Between 50 and 70 percent of patien...

Between 50 and 70 percent of patients requiring palliative care support from distressing dyspnea caused by way of a combination of physiologic and psychologic factors. As the underlying disease progresse deconditioning, cachexia, panic, depression, and insomnia can exacerbate breathlessness. Because opioids are associated with respiratory depression and hypercapnia, they rarely are used to treat dyspnea. Nevertheless, an physicians have found them effective, and Australian consensus guidelines for palliative care indicate that opioids contribute to the management of refractory dyspnea. Abernethy and colleagues evaluated the use of sustained-release oral morphine in the management of refractory dyspnea.

They studied 48 patients attending hospital clinics for respiratory, cardiac, general, or palliative medicine in Australia. These patients had refractory dyspnea at pause despite optimal medical treatment on the contrary had not been treated previously with long-term opioids. Patients were required to have creatinine evens within twice the normal range; to have stable needinesss for medication and oxygen; and to be unrestrained of confusion, substance abuse, or contraindications to opioids. After data were gathered, including activity flushs patients were assigned randomly to receive 20 mg of oral sustained-release morphine or an identical placebo for four days. Patients then were switched to the alternative treatment. All patients were prescribed anticonstipation medication for the eight days of the inquiry The primary outcome was patient perception of dyspnea recorded in succession a visual analog scale. Other issues included the level of morning dyspnea, exercise tolerance, respiratory rate, measured [i]or[/i] regular beat oxygen saturation, insomnia, nausea, confusion, constipation, appetite, somnolence, and well-being.

Five patients withdrew during the placebo treatment, and five withdrew during the opioid therapy. About single in kind half of the withdrawals were attributed to opioid therapy, mainly because of nausea, on the other hand one patient requested morphine therapy for pain during the placebo period. The 38 patients who complet the contemplation were mainly elderly men who used supplemental oxygen for chronic obstructive pulmonary disease (COPD) More than 70 percent were unable to carry abroad any work activities. After four days, patients taking morphine reported a highly significant improvement in dyspnea in succession visual analog scales and improvement in repose Exertional performance and overall thinking principle of well-being were not significantly different during morphine therapy. Respiratory rates, sedation, vomiting, confusion, and anorexia were similar during the morphine treatment compared with the placebo therapy. Side tenors generally were mild and transient. Constipation, the mostly common side effect, often began to liquefy by the fourth day.

The authors deduce that oral sustained-release morphine can benefit patients with intractable breathlessness who already receive optimal conventional therapy. No evidence of respiratory depression was establish and side effects were predictable and controllable. The authors call for larger studies to evaluate the safety of morphine therapy and to clarify the side powers but stress that oral sustained-release morphine could provide significant relief to extremely ill patients with COPD.

ANNE D WALLING, MD

Abernethy AP, et al. Randomised, double blind, placebo controll crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ September 6 2003;327:523-6

EDITOR'S NOTE: The authors are careful to point revealed that until safety is confirmed and other studies are done, the message of this meditation is not that opiates are fine to use in patients with COPD still that they might have a part as an adjunctive therapy in gooded situations. The opportunity to relieve breathlessness and the fear of suffocation in real ill patients is compelling, and these patients were willing to risk side weights and respiratory depression for the chance to relieve dyspnea. The meditation makes one wonder how many other potentially beneficial treatments we withhold or do not consider because of principles ingrained during our training. While the principles remain actual perhaps we apply them too rigorously and do not use up sufficient effort in calculating the risks and benefits of all available therapies for individual patients.--A.D.W.

COPYRIGHT 2004 American Academy of Family Physicians

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