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Kochovska S, Ferreira D, Chang S, Luckett T, Roydhouse J, Ekström M, Currow DC. Caregiver burden due to long-term breathlessness: a hypothesis-generating study. Eur Respir J 2024; 64:2302292. [PMID: 38901885 DOI: 10.1183/13993003.02292-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/31/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
- Joint first authors
| | - Diana Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
- Joint first authors
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Jessica Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Magnus Ekström
- Lund University Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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McCaffrey N, Ratcliffe J, Currow D, Engel L, Hutchinson C. What Aspects of Quality of Life are Important from Palliative Care Patients' Perspectives? A Framework Analysis to Inform Preference-Based Measures for Palliative and End-of-Life Settings. THE PATIENT 2024; 17:39-52. [PMID: 37975965 DOI: 10.1007/s40271-023-00651-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Preference-based outcome measures are commonly applied in economic analyses to inform healthcare resource allocation decisions. Few preference-based outcome measures have been specifically developed for palliative and end-of-life settings. This study aimed to identify which quality-of-life domains are most important to Australians receiving specialised palliative care services to help determine if the development of a new condition-specific preference-based outcome measure is warranted. METHODS In-depth face-to-face interviews were conducted with 18 participants recruited from palliative care services in South Australia. Data were analysed using a framework analysis drawing on findings from a systematic review of international qualitative studies investigating the quality-of-life preferences of patients receiving palliation (domains identified included cognitive, emotional, healthcare, personal autonomy, physical, preparatory, social, spiritual). Participants identified missing or irrelevant domains in the EQ-5D and QLU-C10D questionnaires and ranked the importance of domains. RESULTS A priori domains were refined into cognitive, environmental, financial, independence, physical, psychological, social and spiritual. The confirmation of the eight important quality-of-life domains across multiple international studies suggests there is a relatively high degree of convergence on the perspectives of patients in different countries. Four domains derived from the interviews are not covered by the EQ-5D and QLU-C10D (cognitive, environmental, financial, spiritual), including one of the most important (spiritual). CONCLUSIONS Existing, popular, preference-based outcome measures such as the EQ-5D do not incorporate the most important, patient-valued, quality-of-life domains in the palliative and end-of-life settings. Development of a new, more relevant and comprehensive preference-based outcome measure could improve the allocation of resources to patient-valued services and have wide applicability internationally.
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Affiliation(s)
- Nikki McCaffrey
- Institute for Health Transformation, Deakin Health Economics, SHSD, Faculty of Health, Deakin University, Geelong, VIC, Australia.
| | - Julie Ratcliffe
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Lidia Engel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Claire Hutchinson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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Kochovska S, Ferreira D, Chang S, Luckett T, Roydhouse J, Ekström M, Currow DC. The impact of regular, low-dose, sustained-release morphine for chronic breathlessness on caregiver burden: An exploratory analysis of the BEAMS trial. Palliat Med 2024; 38:156-162. [PMID: 37978419 PMCID: PMC10798016 DOI: 10.1177/02692163231211227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Chronic breathlessness adversely impacts people with chronic obstructive pulmonary disease and their caregivers (family and friends), who may, in turn, experience significant burden due to their caregiving role. Sustained-release morphine may reduce chronic breathlessness in some patients, which may have an impact on caregivers' perceived burden. AIM To explore the impact on caregiver burden of active treatment of people with chronic breathlessness (modified Medical Research Council (mMRC) ⩾ 3) and chronic obstructive pulmonary disease (COPD) with regular, low-dose, sustained-release morphine within a multi-site, double-blind, randomised, placebo-controlled trial. DESIGN Exploratory analysis of self-reported caregiver burden at baseline and end of week 3 in a randomised, double-blind, placebo-controlled study. Caregiver measures included: demographics and perceived burden (Zarit Burden Interview 12-item short-form questionnaire). Patient measures included: worst breathlessness and FitBitR-measures. SETTING/PARTICIPANTS All consenting caregivers of trial patient participants in a multi-site study recruiting from palliative care and respiratory services. RESULTS Caregivers (n = 49; 59% women; median age 68 years [IQR 50-75]) reported median baseline caregiver burden 12 [IQR 5-17], with 53% reporting high burden (⩾13). Eighty-four percent of caregivers reported no change in burden. In people whose worst breathlessness improved, caregiver burden moved in the same direction, though the correlation was not significant (rs = 0.25, p = 0.17). Conversely, caregiver burden worsened as patients' minutes lightly active increased, with the correlation being significant (rs = 0.56, p = 0.04). CONCLUSIONS Caregivers reported high levels of caregiver burden, but patients' response to treatment in terms of their symptom and function may influence change in caregiver burden over a three-week period.
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Affiliation(s)
- Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Diana Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Jessica Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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Ferreira DH, Ekström M, Fazekas B, Currow DC. Testosterone Levels in People Taking Regular Low-Dose Sustained-Release Morphine for Persisting Breathlessness: An Exploratory Study. J Palliat Med 2023; 26:402-405. [PMID: 36394475 DOI: 10.1089/jpm.2022.0381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: The intermediate- and long-term effects of regular low-dose sustained-release (SR) morphine on the testosterone levels of people with persistent breathlessness are unknown. Methods: Exploratory analysis of a randomized controlled trial of the effects of regular SR morphine (0/8/16/24 mg every 24 hours) for persistent breathlessness associated with chronic obstructive pulmonary disease. Total testosterone was measured at baseline and at cessation (greater than or equal to three months on stable medication). Results: Among 20 participants (9 males; median treatment duration between measurements 169 days [IQR 162-175]), only 3 had substantial declines in testosterone levels during the study (morphine 8, 16, 24 mg groups). All three had worsening illness at the time of the second assessment. There was no apparent relationship between change in testosterone, morphine dose, and change in breathlessness. Conclusions: Substantial declines in testosterone were uncommon and were not apparently related to changes in morphine dose or breathlessness, but they were possibly related with worsening illness.
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Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Magnus Ekström
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Belinda Fazekas
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - David C Currow
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
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Lange AV, Mehta AB, Bekelman DB. How Important is Spirometry for Identifying Patients with COPD Appropriate for Palliative Care? J Pain Symptom Manage 2023; 65:e181-e187. [PMID: 36423798 PMCID: PMC10998735 DOI: 10.1016/j.jpainsymman.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Providing palliative care to patients with chronic obstructive pulmonary disease (COPD) is a priority. Spirometry demonstrating airflow limitation is a diagnostic test for COPD and a common inclusion criterion for palliative care research. However, requiring spirometry with airflow limitation may exclude appropriate patients unable to complete spirometry, or patients with preserved-ratio impaired spirometry and symptoms or imaging consistent with COPD. MEASURES To determine differences in quality of life (QOL) and symptoms between patients with COPD identified based on International Classification of Diseases (ICD) codes and spirometry with airflow limitation compared to ICD codes only. INTERVENTION Patients with COPD enrolled in a palliative care trial were included. Patients were at high risk of hospitalization and death and reported poor QOL. Baseline measures of QOL (Functional Assessment of Cancer Therapy-General (FACT-G), the Clinical COPD Questionnaire, and Quality of Life at the End of Life), and symptoms (Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, fatigue, Insomnia Severity Index) were compared. OUTCOMES Two hundred eight patients with COPD were predominantly male, White, and average age was 68.4. Between patients with ICD codes and spirometry with airflow limitation compared to patients with ICD codes only, there were no significant differences in FACT-G (59.0 vs. 55.0, P = 0.33), other measures of QOL, or symptoms between groups. CONCLUSION These results imply that spirometry may not need to be a requirement for inclusion into palliative care research or clinical care for patients with poor quality of life and at high risk for adverse outcomes.
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Affiliation(s)
- Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado.
| | - Anuj B Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado; Division of Pulmonary and Critical Care Medicine, Department of Medicine (A.M.), Denver Health and Hospital Authority; Denver, Colorado
| | - David B Bekelman
- Medical Service (D.B.), Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Denver-Seattle Center of Innovation (D.B.); Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Division of General Internal Medicine, Department of Medicine (D.B.); University of Colorado Anschutz Medical Campus; Aurora, Colorado
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McCaffrey N, Cheah SL, Luckett T, Phillips JL, Agar M, Davidson PM, Boyle F, Shaw T, Currow DC, Lovell M. Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial. PLoS One 2023; 18:e0282465. [PMID: 36854021 PMCID: PMC9974128 DOI: 10.1371/journal.pone.0282465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs. METHODS Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model. RESULTS Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01). CONCLUSIONS In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men. TRIAL REGISTRATION ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.
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Affiliation(s)
- Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood Campus, Burwood, VIC, Australia
- * E-mail:
| | - Seong Leang Cheah
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Jane L. Phillips
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove Brisbane, Queensland
| | - Meera Agar
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Patricia M. Davidson
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital North Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Melanie Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Ferreira DH, Kochovska S, McNeill R, Currow DC. Current pharmacological strategies for symptomatic reduction of persistent breathlessness - a literature review. Expert Opin Pharmacother 2023; 24:233-244. [PMID: 36525673 DOI: 10.1080/14656566.2022.2160239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Persistent breathlessness is a debilitating symptom that is prevalent in the community, particularly in people with chronic and life-limiting illnesses. Treatment includes different steps, including pharmacological treatment aiming to improve the symptom and optimize people's wellbeing. AREAS COVERED PubMed and Google Scholar were screened using 'chronic breathlessness' OR 'persistent breathlessness,' AND 'pharmacological treatment,' OR 'opioids.' This review focuses on pharmacological treatments to reduce persistent breathlessness and discusses possible mechanisms involved in the process of breathlessness reduction through pharmacotherapy. Research gaps in the field of persistent breathlessness research are outlined, and future research directions are suggested. EXPERT OPINION Regular, low-dose (≤30 mg/day), sustained-release morphine is recommended as the first-line pharmacological treatment for persistent breathlessness. Inter-individual variation in response needs to be investigated in future studies in order to optimize clinical outcomes. This includes 1) better understanding the centrally mediated mechanisms associated with persisting breathlessness and response to pharmacological therapies, 2) understanding benefit from the perspective of people experiencing persistent breathlessness, small and meaningful gains in physical activity.
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Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, 2007, Ultimo, Australia
| | - Richard McNeill
- Department of palliative care, Nurse Maude Hospice, 8014, Christchurch, New Zealand.,Department of Medicine, University of Otago, 8011, Christchurch, New Zealand
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
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Sobanski PZ, Currow DC. Regular, low-dose methadone for reducing breathlessness in people experiencing or at risk of neurotoxic effects from morphine: A single-center case series. Front Med (Lausanne) 2022; 9:925787. [PMID: 36544498 PMCID: PMC9760708 DOI: 10.3389/fmed.2022.925787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/20/2022] [Indexed: 12/07/2022] Open
Abstract
Breathlessness is a common symptom suffered by people living with advanced malignant and non-malignant diseases, one which significantly limits their quality of life. If it emerges at minimal exertion, despite the maximal, guidelines-directed, disease-specific therapies, it should be considered persistent and obliges clinicians to prescribe symptomatic, non-pharmacological, and pharmacological treatment to alleviate it. Opioids are recommended for the symptomatic treatment of persistent breathlessness, with morphine most extensively studied for this indication. It is extensively metabolized in the liver into water-soluble 3- and 6-glucuronides, excreted by the kidneys. In the case of advanced renal failure, the glucuronides accumulate, mainly responsible for toxicity 3-glucuronides. Some people, predominantly those with advanced renal failure, develop neurotoxic effects after chronic morphine, even when prescribed at a very low dose. A single-center case series of consecutive patients experiencing neurotoxic effects after long-term, low-dose morphine or at risk of such effects were transferred to methadone to avoid the accumulation of neurotoxic metabolites. Over the course of 4.5 years, 26 patients have been treated with methadone in the median dose of 3.0 mg/24 h p.o., for persisting breathlessness. Sixteen of them had been treated previously with an opioid (usually morphine) at the median dose of 7.0 mg/24 h (morphine oral daily dose equivalent). They were transferred to methadone, with the median dose of 3.0 mg/24 h orally (methadone oral daily dose equivalent), and the median morphine-to-methadone dose ratio was 2.5:1. All patients experienced a meaningful improvement in breathlessness intensity after methadone, by a median of 5 points (range 1-8) on the 0-10 numerical rating scale (NRS) in the whole group, and by 2 points (range 0-8) in those pretreated with other opioids, mainly morphine. Low-dose methadone can be considered an efficient alternative to morphine for reducing breathlessness in people experiencing neurotoxic effects or at risk of developing them following treatment with morphine.
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Affiliation(s)
- Piotr Z. Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Disease, Schwyz Hospital, Schwyz, Switzerland,*Correspondence: Piotr Z. Sobanski,
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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Ferreira DH, Johnson MJ, Janssen DJA, Ekström M, Currow DC. The effect of regular, low-dose, sustained-release morphine on routine physical activity in people with persistent breathlessness: a hypothesis-generating study. Eur Respir J 2022; 60:2201484. [PMID: 36356975 DOI: 10.1183/13993003.01484-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/18/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Research & Development, Ciro, Haelen, The Netherlands
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Ekström M, Ferreira D, Chang S, Louw S, Johnson MJ, Eckert DJ, Fazekas B, Clark KJ, Agar MR, Currow DC. Effect of Regular, Low-Dose, Extended-release Morphine on Chronic Breathlessness in Chronic Obstructive Pulmonary Disease: The BEAMS Randomized Clinical Trial. JAMA 2022; 328:2022-2032. [PMID: 36413230 PMCID: PMC9682426 DOI: 10.1001/jama.2022.20206] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022]
Abstract
Importance Chronic breathlessness is common in people with chronic obstructive pulmonary disease (COPD). Regular, low-dose, extended-release morphine may relieve breathlessness, but evidence about its efficacy and dosing is needed. Objective To determine the effect of different doses of extended-release morphine on worst breathlessness in people with COPD after 1 week of treatment. Design, Setting, and Participants Multicenter, double-blind, placebo-controlled randomized clinical trial including people with COPD and chronic breathlessness (defined as a modified Medical Research Council score of 3 to 4) conducted at 20 centers in Australia. People were enrolled between September 1, 2016, and November 20, 2019, and followed up through December 26, 2019. Interventions People were randomized 1:1:1 to 8 mg/d or 16 mg/d of oral extended-release morphine or placebo during week 1. At the start of weeks 2 and 3, people were randomized 1:1 to 8 mg/d of extended-release morphine, which was added to the prior week's dose, or placebo. Main Outcomes and Measures The primary outcome was change in the intensity of worst breathlessness on a numerical rating scale (score range, 0 [none] to 10 [being worst or most intense]) using the mean score at baseline (from days -3 to -1) to the mean score after week 1 of treatment (from days 5 to 7) in the 8 mg/d and 16 mg/d of extended-release morphine groups vs the placebo group. Secondary outcomes included change in daily step count measured using an actigraphy device from baseline (day -1) to the mean step count from week 3 (from days 19 to 21). Results Among the 160 people randomized, 156 were included in the primary analyses (median age, 72 years [IQR, 67 to 78 years]; 48% were women) and 138 (88%) completed treatment at week 1 (48 in the 8 mg/d of morphine group, 43 in the 16 mg/d of morphine group, and 47 in the placebo group). The change in the intensity of worst breathlessness at week 1 was not significantly different between the 8 mg/d of morphine group and the placebo group (mean difference, -0.3 [95% CI, -0.9 to 0.4]) or between the 16 mg/d of morphine group and the placebo group (mean difference, -0.3 [95%, CI, -1.0 to 0.4]). At week 3, the secondary outcome of change in mean daily step count was not significantly different between the 8 mg/d of morphine group and the placebo group (mean difference, -1453 [95% CI, -3310 to 405]), between the 16 mg/d of morphine group and the placebo group (mean difference, -1312 [95% CI, -3220 to 596]), between the 24 mg/d of morphine group and the placebo group (mean difference, -692 [95% CI, -2553 to 1170]), or between the 32 mg/d of morphine group and the placebo group (mean difference, -1924 [95% CI, -47 699 to 921]). Conclusions and Relevance Among people with COPD and severe chronic breathlessness, daily low-dose, extended-release morphine did not significantly reduce the intensity of worst breathlessness after 1 week of treatment. These findings do not support the use of these doses of extended-release morphine to relieve breathlessness. Trial Registration ClinicalTrials.gov Identifier: NCT02720822.
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Affiliation(s)
- Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences, Respiratory Medicine, Allergology, and Palliative Medicine, Lund University, Lund, Sweden
- Faculty of Health Improving Palliative, Aged, and Chronic Care Through Clinical Research and Translation, University of Technology Sydney, Ultimo, Australia
| | - Diana Ferreira
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, Australia
| | - Sungwon Chang
- Faculty of Health Improving Palliative, Aged, and Chronic Care Through Clinical Research and Translation, University of Technology Sydney, Ultimo, Australia
| | - Sandra Louw
- McCloud Consulting Group, Belrose, Australia
| | - Miriam J. Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, England
| | - Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia
| | - Belinda Fazekas
- Faculty of Health Improving Palliative, Aged, and Chronic Care Through Clinical Research and Translation, University of Technology Sydney, Ultimo, Australia
| | - Katherine J. Clark
- Palliative Care Network, Northern Sydney Local Health District, Sydney, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
| | - Meera R. Agar
- Faculty of Health Improving Palliative, Aged, and Chronic Care Through Clinical Research and Translation, University of Technology Sydney, Ultimo, Australia
| | - David C. Currow
- Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, Australia
- Palliative and Supportive Services, Flinders University, Adelaide, Australia
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11
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Ferreira D, Kochovska S, Honson A, Phillips J, Currow D. Patients’ and their caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD: a qualitative study. BMJ Open Respir Res 2022; 9:9/1/e001210. [PMID: 35606022 PMCID: PMC9125765 DOI: 10.1136/bmjresp-2022-001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Regular, low-dose, sustained-release morphine is effective in reducing chronic breathlessness in people with advanced disease, particularly in patients with chronic obstructive pulmonary disease (COPD). Despite experiencing a reduction in breathlessness, some patients choose not to continue long-term treatment. Aim This study aimed to explore patients’ and caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD. Methods A qualitative study embedded in a randomised controlled trial (RCT) of regular low-dose, sustained-release morphine for chronic breathlessness for people with COPD and modified Medical Research Council breathlessness scale 3–4. After completing the RCT or withdrawing, patients and their caregivers were invited to participate in interviews in their homes focused on their experiences with the trial medication while still blinded to the arm to which they had been allocated. Data analysis used a constant comparative method informed by the principles of grounded theory. Results Thirteen patients and nine caregivers participated. Four themes were identified: (1) Receptivity and knowledge; (2) Function as a priority; (3) Harmful and helpful side effects; and (4) Therapy-centred aspects. The concept of ‘net effect’ emerged from the interplay between themes, subthemes and the decision to continue taking sustained-release morphine during the trial and after trial completion. Conclusion Clinicians’ support and preconceived ideas about morphine influence the decision to commence sustained-release morphine. The hope for functional improvement is the great driver influencing positively the decision to take sustained-release morphine in the long term. The degree of symptom reduction, improved function, side-effects’ severity and caregivers’ availability creates a net effect driving patients’ decisions to continue or discontinue the medication.
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Affiliation(s)
- Diana Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Aaron Honson
- Palliative Care Clinical Studies Collaborative (PaCCSC), Flinders University, Adelaide, South Australia, Australia
| | - Jane Phillips
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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12
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Huhn S, Axt M, Gunga HC, Maggioni MA, Munga S, Obor D, Sié A, Boudo V, Bunker A, Sauerborn R, Bärnighausen T, Barteit S. The Impact of Wearable Technologies in Health Research: Scoping Review. JMIR Mhealth Uhealth 2022; 10:e34384. [PMID: 35076409 PMCID: PMC8826148 DOI: 10.2196/34384] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/23/2021] [Accepted: 12/17/2021] [Indexed: 12/23/2022] Open
Abstract
Background Wearable devices hold great promise, particularly for data generation for cutting-edge health research, and their demand has risen substantially in recent years. However, there is a shortage of aggregated insights into how wearables have been used in health research. Objective In this review, we aim to broadly overview and categorize the current research conducted with affordable wearable devices for health research. Methods We performed a scoping review to understand the use of affordable, consumer-grade wearables for health research from a population health perspective using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) framework. A total of 7499 articles were found in 4 medical databases (PubMed, Ovid, Web of Science, and CINAHL). Studies were eligible if they used noninvasive wearables: worn on the wrist, arm, hip, and chest; measured vital signs; and analyzed the collected data quantitatively. We excluded studies that did not use wearables for outcome assessment and prototype studies, devices that cost >€500 (US $570), or obtrusive smart clothing. Results We included 179 studies using 189 wearable devices covering 10,835,733 participants. Most studies were observational (128/179, 71.5%), conducted in 2020 (56/179, 31.3%) and in North America (94/179, 52.5%), and 93% (10,104,217/10,835,733) of the participants were part of global health studies. The most popular wearables were fitness trackers (86/189, 45.5%) and accelerometer wearables, which primarily measure movement (49/189, 25.9%). Typical measurements included steps (95/179, 53.1%), heart rate (HR; 55/179, 30.7%), and sleep duration (51/179, 28.5%). Other devices measured blood pressure (3/179, 1.7%), skin temperature (3/179, 1.7%), oximetry (3/179, 1.7%), or respiratory rate (2/179, 1.1%). The wearables were mostly worn on the wrist (138/189, 73%) and cost <€200 (US $228; 120/189, 63.5%). The aims and approaches of all 179 studies revealed six prominent uses for wearables, comprising correlations—wearable and other physiological data (40/179, 22.3%), method evaluations (with subgroups; 40/179, 22.3%), population-based research (31/179, 17.3%), experimental outcome assessment (30/179, 16.8%), prognostic forecasting (28/179, 15.6%), and explorative analysis of big data sets (10/179, 5.6%). The most frequent strengths of affordable wearables were validation, accuracy, and clinical certification (104/179, 58.1%). Conclusions Wearables showed an increasingly diverse field of application such as COVID-19 prediction, fertility tracking, heat-related illness, drug effects, and psychological interventions; they also included underrepresented populations, such as individuals with rare diseases. There is a lack of research on wearable devices in low-resource contexts. Fueled by the COVID-19 pandemic, we see a shift toward more large-sized, web-based studies where wearables increased insights into the developing pandemic, including forecasting models and the effects of the pandemic. Some studies have indicated that big data extracted from wearables may potentially transform the understanding of population health dynamics and the ability to forecast health trends.
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Affiliation(s)
- Sophie Huhn
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Miriam Axt
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Hanns-Christian Gunga
- Charité - Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environment, Berlin, Germany
| | - Martina Anna Maggioni
- Charité - Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environment, Berlin, Germany.,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | | | - David Obor
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Ali Sié
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany.,Centre de Recherche en Santé Nouna, Nouna, Burkina Faso
| | | | - Aditi Bunker
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Rainer Sauerborn
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany.,Harvard Center for Population and Development Studies, Cambridge, MA, United States.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Sandra Barteit
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg University, Heidelberg, Germany
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13
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Blumenfeld-Kouchner F, Bullis L, Koch K. Transmucosal Buprenorphine in the Treatment of Dyspnea: Case Series and Review of the Literature. Palliat Med Rep 2021; 2:21-24. [PMID: 34223499 PMCID: PMC8241374 DOI: 10.1089/pmr.2020.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 11/23/2022] Open
Abstract
Full μ-opioid agonists are commonly employed in advanced disease to relieve dyspnea of various etiologies. Although there are ongoing debates and studies regarding the relative efficacy of different agents, a factor limiting more general use is a concern about side effects, in particular respiratory depression. Buprenorphine is a partial μ receptor agonist and a κ-opioid receptor antagonist, with a better safety profile than full μ receptor agonists. We conducted a literature search, which did not reveal any studies looking at the use of buprenorphine to treat dyspnea. We also report a case series of three patients with dyspnea of various etiologies treated with buprenorphine, with an apparent excellent response of dyspnea to treatment, without any significant side effects. Given those results, as well as the potential impact of κ-opioid receptor antagonism on dyspnea-associated anxiety, we conclude that there is a need for controlled studies of buprenorphine against full μ-opioid agonists for the symptomatic treatment of dyspnea in palliative care.
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Affiliation(s)
- François Blumenfeld-Kouchner
- Aurora Medical Group Palliative Care, Milwaukee, Wisconsin, USA.,Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Lisa Bullis
- Aurora Medical Group Palliative Care, Milwaukee, Wisconsin, USA
| | - Kathy Koch
- Advocate Aurora Library, Advocate Aurora Health, Grafton, Wisconsin, USA
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14
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Hui D, Maddocks M, Johnson MJ, Ekström M, Simon ST, Ogliari AC, Booth S, Ripamonti C. Management of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines †. ESMO Open 2020; 5:e001038. [PMID: 33303485 PMCID: PMC7733213 DOI: 10.1136/esmoopen-2020-001038] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Magnus Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Anna C Ogliari
- Pulmonary Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK; Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK
| | - CarlaI Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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15
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Mori M, Yamaguchi T, Matsuda Y, Suzuki K, Watanabe H, Matsunuma R, Kako J, Imai K, Usui Y, Matsumoto Y, Hui D, Currow D, Morita T. Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer. ESMO Open 2020; 5 Suppl 1:e000603. [PMID: 33558034 PMCID: PMC7046422 DOI: 10.1136/esmoopen-2019-000603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/01/2019] [Accepted: 02/04/2020] [Indexed: 12/14/2022] Open
Abstract
Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | | | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yuko Usui
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Currow
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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16
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Currow DC, Kochovska S, Ferreira D, Johnson M. Morphine for the symptomatic reduction of chronic breathlessness: the case for controlled release. Curr Opin Support Palliat Care 2020; 14:177-181. [PMID: 32740277 DOI: 10.1097/spc.0000000000000520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Clinicians who seek to reduce the symptomatic burden of chronic breathlessness by initiating regular low-dose morphine has the choice of immediate or sustained-release formulations - which will be better for this often frail population, and which has the more robust evidence to inform its prescription? Both formulations can be used. RECENT FINDINGS For chronic breathlessness, three factors consistently favour the use of regular, low-dose, sustained-release morphine over immediate-release formulations: SUMMARY: As the evidence base expands for the symptomatic reduction of chronic breathlessness, pharmacological interventions will play a part. Using the best available evidence underpins patient-centred approaches that seek to predictably maximize the net effect.As such, the weight of evidence in patient-centred clinical care favours the use of regular, low-dose sustained-release morphine for the symptomatic reduction of chronic breathlessness.
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Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Diana Ferreira
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Miriam Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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17
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Ferreira DH, Boland JW, Kochovska S, Honson A, Phillips JL, Currow DC. Patients' and caregivers' experiences of driving with chronic breathlessness before and after regular low-dose sustained-release morphine: A qualitative study. Palliat Med 2020; 34:1078-1087. [PMID: 32519599 DOI: 10.1177/0269216320929549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic breathlessness is a disabling syndrome that profoundly impacts patients' and caregivers' lives. Driving is important for most people, including those with advanced disease. Regular, low-dose, sustained-release morphine safely reduces breathlessness, but little is known about its impact on driving. AIM To understand patients' and caregivers' (1) perspectives and experiences of driving with chronic breathlessness; and (2) perceived impact of regular, low-dose, sustained-release morphine on driving. DESIGN A qualitative study embedded in a pragmatic, phase III, randomised, placebo-controlled trial of low-dose, sustained-release morphine (⩽32 mg/24 h) for chronic breathlessness. Semi-structured interviews were conducted immediately after participants withdrew or completed the randomised, placebo-controlled trial. Informed by grounded theory, a constant comparative approach to analysis was adopted. SETTING/PARTICIPANTS Participants were recruited from an outpatients palliative care service in Adelaide, Australia. Participants included patients (n = 13) with severe breathlessness associated with chronic obstructive pulmonary disease and their caregivers (n = 9). RESULTS Participants were interviewed at home. Eleven received morphine 8-32 mg. Three themes emerged: (1) independence; (2) breathlessness' impact on driving; and (3) driving while taking regular, low-dose, sustained-release morphine. CONCLUSION Driving contributed to a sense of identity and independence. Being able to drive increased the physical and social space available to patients and caregivers, their social engagement and well-being. Patients reported breathlessness at rest may impair driving skills, while the introduction of sustained-release morphine seemed to have no self-reported impact on driving. Investigating this last perception objectively, especially in terms of safety, is the subject of ongoing work.
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Affiliation(s)
- Diana H Ferreira
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Aaron Honson
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - David C Currow
- Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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18
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Johnson MJ, Currow DC. Opioids for breathlessness: a narrative review. BMJ Support Palliat Care 2020; 10:287-295. [DOI: 10.1136/bmjspcare-2020-002314] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 01/14/2023]
Abstract
Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10–30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world’s therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data.
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19
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Ferreira DH, Kochovska S, Honson A, Phillips JL, Currow DC. Two faces of the same coin: a qualitative study of patients' and carers' coexistence with chronic breathlessness associated with chronic obstructive pulmonary disease (COPD). BMC Palliat Care 2020; 19:64. [PMID: 32375747 PMCID: PMC7203967 DOI: 10.1186/s12904-020-00572-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic breathlessness is a recognized clinical syndrome that severely impacts patients and carers, who become increasingly restricted in their daily activities. Often, patients become reliant on their carers, who are required to provide constant support. Although individual experiences of breathlessness have been previously investigated, there are few studies exploring contemporaneous experiences of breathlessness of the patient and their carer. This study aimed to understand the experience of severe chronic breathlessness in people with chronic obstructive pulmonary disease (COPD) from the perspective of the patient and carer unit. METHODS A qualitative study embedded in a randomised, placebo-controlled effectiveness study (RCT) of regular, low-dose (≤32 mg/day), sustained-release morphine for chronic breathlessness associated with COPD. Recruitment occurred between July 2017 and November 2018 in one respiratory and palliative care services, in South Australia. Participants were community-dwelling patients with COPD and severe breathlessness (modified Medical Research Council scale 3 or 4) and their carers. Separate semi-structured interviews were conducted with patients and carers, recorded and transcribed verbatim. Analysis was informed by grounded theory using a constant comparative approach. RESULTS From the 26 patients with a carer recruited for the RCT in South Australia, nine were interviewed in their homes. Six patients were men, median age 77 years. Carers were mostly women, who were their wives (n = 6), median age 70. Five themes emerged from the data: (1) shrinking world; (2) mutual adaptation; (3) co-management; (4) emotional coping; and (5) meaning in the face of death. CONCLUSION Chronic breathlessness is a systemic condition that permeates all aspects of the patient's and carer's lives. Working as a team, patients and carers manage chronic breathlessness to achieve maximal function and well-being. Patients and carers share many aspects of the experience of breathlessness, but the carer seems particularly susceptible to emotional distress. Future chronic breathlessness interventions should target the patient and the carer, both together and separately to address their common and individual needs. TRIAL REGISTRATION The main trial is registered (registration no. NCT02720822; posted March 28, 2016).
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Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| | - Aaron Honson
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
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20
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Burge AT, Cox NS, Abramson MJ, Holland AE. Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2020; 4:CD012626. [PMID: 32297320 PMCID: PMC7160071 DOI: 10.1002/14651858.cd012626.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far. OBJECTIVES In people with COPD, which interventions are effective at improving objectively-assessed physical activity? SEARCH METHODS We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies. SELECTION CRITERIA We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions. DATA COLLECTION AND ANALYSIS We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data. MAIN RESULTS We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training. AUTHORS' CONCLUSIONS A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.
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Affiliation(s)
- Angela T Burge
- La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and SportMelbourneVictoriaAustralia
- Institute for Breathing and SleepMelbourneAustralia
- Alfred HealthPhysiotherapyPO Box 315MelbourneAustraliaPrahran VIC 3181
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
| | - Narelle S Cox
- Institute for Breathing and SleepMelbourneAustralia
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
- School of Allied Health, Human Services and Sport, La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and OrthoticsMelbourneVictoriaAustralia3004
| | - Michael J Abramson
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneVictoriaAustralia3004
| | - Anne E Holland
- La Trobe UniversityDepartment of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and SportMelbourneVictoriaAustralia
- Institute for Breathing and SleepMelbourneAustralia
- Alfred HealthPhysiotherapyPO Box 315MelbourneAustraliaPrahran VIC 3181
- Monash UniversityDepartment of Allergy, Clinical Immunology and Respiratory MedicineMelbourneAustralia
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Johnson MJ, Sbizzera I, Fairhurst C, Fazekas B, Agar M, Ekstrom M, Currow DC. No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness. BMJ Support Palliat Care 2019; 10:421-428. [DOI: 10.1136/bmjspcare-2019-002009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/16/2019] [Accepted: 10/28/2019] [Indexed: 11/03/2022]
Abstract
ObjectivesWe aimed to identify and evaluate: (1) treatment-emergent adverse events (TEAE (worse or new since baseline)) and the subgroup of severe TEAEs in a placebo-controlled 7-day randomised trial of regular, low-dose, sustained-release oral morphine for chronic breathlessness and (2) clinical characteristics associated with TEAE.MethodsSafety analysis of trial data. Adults with chronic breathlessness (modified Medical Research Council breathlessness score ≥2) due to heart or lung disease, or cancer, not on regular opioids were eligible. Symptoms associated with opioids (TEAE of special interest) were systematically sought using Common Terminology Criteria for Adverse Events (CTCAE) grading. Other harms could be reported at any time. The relationship between characteristics and presence of ≥1 TEAE of special interest was explored using univariable logistic regression analyses.Results1449/5624 (26%) Adverse Events from 279 participants were TEAE of which 150/1449 (10%) were severe (CTCAE grades 3–5). 1086/5624 (75%) were events of special interest of which 41/1086 (4%) were severe. Compared with placebo, morphine was not associated with more TEAE or severe TEAE of special interest (TEAE: OR 0.53, 95% CI 0.21 to 1.38, p=0.20; severe TEAE: OR 0.96, 95% CI 0.27 to 3.41, p=0.95) nor with CTCAE severity grade (χ2=4.39, p=0.50). Among the 26/150 (17%) with severe TEAEs, study withdrawal was more common in the morphine arm (18/26 (69%) morphine arm; 8/26 (30%) placebo arm). None of the severe TEAEs was a respiratory harm.ConclusionsSevere morphine-associated toxicity was uncommon and not associated with study arm. Clinical consequences were minor and self-limiting.Trial registration numberACTRN126000806268.
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Currow D, Louw S, McCloud P, Fazekas B, Plummer J, McDonald CF, Agar M, Clark K, McCaffrey N, Ekström MP. Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax 2019; 75:50-56. [PMID: 31558624 DOI: 10.1136/thoraxjnl-2019-213681] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Morphine may decrease the intensity of chronic breathlessness but data from a large randomised controlled trial (RCT) are lacking. This first, large, parallel-group trial aimed to test the efficacy and safety of regular, low-dose, sustained-release (SR) morphine compared with placebo for chronic breathlessness. METHODS Multisite (14 inpatient and outpatient cardiorespiratory and palliative care services in Australia), parallel-arm, double-blind RCT. Adults with chronic breathlessness (modified Medical Research Council≥2) were randomised to 20 mg daily oral SR morphine and laxative (intervention) or placebo and placebo laxative (control) for 7 days. Both groups could take ≤6 doses of 2.5 mg, 'as needed', immediate-release morphine (≤15 mg/24 hours) as required by the ethics review board. The primary endpoint was change from baseline in intensity of breathlessness now (0-100 mm visual analogue scale; two times per day diary) between groups. Secondary endpoints included: worst, best and average breathlessness; unpleasantness of breathlessness now, fatigue; quality of life; function; and harms. RESULTS Analysed by intention-to-treat, 284 participants were randomised to morphine (n=145) or placebo (n=139). There was no difference between arms for the primary endpoint (mean difference -0.15 mm (95% CI -4.59 to 4.29; p=0.95)), nor secondary endpoints. The placebo group used more doses of oral morphine solution during the treatment period (mean 8.7 vs 5.8 doses; p=0.001). The morphine group had more constipation and nausea/vomiting. There were no cases of respiratory depression nor obtundation. CONCLUSION No differences were observed between arms for breathlessness, but the intervention arm used less rescue immediate-release morphine. TRIAL REGISTRATION NUMBER ACTRN12609000806268.
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Affiliation(s)
- David Currow
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia .,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John Plummer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christine F McDonald
- Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Meera Agar
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, Saint Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nikki McCaffrey
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Deakin Health Economics, Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Magnus Pär Ekström
- IMPACCT, Faculty of Heath, University of Technology Sydney, Sydney, New South Wales, Australia.,Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
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Measurement of physical activity in clinical practice and research: advances in cancer and chronic respiratory disease. Curr Opin Support Palliat Care 2019; 12:219-226. [PMID: 29979317 DOI: 10.1097/spc.0000000000000372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Physical activity has emerged as an important health outcome and its assessment, in particular with objective monitors, has proliferated in recent years. This review considers recent advances in physical activity measurement and clinical trials in cancer and chronic respiratory diseases where physical activity was a primary or key secondary outcome focusing on methodological learning points. RECENT FINDINGS There is growing data on (i) the validity of commercial 'consumer' physical activity monitors, e.g. FitBit, and (ii) the role of hybrid physical activity assessments; combining objective and subjective measures to understand physical activity quantity and quality. In both cases, adherence is challenging and can be optimized using short monitoring protocols, e.g., 3-4 days, and by providing clear instructions and support materials to participants. Studies in cancer and chronic respiratory disease have found mixed effects from physical activity interventions based on pedometers, behavior change techniques, online resources, and/or therapeutic nutrition. The most responsive physical activity outcomes and minimum clinically important differences are still to be understood. SUMMARY Physical activity measures provide an opportunity to detect changes in health behavior. However, measuring physical activity as a trial endpoint is challenging and focusing effort to ensure optimal participant compliance is important.
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Verberkt CA, van den Beuken-van Everdingen MH, Schols JM, Datla S, Dirksen CD, Johnson MJ, van Kuijk SM, Wouters EF, Janssen DJ. Adverse respiratory effects of opioids for chronic breathlessness: to what extent can we learn lessons from chronic pain? Eur Respir J 2018; 52:52/1/1800882. [DOI: 10.1183/13993003.00882-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/20/2018] [Indexed: 11/05/2022]
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Dal-Ré R, Janiaud P, Ioannidis JPA. Real-world evidence: How pragmatic are randomized controlled trials labeled as pragmatic? BMC Med 2018; 16:49. [PMID: 29615035 PMCID: PMC5883397 DOI: 10.1186/s12916-018-1038-2] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/15/2018] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Pragmatic randomized controlled trials (RCTs) mimic usual clinical practice and they are critical to inform decision-making by patients, clinicians and policy-makers in real-world settings. Pragmatic RCTs assess effectiveness of available medicines, while explanatory RCTs assess efficacy of investigational medicines. Explanatory and pragmatic are the extremes of a continuum. This debate article seeks to evaluate and provide recommendation on how to characterize pragmatic RCTs in light of the current landscape of RCTs. It is supported by findings from a PubMed search conducted in August 2017, which retrieved 615 RCTs self-labeled in their titles as "pragmatic" or "naturalistic". We focused on 89 of these trials that assessed medicines (drugs or biologics). DISCUSSION 36% of these 89 trials were placebo-controlled, performed before licensing of the medicine, or done in a single-center. In our opinion, such RCTs overtly deviate from usual care and pragmatism. It follows, that the use of the term 'pragmatic' to describe them, conveys a misleading message to patients and clinicians. Furthermore, many other trials among the 615 coined as 'pragmatic' and assessing other types of intervention are plausibly not very pragmatic; however, this is impossible for a reader to tell without access to the full protocol and insider knowledge of the trial conduct. The degree of pragmatism should be evaluated by the trial investigators themselves using the PRECIS-2 tool, a tool that comprises 9 domains, each scored from 1 (very explanatory) to 5 (very pragmatic). CONCLUSIONS To allow for a more appropriate characterization of the degree of pragmatism in clinical research, submissions of RCTs to funders, research ethics committees and to peer-reviewed journals should include a PRECIS-2 tool assessment done by the trial investigators. Clarity and accuracy on the extent to which a RCT is pragmatic will help understand how much it is relevant to real-world practice.
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Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, E-28040, Madrid, Spain
| | - Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy, Biomedical Data Science, Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA.
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