title: Opioid therapy for refractory dyspnea in patients with advanced chronic obstructive pulmonary disease: patients' experiences and outcomes.
abstract: BACKGROUND
  Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients' experiences when opioids are added to optimized conventional treatments for advanced COPD.
  
  
  METHODS
  A total of 44 patients (median age 74, range 51-89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid "helpfulness" and adverse effects before, at 2 months and at 4-6 months after opioids were started.
  
  
  RESULTS
  Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients' overall positive experiences: small gains have big impact; realign hopes with reality; and "try it." Significant improvements were observed in median (interquartile range) scores between baseline and 4-6 months' assessment for health-related quality of life (Chronic Respiratory Questionnaire: 3.5 [2.8-4.0] v. 4.2 [3.6-4.8]; and Chronic Respiratory Questionnaire-Dyspnea domain: 2.8 [2.3-3.6] v. 3.9 [2.8-4.5]) and decreases in severity of dyspnea (numerical rating scale: 7.0 [5.0-8.0] v. 5.0 [4.0-6.0]). Adverse effects were minimal for most patients.
  
  
  CONCLUSIONS
  Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting.
  
  
  BACKGROUND
  ClinicalTrial.gov, no. NCT00982891.
authors: Division of Respirology, QEII Health Sciences Centre, Halifax, NS ; Division of Palliative Medicine, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS.
authors: Graeme M
authors: GM
authors: Rocker
authors: Division of Respirology, QEII Health Sciences Centre, Halifax, NS.
authors: A Catherine
authors: AC
authors: Simpson
authors: Division of Palliative Medicine, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS.
authors: Robert
authors: R
authors: Horton
authors: Department of Critical Care and Division of Respirology, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont.
authors: Tasnim
authors: T
authors: Sinuff
authors: Division of Respirology, QEII Health Sciences Centre, Halifax, NS.
authors: Jillian
authors: J
authors: Demmons
authors: Division of Respirology, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS.
authors: Paul
authors: P
authors: Hernandez
authors: Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, Sask.
authors: Darcy
authors: D
authors: Marciniuk