Morphine and other Opiates can be used for the palliation of breathlessness in patients with advanced COPD unresponsive to other medical therapy. Though some research studies do support the usefulness of morphine in advanced COPD, there is difference of opinion among pulmonologists and professional associations do not recommend using it as of now except for terminal illness.
Chronic Obstructive Pulmonary Disease (COPD) is characterized by irreversible obstruction to outflow of air from the lungs. In short patients with COPD can inspire air but have difficulty in expiring air out of the lung. COPD is strongly associated with smoking though non-smokers do sometime get COPD. The lung in COPD is characteristically hyper-inflated with increase in the lung volumes resulting in a barrel shaped chest wall. These patient also get frequent respiratory tract infections that aggravates the underlying COPD and manifests as increased breathlessness, wheezing, cough with or without sputum, fever etc. COPD is diagnosed by means of pulmonary function testing which would reveal decreased expiratory volume and non-reversibility of the obstruction after bronchodilator therapy.
A person with COPD gradually loses his lung function overtime with increasing breathlessness refractory to all pharmacological interventions. COPD can be ‘managed’ and the acute exacerbations can be treated but COPD cannot be ‘cured’ with the current medical knowhow available. As the disease becomes advanced the symptoms of COPD especially the breathlessness becomes disabling and denies the patient the joy of carrying out day to day activities. They may need long term supplemental oxygen therapy at home and have to restrict their physical activity.
Breathlessness is a complex SUBJECTIVE feeling of getting insufficient air. Essential to managing breathlessness in advanced COPD is recognition that breathlessness is a subjective feeling and shaped by variety of factors including anxiety, tolerance to ailments, mental health, past experiences, psychosocial factors etc. In fact several non-pharmacological additional intervention for the management of COPD stress on anxiolysis and relaxation techniques. Other recommended strategies include pursed lip breathing, paced activities and slow exercise training.
When the limitation of current standard medications in advanced COPD becomes obvious, more effective drugs or palliation to resolve some of the discomfort associated with COPD is warranted. Dr.G.M.Rocker, Halifax Infirmary, Nova Scotia, Canada in an article published in pulmonary medical journal ‘Thorax’ argues in favor of using morphine and other opioids in the management of refractory breathlessness in advanced COPD patients. He cites several academic papers and his own personal experience and that of his colleagues in using opioids for advanced COPD.
As early as 20 years ago, morphine was reported to reduce the symptoms of breathlessness associated with COPD. Since then several trails have been conducted on this subject which report outcomes ranging from no benefit to partial benefit is certain proportion of the study population. Studies also suggested improvement in the exercise tolerance in advanced COPD patients using opioid drugs. Recently Currow et al reported that 51% of the patients with advanced COPD found morphine –SR (sustained release) medications to be helpful in managing their disease and elected to continue the treatment with morphine.
There are several issues that need to be sorted out before opioid may be widely used in treating breathlessness associated with advanced COPD. One is the lack of large double blind randomized controlled trails to evaluate the usefulness of opioids in the setting of advanced COPD. Other factors include patient and physician’s reluctance to use a controlled substance with a possibility of abuse and overdose. Commonest side effect complained by the patients is constipation and others include nausea, confusion, drowsiness and lethargy. Though opioids are known to cause respiratory depression, morphine in low doses does not appear to decrease the respiratory drive.
All major professional bodies including the American Thoracic Society and European Respiratory Society do not recommend the use of opioids in advanced COPD except in the terminal cases. In conclusion, use of opioids in advanced COPD for palliation of the breathlessness may be helpful but needs further clinical studies and recommendation from professional bodies to become widely acceptable.
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