Title: Effect of Regular, Low-Dose, Extended-release Morphine on Chronic Breathlessness in Chronic Obstructive Pulmonary Disease: The BEAMS Randomized Clinical Trial

Background: 1-2 sentences that provide context to this article and why you have chosen it. You may want to cite a reference, but this is not required. BEAMS (Breathlessness, Exertion, And Morphine Sulfate) article selected as offered by cohort colleague during discussion of Oral Case Presentation in seminar on 02/09/2023, addressing the topic of opioid use for symptom management in advanced stage Chronic Obstructive Pulmonary Disease (COPD).

Design and Participants: 3-4 sentences which outline the population in the study and how the study was designed. You may need to describe an intervention and tool if important to understanding the findings. Multicenter, double-blind, placebo-controlled randomized clinical trial studying individuals with COPD and chronic breathlessness. Breathlessness defined as Medical Research Council score of 3-4: corresponding to patient statements of “I stop for breath after walking about 100 yards or after a few minutes on the level,” “I am too breathless to leave the house,” or “I am breathless when dressing” despite optimal treatment for underlying causes as confirmed by a specialist physician. A list of exclusion criteria included central hypoventilation syndrome. People were enrolled in 20 centers throughout Australia between September 2016 to November 2019 and followed up through December 26, 2019. Researchers examined the effect of different doses of extended-release morphine on worst breathlessness after 1 week of treatment. The intervention consisted of 8 mg/d or 16 mg/d doses of oral extended-release morphine or placebo during week 1, followed by subsequent randomized dose escalations of 8 mg/day on weeks 2 and 3.

Results: This section will come directly from the abstract or body of the paper. You should provide context or explanation as needed for results or statistics that are presented.  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]).

Commentary: In this section you will interpret the study, the results, and findings as well as a critical review that identifies unanswered questions, concerns with study design and areas for future research. In this randomized clinical trial including 156 people with COPD and chronic breathlessness, treatment with 8 mg/d and 16 mg/d of oral extended-release morphine for 1 week resulted in a mean difference of −0.3 and −0.3, respectively, for change in the intensity of worst breathlessness compared with placebo; neither difference was statistically significant. The scores range from 0 to10 (a score of 10 being the worst or most intense) on the numerical rating scale that was used. The study findings may not be applicable to people with very advanced COPD and breathlessness who are in palliative care or near the end of life, at which time treatment with opioids may be useful to provide relief of severe dyspnea. Further research is needed to determine if specific groups of people with COPD are more likely to experience a reduction in breathlessness with morphine, if some may benefit from higher doses of morphine, and to clarify the role of short-acting opioids for severe episodes of breathlessness.

Bottom Line: 1-2 sentences that summarize the findings and link them to changes in practice.  Long-acting opioids do not have an evidence-base in the management of chronic severe breathlessness in COPD. The safety of morphine for persistent breathlessness is unclear.

Source: The reference for the article in AMA style Ekström M, et al. Effect of regular, low-dose, extended-release morphine on chronic breathlessness in chronic obstructive pulmonary disease: the BEAMS randomized clinical trial. JAMA. 2022;328(20):2022-2032. doi:10.1001/jama.2022.20206