Natasha Smallwooda,b , David Currowc, Sara Boothd, Anna Spathise, Louis Irvinga, and Jennifer Philipf,g a
Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, Australia;bDepartment of Medicine (Royal Melbourne Hospital), University of Melbourne, Victoria, Australia;cFaculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia;dUniversity of Cambridge, Cambridge, UK;eCambridge University Hospitals NHS Foundation Trust, Cambridge, UK;fPalliative Medicine, St Vincent’s Hospital and Victorian Comprehensive Cancer Centre, University of Melbourne;gSt Vincent’s Hospital, Fitzroy, Victoria, Australia
ABSTRACT
This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A volun- tary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medi- cine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both special- ties most commonly recommended a combination of non-pharmacological and pharmacological breathless- ness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no spe- cific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the comple- mentary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.
ARTICLE HISTORY
Received 20 March 2018 Accepted 15 July 2018
KEYWORDS
COPD; breathlessness; palliation; survey; health professionals; opioids; professional attitudes
Abbreviations
ANZ Australia and New Zealand
COPD chronic obstructive pulmonary disease
PR Pulmonary rehabilitation
Introduction
Chronic obstructive pulmonary disease (COPD) is character- ised by airflow limitation, persistent symptoms and respira- tory failure in advanced disease (1). Many patients with severe COPD experience reduced quality of life due to chronic breathlessness (2). The chronic breathlessness syn- drome has recently been defined as breathlessness which persists despite optimal treatment of the underlying causes and which results in disability (3).
Managing severe, chronic breathlessness can be challeng- ing and may require a stepped, multi-disciplinary approach, including: (1) optimising disease-directed therapy (including
inhaled and oral pharmacotherapy, smoking cessation, self- management education and domiciliary oxygen); (2) non- pharmacological management strategies (including but not limited to physical activity, pulmonary rehabilitation (PR), breathing exercises and the use of a handheld fan) and (3) adding opioids if required (1,4,5). A series of studies suggest regular, low dose morphine may safely reduce chronic breathlessness in patients with advanced disease (6–10). However, the off-label prescription of morphine to treat chronic breathlessness requires thorough evaluation of bene- fits and risks, with dosing individualised and close supervi- sion required to determine response and monitor for side effects (11).
Despite COPD guidelines recommending active manage- ment of chronic breathlessness (1,4,5,12,13), this symptom remains under-recognised and undertreated, and few patients access specialist palliative care (14–21), with lack of clinician knowledge and experience reported as obstacles (17,22,23). Therefore, we aimed to survey doctors working in respiratory and palliative medicine in different countries
COPD: JOURNAL OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 2018, VOL. 15, NO. 3, 294–302
to explore knowledge and attitudes regarding managing chronic breathlessness and the role of specialist palliative care services. In this manuscript, we report specialists’ knowledge and experience managing chronic breathlessness in COPD.
Methods
An anonymous, voluntary questionnaire was designed for specialists and specialist trainees working in respiratory medicine in Australia and New Zealand (ANZ) and pallia- tive medicine in ANZ and the United Kingdom (UK). As a literature search revealed no appropriate survey instrument, we developed a new questionnaire (see supplementary data). Participants answered between 21 and 26 questions, with logic embedded within the electronic survey to determine the next question according to previous response or spe- cialty background.
A case vignette was included, which described an opti- mally treated outpatient with severe COPD. The patient in the case vignette had severe, worsening, chronic breathless- ness over many years, with a modified Medical Research Council (mMRC) breathlessness score of 4 out of 4 (i.e. severe breathlessness affecting dressing and bathing, or mak- ing the person housebound). Survey participants were informed the patient was neither anxious nor in the ter- minal phase (last few days). Respondents were asked to con- sider how they would manage the case patient or COPD patients similar to the case. The questionnaire focussed on four themes: respondent demographics; management strat- egies for chronic breathlessness; the role of specialist pallia- tive care and advance care planning.
The survey was piloted on 30 doctors from both special- ties in all three countries to ensure user acceptability, face validity and comprehensiveness prior to full distribution. The Thoracic Society of Australia and New Zealand, the Australian and New Zealand Society of Palliative Medicine and the Association for Palliative Medicine of Great Britain and Ireland distributed the survey, with each society mem- ber receiving two email invitations including the survey link, approximately 2–4 weeks apart. Additionally, each society included information about the survey on their websites and in electronic members’ newsletters. Paper copies of the sur- vey were also distributed at two Australian palliative care meetings and one Australian respiratory meeting. Ethics approval was granted by the Melbourne Health Research Office (approval number: QA20141).
Statistical analysis
Data are reported descriptively using frequencies and pro- portions. Proportions were calculated using the total number of respondents with complete questionnaires (n ¼ 440), unless otherwise stated. Responder demographics (age and
The Chi-Squared test and Student’s t-test were used to identify associations between outcomes from survey ques- tions and key exposure variables measured as either propor- tions or continuous numerical data respectively. Logistic regression models were used to further explore significant associations. Exposure variables were defined as: age, gender, country of practice, specialty, medical position, places of work, mean years worked in specialty including years in spe- cialist training and mean number of patients with severe COPD seen per month. Statistical analyses were performed using IBM SPSS Statistics Version 24.0.
Results
Respondent demographics
The survey was distributed to 1,749 respiratory and pallia- tive medicine doctors in ANZ and the UK, with 577 (33.0%) responses received (Figure 1). Of 440 (25.2%) responses included, 263 were palliative medicine doctors, with 98 (37.3%) from Australia, 21 (11.8%) from New Zealand and 134 (51.0%) from the UK (Table 1). Of 177 responses received from respiratory doctors, 152 (85.9%) respondents were Australian and 25 (14.1%) were from New Zealand. Due to the smaller number of specialists in New Zealand, responses from that country were combined with Australian participants. The gender and age characteristics of partici- pants were similar to those reported in census data for the entire respiratory and palliative medicine workforces in ANZ and the UK (14,24–27).
Patient management: investigations
The minority of respiratory (29.9%) and palliative medicine doctors (17.9%) reported using a breathlessness scale (such as the Borg score) in clinical practice (OR¼ 2.0, 95% CI¼ 1.3–3.1, p ¼ 0.003). In response to the case vignette, the investigations most commonly recommended by respiratory doctors were echocardiography (102, 57.6%), overnight oximetry (64, 36.2%), or no further investigations (54, 30.5%). Palliative medicine doctors most commonly recom- mended no further investigations required (155, 58.9%), overnight oximetry (41, 15.5%) or echocardiography (36, 13.7%). Palliative medicine doctors were three times more likely to recommend that no further investigations were required as compared to respiratory doctors (OR¼ 3.3, 95% CI¼ 2.2–4.9, p < 0.0001). Additionally, palliative medicine doctors from ANZ were significantly more likely to recom- mend that no further investigations were required as com- pared with colleagues in the UK (p ¼ 0.001). Fourteen (5.3%) palliative medicine doctors responded that determin- ing which investigations were required was the respiratory team’s role.
chronic breathlessness, with those who saw fewer patients with severe COPD each month (mean¼ 10.7, SD ¼ 9.6), sig- nificantly more likely to report uncertainty or insufficient knowledge (p ¼ 0.023).
Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness (p ¼ 0.318), whereas respiratory and palliative medicine doctors had signifi- cantly different approaches (p < 0.0001;
doctors did not make any recommendations for managing the chronic breathlessness described in the case vignette, as com- pared with 4 (1.5%) palliative medicine doctors.
Non-pharmacological management of breathlessness
The non-pharmacological strategies most commonly recom-
Table 1. Participant demographics.
Respiratory medicine Palliative medicine (n ¼ 263)
Specialties compared ANZ (n ¼ 177) ANZ (n ¼ 129) UK (n ¼ 134) All (n ¼ 263)
Female 61 (34.4%) 80 (62.0%) 112 (83.6%) 192 (73.0%) p < 0.0001 Age 25–35 40 (22.6%) 25 (19.3%) 31 (23.1%) 56 (21.3%) p ¼ 0.953 36–45 57 (32.2%) 27 (20.9%) 50 (37.3%) 77 (29.3%) 46–55 39 (22.0%) 31 (24.0%) 36 (26.9%) 67 (25.5%) 56–65 27 (15.3%) 29 (22.5%) 15 (11.2%) 44 (16.7%) >65 8 (4.5%) 11 (8.5%) 0 11 (4.2%) Missing 6 (3.4%) 6 (4.7%) 2 (1.5) 8 (3.0%) Position Consultant 145 (81.9%) 89 (69.0%) 107 (79.9%) 196 (74.5%) p ¼ 0.068 Specialist trainee 32 (18.1%) 40 (31.0%) 27 (20.1%) 67 (25.5%)
Mean years in specialty* 15.0 (10.8) 12.5 (9.1) 12.3 (7.3) 12.4 (8.2) p ¼ 0.006
Places of work
Acute hospital inpatients 158 (89.3%) 27 (20.9%) 26 (19.4%) 53 (20.2%) p < 0.0001
Acute hospital consultation service 95 (53.7%) 72 (55.8%) 58 (43.3%) 130 (49.4%) p ¼ 0.383
Community 10 (5.6%) 57 (44.2%) 63 (47.0%) 120 (45.6%) p < 0.0001
Outpatient clinics 145 (81.9%) 50 (38.8%) 39 (29.1%) 89 (33.8%) p < 0.0001
Hospice/palliative care unit 2 65 (50.4%) 101 (75.4%) 166 (63.1%) p < 0.0001
Private practice 81 (45.8%) 7 (5.4%) 1 (0.7%) 8 (3.0%) p < 0.0001
Mean no. of severe COPD patients seen/month* 14.1 (12.0) 3.1 (3.1) 2.5 (3.4) 2.8 (3.3) p < 0.0001
Data are represented as either frequencies or means (denoted by ), with either proportions or standard deviations in parentheses.
1749 doctors emailed the survey: 1047 Palliave medicine &
702 Respiratory medicine 577 (33.0%) respondents commenced the survey 440 (25.2%) respondents completed the full
survey
137 exclusions: 94 incomplete responses,
35 responses from other specialists (not palliave medicine or respiratory
medicine), 8 responses from non- medical professionals 263(25.1%)Palliave medicine parcipants 177 (25.2%) Respiratory medicine parcipants
Figure 1. Survey distribution.
specialties also commonly recommended: breathing training techniques, anxiety management strategies and the use of a handheld fan to move cool air on the face, however, pallia- tive medicine doctors were significantly more likely to rec- ommend each of these strategies than respiratory doctors (p < 0.0001). Palliative medicine doctors were also more likely to recommend multiple strategies, multidisciplinary care and self-management education.
Pharmacological breathlessness management
Three quarters of palliative medicine doctors (197, 74.9%), recommended initiating short acting oral morphine 2.5–5 mg 4–6 hourly as required for the case patient’s breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001)
within respiratory medicine (p ¼ 0.001). For palliative medi- cine doctors, recommending morphine for chronic breathless- ness was not associated with participants’ demographic characteristics or experience.
Significantly more palliative medicine doctors regularly (213, 81.0%) or occasionally (50, 19.0%) prescribed opioids for severe, chronic breathlessness in COPD, as compared with respiratory doctors of whom 63 (35.6%) regularly and 98 (55.4%) occasionally prescribed opioids (p < 0.0001). Sixteen (9.0%) respiratory doctors reported never prescribing opioids for severe chronic breathlessness. The most common barriers cited by respiratory doctors to prescribing opioids for chronic breathlessness in COPD were: the risk of respiratory depression (34, 19.3%), insufficient knowledge or experience prescribing opioids (20, 11.3%) and not seeing many patients with severe COPD and chronic breathlessness
Table 2. Recommended management of severe chronic breathlessness in COPD. Recommendation
Respiratory medicine (n ¼ 177)
Palliative medicine ANZ (n ¼ 129)
Palliative medicine UK (n ¼ 134)
Palliative medicine All (n ¼ 263) No specific management (pharmacological or non- pharmacological) recommended 19 (10.7%) 2 (1.6%) 2 (1.5%) 4 (1.5%) Review Step 1 8 (4.5%) 1 (0.8%) 1 (0.7%) 2 (0.8%)
Add Step 2 only 29 (16.4%) 5 (3.9%) 10 (7.4%) 15 (5.7%)
Review Step 1 and add Step 2 12 (6.8%) 0 0 0
Add Step 3 only 31 (17.5%) 27 (20.9%) 19 (14.2%) 46 (17.5%)
Review Step 1 and add Step 3 5 (2.8%) 0 0 0
Add Steps 2 and 3 55 (31.1%) 81 (62.8%) 95 (70.9%) 176 (66.9%)
Review Step 1 and add Steps 2 and 3
18 (10.2%) 13 (10.1%) 7 (5.2%) 20 (7.6%)
Step 1: Optimise current disease directed treatment (including: optimise inhalers and technique, consider steroids, theophylline, domiciliary oxygen ther- apy). Step 2: Initiate non-pharmacological strategies (for more detail seeTable 3). Step 3: Add‘palliative’ pharmacological treatments (i.e. opioids and benzodiazepines). Answers from two survey questions were combined to determine the overall approach to chronic breathlessness.
Table 3. Non-pharmacological breathlessness management strategies. Recommended strategy Respiratory medicine (n ¼ 177) Palliative medicine (n ¼ 263) Non-pharmacological strategies Fan 25 (14.1%) 158 (60.1%) p < 0.0001
Breathing training techniques 28 (15.8%) 132 (50.2%) p < 0.0001
Pulmonary rehabilitation or exercise programme 97 (54.8%) 37 (14.1%) p < 0.0001
Anxiety management (including relaxation or distraction techniques) 26 (14.7%) 100 (38.0%) p < 0.0001
Physiotherapy 11 (6.2%) 79 (30.0%) p < 0.0001
Pacing, energy conservation and fatigue management 8 (4.5%) 53 (20.2%) p < 0.0001
Occupational therapy 5 (2.8%) 41 (15.6%) p < 0.0001
Psychology referral 20 (11.3%) 16 (6.1%) p ¼ 0.051
Complementary therapies (including acupuncture and music therapy) 0 24 (9.1%) p < 0.0001
Walking aids and home modifications 6 (3.4%) 18 (6.8%) p ¼ 0.123
Positioning to alleviate breathlessness 5 (2.8%) 17 (6.5%) p ¼ 0.082
Social or home needs assessment 7 (4.0%) 8 (3.0%) p ¼ 0.571
Discussions regarding the future– concerns, fears and expectations 2 (1.1%) 6 (2.3%) p ¼ 0.356
Breathlessness MDT clinic/service 1 (0.6%) 18 (6.8%) p ¼ 0.002
Education regarding breathlessness or a breathlessness plan 5 (2.8%) 27 (10.3%) p ¼ 0.003
Patient support groups 0 8 (3.0%) p ¼ 0.020
Domiciliary oxygen 4 (2.3%) 8 (3.0%) p ¼ 0.658
Cognitive behavioural therapy 5 (2.8%) 7 (2.7%) p ¼ 0.950
Community COPD nurse support 3 (1.7%) 3 (1.1%)
Palliative care input 3 (1.7%) 2 (0.8%)
Domiciliary non-invasive ventilation 1 (0.6%) 1 (0.4%)
No question response 45 (25.4%) 46 (17.5%) p ¼ 0.045
Data are represented as frequencies with proportions in parentheses.
When there were less than five respondents in both groups the Chi-Squared test was not performed.
Twenty-five (8.5%) respiratory and 5 (1.9%) palliative medicine doctors recommended adding a benzodiazepine as their first line pharmacological agent to treat the patient described in the case vignette, who was neither anxious nor in the terminal phase (Table 4). Significantly more palliative medicine doctors reported regularly (40, 15.2%) or occasion- ally (167, 63.5%) prescribing benzodiazepines for chronic breathlessness, as compared with 16 (9.0%) respiratory doctors regularly prescribing and 100 (56.5%) occasionally prescribing benzodiazepines (p ¼ 0.004). Frequency of prescribing benzo- diazepines for chronic breathlessness was not associated with participants’ demographic characteristics or experience for both specialties.
Discussion
Current evidence suggests that patients with severe, chronic breathlessness are under-recognised and undertreated
with a different approach to managing chronic breathlessness, with palliative medicine doctors more frequently recommending a combination of non-pharmacological and pharmacological (opioid) strategies. While this approach was also recommended by a third of respiratory doctors’, their responses were more var- ied and focussed on the earlier steps in managing severe, chronic breathlessness. While any active initial approach to managing severe, chronic breathlessness may be considered reasonable for the case vignette described, it is essential that this distressing symptom is actively managed and not under-treated. Thus if severe, chronic breathlessness persists despite early step interven- tions, then treatment should be escalated and may include opioids after a thorough evaluation of risks and benefits.
Non-pharmacological breathlessness management strategies
Opioids are just one aspect of breathlessness management
Table 4. Pharmacological breathlessness management recommendations. Recommendationa Respiratory medicine (n ¼ 177) Palliative medicine ANZ (n ¼ 129) Palliative medicine UK (n ¼ 134) Palliative medicine
All (n ¼ 263) Specialties compared
Short acting oral morphine 73 (41.2%) 100 (77.5%) 97 (72.4%) 197 (74.9%) p < 0.0001
10 mg long-acting morphine/day 17 (9.6%) 8 (6.2%) 4 (3.0%) 12 (4.6%)
20 mg long-acting morphine/day 2 (1.1%) 3 (2.3%) 0 3 (1.1%)
Benzodiazepine regularly 4 (2.3%) 0 0 0
Benzodiazepine as needed 11 (6.2%) 3 (2.3%) 2 (1.5%) 5 (1.9%)
Don’t know 1 (0.6%) 0 1 (0.7%) 1 (0.4%)
Prescription of opioid frequency
Regularly 63 (35.6%) 107 (82.9%) 106 (79.1%) 213 (81.0%) p < 0.0001 Occasionally 98 (55.4%) 22 (17.1%) 28 (20.9%) 50 (19.0%) Never 16 (9.0%) 0 0 0 Prescription of benzodiazep- ine frequency Regularly 16 (9.0%) 18 (14.0%) 22 (16.4%) 40 (15.2%) p ¼ 0.004 Occasionally 100 (56.5%) 88 (68.2%) 79 (59.0%) 167 (63.5%) Never 61 (34.5%) 23 (17.8%) 33 (24.6%) 56 (21.3%)
Data are represented as frequencies with proportions in parentheses.
For short acting oral morphine the suggested dose was morphine 2.5–5mg 4–6 hourly PRN. For Benzodiazepine regularly the suggested dose was Lorazepam 0.5 mg BD. For Benzodiazepine as needed the suggested dose was Lorazepam 0.5 mg PRN.
a
Only respondents who had previously responded‘Yes’ of ‘Don’t know’ to the earlier question regarding whether to initiate a specific pharmacological treatment for breathlessness, were eligible to answer this question, therefore, for respiratory medicine (n ¼ 124) and for palliative medicine (n ¼ 239).
Table 5. Physicians’ reasons for occasionally or never prescribing opioids for breathlessness.
Respiratory medicine (n ¼ 114) Palliative medicine (n ¼ 50) Specialties compared
Insufficient knowledge or experience prescribing opioids 20 (11.3%) 1 (0.4%) p < 0.0001
Not comfortable prescribing addictive drugs 10 (5.6%) 2 (0.8%) p ¼ 0.002
Opioids ineffective for chronic breathlessness 5 (2.8%) 3 (1.1%)
Not aware of guidelines recommending opioids 12 (6.8%) 0 p < 0.0001
Risk of respiratory depression 34 (19.2%) 2 (0.8%) p < 0.0001
Opioids are contraindicated in patients with hypercapnoea 9 (5.1%) 1 (0.4%) p ¼ 0.001
Opioids are only relevant for patients in the terminal phase 6 (4.7%) 1 (0.4%) p ¼ 0.013
Opioids should be initiated by Palliative Medicine 1 (0.6%) 2 (0.8%)
Infrequently see COPD patients with chronic breathlessness 15 (8.5%) 24 (9.1%) p ¼ 0.757
Recommend non-pharmacological strategies before opioids 11 (12.4%) 2 (0.8%)
Patient reluctance to accept 6 (3.4%) 2 (0.8%)
Side effects may outweigh clinical benefits 3 (1.7%) 2 (0.8%)
Benzodiazepines may work well with less side effects 4 (2.3%) 0
Opioids are not licenced for dyspnoea 3 (1.7%) 0
Inadequate ability to follow up patients started on opioids 2 (1.1%) 1 (0.4%)
Data are shown as frequencies with proportions in parentheses. Percentages are calculated for the total cohort (either 177 respiratory doctors or 263 palliative medicine doctors).
When there were less than five respondents in both groups the Chi-Squared test was not performed.
pharmacological strategies should be the next recommended step for patients with chronic breathlessness who are already on optimal disease-directed therapy. While palliative medi- cine doctors tended to suggest a greater range of strategies and multidisciplinary input, respiratory doctors focussed sig- nificantly on PR. This may have arisen because respiratory doctors have greater awareness of PR and of the substantial evidence which underpins it (28), than they have of other non-pharmacological strategies. Similarly, given that PR is usually a multidisciplinary and multi-component interven- tion, which often includes significant patient education, respiratory doctors may assume that many non-pharmaco- logical breathlessness approaches will be included within PR education.
There is strong evidence to support the provision of PR to all patients with COPD as part of standard care. However, the UK national PR audit demonstrated that out of all patients referred for PR only 9% had very severe breathless- ness (mMRC 4) and only about 40% completed the PR pro- gramme (29). Therefore, as PR appears to be inaccessible for patients with severe COPD and chronic breathlessness, alter- native and additional models of care, which offer comprehen- sive, breathlessness management are needed.
Opioid attitudes and prescription
Opioids are recommended when severe, chronic breathless- ness persists, despite utilising all other disease-directed and non-pharmacological management strategies (1,4,5). Current evidence suggests opioids improve breathlessness in the short term, however, long-term studies and evidence sug- gesting an improvement in quality of life are lacking (7). Additionally, not all patients prefer opioid treatment for chronic breathlessness to placebo, and the individual clinical response varies both in terms of benefits and side effects (8,30). Therefore, some clinicians debate the role of opioids for managing chronic breathlessness while clinical trials are on-going (31,32).
Given that expertise in symptom palliation and experi- ence prescribing opioids are key aspects of palliative medi- cine, unsurprisingly these doctors were more likely to recommend morphine as their first line medication for chronic breathlessness than respiratory doctors. However, interestingly just over half the respiratory doctors also rec- ommended an opioid as their first line treatment and 91% reported prescribing opioids regularly or occasionally for chronic breathlessness in COPD. These results are similar to findings from surveys of respiratory doctors in Portugal, the Netherlands and Spain, where 70–96% of respondents reported having experience prescribing opioids to COPD patients with chronic breathlessness (33–35).
Notably respiratory doctors who were younger, had worked for less years in their specialty or were trainees were significantly more likely to recommend opioids as their first
Australia were surveyed using a similar questionnaire, nearly two thirds (64%) recommended morphine as their first line treatment and 70% had experience prescribing opioids for chronic breathlessness (36). By contrast a survey of Spanish respiratory physicians did not identify a relationship between years of experience and frequency of prescribing opioids for chronic breathlessness in COPD (35). These results may point to a generational change in ANZ doctors’ attitudes towards opioids, with less negativity and increased awareness that opioids may have a role in managing chronic breathlessness in COPD.
While there is evidence to support the use of either immediate release or extended release morphine prepara- tions to treat chronic breathlessness in opioid-naïve respira- tory patients (6,37), most respiratory and palliative medicine doctors recommended low dose immediate release morphine as per the recommendations from both the American and Canadian Thoracic Societies (4,38). Similarly, amongst Australian junior doctors and Canadian clinicians the most commonly chosen opioid initiation regimen for chronic breathlessness was low dose immediate release morphine as required (36,39).
Barriers to opioids
Respiratory doctors who reported prescribing opioids occa- sionally or never for chronic breathlessness in COPD cited significantly more barriers than their palliative medicine col- leagues. While very few cited concerns regarding gastrointes- tinal side effects or patient reluctance to accept opioids as barriers, one fifth were concerned about respiratory depres- sion. Similarly, other surveys including junior doctors, general practitioners, general medicine physicians and respiratory physicians have also identified that between 15–56% of respondents were concerned about respiratory depression, when opioids were prescribed to treat chronic breathlessness