlessness becomes difficult to control with nonpharmacological measures and salbutamol, and the patient has intermittent episodes of breathlessness with panic when mobilising.
Consider adding an immediate-release oral opioid to the breathlessness action plan, with a limit of 3 doses before further advice is sought (eg call local palliative care service or GP, or call 000 if it is an emergency).
A scenario in which a regular opioid may be started for chronic breathlessness
An older patient has advanced interstitial lung disease and is becoming breathless on minimal movement, such as attending to their daily personal care and moving in bed. Their oxygen therapy has been reviewed and optimised. The patient has found intermittent doses of an immediate-release opioid helpful for temporarily relieving breathlessness, and has been using one dose daily each morning before showering.
Consider starting a regular modified-release opioid and stopping the immediate-release opioid before showering. An immediate-release opioid could be used when required for acute breathlessness that is unresponsive to measures outlined in the patient’s breathlessness action plan.