Opioid therapy for breathlessness on exertion in palliative care
If an opioid is appropriate for breathlessness on exertion in a patient with palliative care needs (see Principles and choice of opioid therapy for chronic breathlessness in palliative care), as part of a breathlessness action plan, use:
morphine immediate-release 1 to 2.5 mg orally, as a single dose, 15 to 45 minutes before the event12. morphine
If another dose is required for an event, the minimum time between doses is 1 hour. If 3 doses are required in 24 hours, seek specialist advice.
Adjust dose according to effectiveness and tolerability. 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).
If breathlessness occurs with minimal exertion frequently throughout the day (eg more than 3 times a day), and the patient finds opioids beneficial, consider starting regular opioid therapy to decrease the frequency and severity of breathlessness on exertion and as-required opioid use.
For patients who already take a regular opioid for another indication (eg pain), the above dose of morphine (or equivalent dose of another opioid) can be used; however, if this dose is ineffective, consider increasing to the dose the patient uses for breakthrough pain. A higher maximum total daily dose (ie greater than 30 mg oral morphine equivalent) may be required in patients who take a regular opioid for another indication. Seek specialist advice if the patient’s cumulative total daily opioid dose is higher than 100 mg oral morphine equivalent.