Use of Opioids for Shortness of Breath in Hospice Care and End of Life

By: Anthony Fountoulakis, PharmD Candidate 2021

Michelle Huber, R.Ph., PharmD, BCGP

There is an increasing need for relief of symptoms in advanced or end stage diseases towards the end of life. Some of these symptoms include pain from diseases, movement and daily activities, shortness of breath, constipation and increased oral secretions. Pain is often the most likely symptom for initiating opioid therapy. Morphine is an opioid medication, with very powerful effects of reducing pain in patients due to numerous circumstances. It can be taken by mouth for pain after surgeries, accidents, or generalized pain that just isn’t tolerable or managed by other medications such as acetaminophen or ibuprofen. Other common opioids that are used besides morphine include: hydrocodone, oxycodone, hydromorphone, and fentanyl. Pain is often the most likely symptom for initiating opioid therapy but another symptom that opioids are very effective for helping is the increasing difficulty of breathing and shortness of breath.

The shortness of breath or difficulty breathing is called dyspnea. It is a discomfort described by the patient as an increase in effort, chest tightness, incomplete exhalation, or feeling of suffocation. Additionally, it is experienced by up to 70% of patients nearing the end of life and even more so among those with heart disease and heart failure or who already have breathing disorders such as lung cancer or COPD. Some non-medication options that can help with these symptoms include improving air circulation such as using a fan, repositioning the patient, providing stimulation to distract the patient such as by conversation or companionship, and ultimately preparing the patient and family for the symptoms to worsen over time. With this preparation, education is provided for what steps may be taken, and what medication options are available.

The primary medications for helping these symptoms are opioids. Morphine, oxycodone, hydromorphone, hydrocodone and fentanyl may work considering their similar mechanism of action within the body. Morphine is used most often as it is available as a pill or a liquid and can be easily dose adjusted. Opioids should always be started at the lowest possible dose and slowly adjusted to find the balance of relieving the dyspnea but not causing significant undesired adverse effects. Morphine or opioids can act through many different pathways to relieve the symptoms of dyspnea. Morphine may reduce the patient’s perception of dyspnea. It can cause vasodilation or the opening of blood vessels in the lungs and improve the exchange of oxygen in the lungs. Dyspnea can both cause and be caused by anxiety in a continuous cycle, so morphine’s calming and drowsiness inducing effects can certainly help as well. Lastly, morphine can ease any pain that may be contributing to breathing discomfort and improve breathing quality further. Through all these mechanisms, morphine reduces the patient’s awareness of the struggle to breath, which results in easing breathing altogether.

A review of literature on use of opioids for dyspnea at end of life show:

• Opioids are the drugs of choice for treating dyspnea that cannot be managed by other disease-specific therapy in advanced disease.4,5
• Opioids do not shorten life. 4,5
• Opioids used in appropriate doses do not cause respiratory depression in patients who have dyspnea from advanced disease. 4,5

Morphine or other opioids are typically dosed up to the desired effect in the patient. If someone is already on morphine for pain, they may be more tolerable to the dose they are on so slowly increasing the dose can help relieve dyspnea. If an opioid is not being used, starting low and going slow with dose increases is the standard method of care. These medications are easily monitored by the patient and family members or caregivers for effectiveness when used as needed or with a scheduled dose. Opioids may provide a very safe and effective treatment for shortness of breath when other medication options no longer work. The goal of therapy is to improve the patient’s comfort so that they may rest easy as they continue their journey at end of life.

1. Lexi-Comp, Lexi-Drugs- Morphine; UpToDate, Inc. 2021, Accessed 3/19/2021

2. Dudgeon, D.; Assessment and Management of Dyspnea in Palliative Care. UpToDate, Inc.; February 2021, Accessed 3/19/2021.

3. Grauer, P., Kimbrel, J., McCrate Protus, B.; Palliative Care Consultant a Reference Guide for Palliative Care. HospiScript, 2015, pp 79-86.

4. Gallagher R. The use of opioids for dyspnea in advanced disease. CMAJ. 2011 Jul 12; 183(10): 1170.doi: 10.1503/cmaj110024

5. Opioids in the Palliative Treatment of Dyspnea. Am Family Physician. 2003 Apr 15;67(8):1821-1822