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Attitudes to morphine in chronic heart failure patients
  1. Stephen G Oxberry1,
  2. Lesley Jones2,
  3. Andrew L Clark3,
  4. Miriam J Johnson4
  1. 1Department of Palliative Medicine, Kirkwood Hospice, Huddersfield, UK
  2. 2Department of Health Sciences, Hull York Medical School, University of York, York, UK
  3. 3Department of Academic Cardiology, University of Hull, Hull, UK
  4. 4Department of Palliative Medicine, Hull York Medical School, University of Hull, Hull, UK
  1. Correspondence to Dr Stephen Oxberry, Kirkwood Hospice, 21 Albany Road, Dalton, Huddersfield HD5 9UY, UK; Stephen.Oxberry{at}hyms.ac.uk

Abstract

Objectives Low-dose opioids are used for the palliation of pain, breathlessness and cough in advanced chronic heart failure (CHF) patients. The authors wanted to determine any potential barriers or facilitators to opioid administration in patients with CHF by assessing their knowledge, concerns and attitudes to morphine therapy.

Methods Semistructured interviews were held with a purposive sample of 10 men with symptoms of CHF. Data were analysed using a constant comparative approach until thematic saturation.

Results Four key areas emerged: medication use; symptoms; prior morphine experience; and attitudes, concerns and anxieties regarding morphine use. Despite polypharmacy, participants said that morphine would be acceptable if it was monitored by a trusted healthcare professional. Many patients had experienced morphine before, often in life-threatening situations such as myocardial infarction, when it had helped greatly. Opioids were not strongly associated exclusively with death and dying (in contrast to patient reports in the cancer literature).

Conclusions Although some concerns about morphine were expressed, these did not appear to override a willingness to consider its use if recommended by a trusted clinician. However, some participants perceived that their doctor was concerned about its use, holding it as a last reserve. Morphine appears to be an acceptable breathlessness treatment option to these people with CHF. Prescribers may need education and reassurance if these medicines are to be used to their full potential and views may be different in other communities.

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Introduction

Opioids or ‘morphine-like’ medicines, traditionally considered analgesics for severe pain, reserved for serious illness or for people near to death, conjure a variety of different thoughts in the minds of both medical and lay people. Studies conducted in the field of cancer indicate that morphine may be associated strongly with fears of imminent death, dependence, illicit use and unwanted effects ranging from sedation to respiratory depression. These beliefs can affect healthcare professionals (resulting in a barrier to their prescription)1–5 or patients (resulting in a barrier to concordance with opioid medication), despite evidence that the appropriate use of opioids is both safe and effective.6

Over the past 10–15 years, understanding of the pathophysiology of chronic heart failure (CHF) has led to medical management that has doubled life expectancy and greatly improved symptom control.7 People with CHF are usually older people (10% of the over 75-year-olds in the UK) and have comorbidities, resulting in polypharmacy and other non-cardiac symptoms.8 Patients' knowledge about CHF medications is generally poor.9

Opioids are useful in the management of breathlessness and cough.10–14 Guidelines for the management of CHF suggest that low-dose opioids may be helpful in the management of intractable breathlessness.15 There are no published data on the views of people with CHF regarding opioid use for breathlessness. We therefore conducted this semistructured one-to-one interview study to explore the experience of people with CHF concerning their medication, symptoms and fears, beliefs, knowledge and attitudes to morphine therapy. Our aim was to understand any potential barriers or facilitators to opioid administration in patients with CHF.

Methods

National Health Service ethical committee and research governance permissions were obtained. Each participant gave informed written consent following full explanation of the nature and purpose of the study, in accordance with the Helsinki declaration (2000). Demographic information (age, ethnicity, illness diagnosis) was recorded with a review of the case notes. After the interview, all participants were given contact details in case they should wish to discuss any aspect of the research.

Sampling and setting

A purposive sample of patients with symptoms of CHF was used over a 9-month period. Patients with New York Heart Association (NYHA) Grades II, III or IV (symptoms on moderate, mild or no exertion) were identified, in heart failure clinics based in a tertiary centre, as potentially suitable by the heart failure nurse specialist (HFNS) and given a patient information leaflet. The patients were then contacted by telephone. This patient group is most likely to be offered opioids for symptom relief. Patients chose the interview location: either in hospital coinciding with a clinic visit or at home. No formal sample size was calculated for the study, in keeping with the qualitative methodological approach. Data collection continued until theoretical saturation of emerging themes was achieved.

Topic guide

A topic guide was used as the framework for the semistructured interviews, all of which were conducted by SGO. Table 1 summarises the key points from the topic guide, drawn from the published literature in CHF and the ‘opioid barriers’ work in oncology. The topic guide for the interview had been reviewed (and approved) by volunteers from a local Heart Failure Patient Support Group. The interview was conducted in a quiet area. A friend or family member was allowed to observe if the participant wished. Interviews were audio-recorded and professionally transcribed verbatim and lasted between 19 and 43 min. Notes on aspects of the interview not likely to be identified by audio alone were made immediately following the interview by the interviewer. Both the transcript and field notes were drawn together to identify and gain consensus on the key themes that emerged.

Table 1

Key points from the topic guide

Participants

Of the 17 patients invited for interview, seven declined. Reasons given for refusal included the overall state of the patient's health and the feeling that the subject was not relevant to the specific patient's health. Ten male participants were interviewed. Their mean age was 72 years (range 53–86 years) and all were Caucasian. Six participants had NYHA class II symptoms; three had class III symptoms and one had class IV symptoms. All had been known to the cardiac clinic for over a year. Participants' characteristics are shown in table 2.

Table 2

Characteristics of the study participants

Analysis

Data obtained from the interviews were analysed according to the principles of modified grounded theory. This is an inductive process involving the generation of categories obtained from the data using a constant comparative approach.16 ,17 Open coding of data was used to yield concepts and categories. Formal theory was generated from exploration of the concepts and categories which allowed the formation of subsequent hypotheses. An iterative approach allowed the topic guide to be modified, taking new concepts or themes into account. The three researchers familiarised themselves with the data and sought consensus over the emerging themes, which was an ongoing process in keeping with the constant comparative approach. Any potential groupings were noted as subordinate themes accompanied by verbatim examples and formation of hypotheses.

Our theoretical framework is based upon an acceptance that the participants' beliefs about their behaviour are valid: if we wish to understand patients' perceptions, we have to accept that they believe what they are saying. That is, it is important to adhere to the conventions of qualitative methodology which explicitly attempts to access everyday meanings and understanding.18

Results

‘I would not hesitate if it was morphine, because I've seen the good that it does, and if somebody recommended it who I trusted, yeah, I'd take it. No problem’ (Participant 9).

Four key areas emerged: medication use; symptoms; prior morphine experience; and attitudes, concerns and anxieties regarding morphine use. The four were interlinked and the first three areas provided the context for the last. Subordinate themes are listed and illustrated with verbatim quotes in boxes 1–4.

Box 1

Key areas that emerged from the data analysis: medication use

Superordinate theme: medication use

Subordinate themes

Polypharmacy

Quote 1: ‘You wouldn’t believe it, five/six years I used to take nothing, the odd Paracetamol for a headache or anything, and now it's, it's like a pick and mix. So it's a bit of a, but when people come and visit they're saying “Are you Boots the Chemist?” I went “No” they said “Well look at that”. Well if I don't take ‘em, I won’t be here.' Participant 5

Concordance

Quote 2: ‘…and I always write everything down, I have cards in front of me in a morning before I start to take my medicines to make sure I don’t duplicate anything or get anything wrong.' Participant 1

Knowledge/information

Quote 3: ‘They’re for me tick-tock but I don't know what they do.' Participant 6

Quote 4: ‘I don't know a lot about my medicine at all and, quite frankly, if I did, I don't know how much it's going to help me…. I'm happy as I am.' Participant 3

Faith in healthcare professionals

Quote 5: ‘If there's anything wrong with my car I'll take it to a garage, and the mechanic who knows a lot more about the car will give me the right things to get it working right, and I have the same trust in … the clinicians here, that they know what they're doing.' Participant 9

Quote 6: ‘I believe when you say,’ trust me I'm a doctor,' I'm a big believer in that and if you told me to take this and take this it would be better for me I will do that simply because as a layman I'm subject to your abilities.' Participant 1

Quote 7: ‘The specialists or the doctors must know they (the medications) work or else they wouldn’t prescribe ‘em.’ Participant 5

Box 2

Key areas that emerged from the data analysis: symptoms

Superordinate theme: symptoms

Subordinate themes

Self-reported symptoms

Quote 8: ‘Breathlessness is always a problem…. Particularly … getting out of bed and particularly when, if I bent down, say if I bent down for two or three minutes, then the dizziness with the breathlessness is quite … alarming…. That's breathlessness and pain…. Most physical exertion causes some pain.' Participant 6

Role of age/comorbidities

Quote 9: ‘Well I, I should imagine at my age … I’m eighty-four this year, and … anything could happen now, cos at present moment all our friends are all in that bracket of eighty, eighty-four, eighty-six including this year we've lost two of ‘em already, but that’s life, that's the way things are.' Participant 2

Symptom variability

Quote 10: ‘It, it very much varies, sometimes even, you know, but the whole, my whole condition seems to vary a lot. Sometimes I can be fine … doing reasonably, you know, well … oh cleaning and one thing and another, another day after I've bent down with the dustpan and brush to sweep up a few bits I can feel breathless.’ Participant 7

Sense of loss, including role

Quote 11: ‘Because I’m aware that … I'm limited now to what I can do, I mean I used to love doing gardening, but I can't do it now, I don't do it now, whether I could do it or I can't do it because I can't get about, but…' Participant 3

Quote 12: ‘There’s silly little things you miss, you know, you can't do, I can't bend down and tie my shoelaces, I can't, if I drop something on the floor I can't pick it up.' Participant 5

Quote 13: ‘But I’ve always been used to doing the manly things, like carrying out the rubbish, the big black … bin that's in, in the rubbish, now I have to watch her take that out. I have to watch her cut the grass, I have to watch her doing the heavy lifting and, you know, that, that drives me potty … and every now and again, if she's not around, I lift something a bit too heavy that I know I shouldn't lift. I suffer for it, you know.' Participant 9

Quote 14: ‘It’s frustrating watching your wife doing what you know that you ought to be doing. I mean you know why you're not doing it, but it does stop you feeling you're inadequate.' Participant 6

Lifestyle adaptation

Quote 15: ‘When I get up in a morning I’m thinking mm, feel OK, and sometimes if you’ve had a bad night, you can't sleep and you're breathless and everything and you think mm, and some days you just can't be bothered to do anything.' Participant 5

Quote 16: ‘Oh the, the bath situation, I can get in the bath with not too much difficulty, but getting out is an absolute, I fall out. I actually, I actually do fall out the bath. I put my hands out to hit the wall other side, and getting dry is an absolute … major effort. In fact I couldn’t do it if it weren't for these towelling robes, and I have to use one of them otherwise I couldn't…' Participant 6

Attitudes of others

Quote 17: ‘The one thing that does frighten us … the queue for the lift was absolutely packed out so I thought I’d try and walk up the stairs. I didn't get very far, I had staff running out all over place and they wanted to send for an ambulance, I said “No just leave me alone, I'll take me spray” and I won't do that again, I'll make sure somebody's with me. It happened at me son's house, and the bathroom and toilet's upstairs, so you have to go upstairs, and it's … effort and it's a … a worry, but what's more worrying is the look on people's face when you come back in room, cos they are absolutely taken aback aren't they?' Participant 9

Box 3

Key areas that emerged from the data analysis: prior morphine experience

Superordinate theme: prior morphine experience

Subordinate themes

Direct (self)

Quote 18: ‘Yeah. I’ve had morphine, one or two, when I've had me heart attacks … I, I know they give me a morphine, and they usually do it in small doses until they reach a level that … the pain's gone.' Participant 6

Direct (others)

Quote 19: ‘….wouldn’t have the quality of life he has now without morphine' …. ‘he’s got life again, you know, so, which is great.' Participant 9

Indirect (media, etc)

Quote 20: ‘We don’t see the medical side of it … used properly. You see that illegal side of it' ‘Well I’ve seen these programmes where you’ve seen drug addicts and what have yah.' (on television) Participant 8

Box 4

Key areas that emerged from the data analysis: attitudes, concerns and anxieties

Superordinate theme: attitudes, concerns, anxieties

Subordinate themes

Side effects

Quote 21: ‘Catch 22, if I take it and it does me any good, if I take it but it don’t do me any good, but I get addicted, is that good or bad?' Participant 5

Masking pathology

Quote 22: ‘The, the trouble with morphine, it works very well at reducing pain, but I think it can also hide the pain that they ought, ought to be knowing about. That's the thing that I'm frightened of morphine might do, mask it up, … But if I have another, ever have another one (MI) I'd like to be given morphine cos it's a hell of a pain (laughs)…' Participant 6

Acceptability

Quote 23: ‘Q: OK. And if we found that something, a, a medicine a bit like morphine could help with breathlessness, could help people sort of … you know, sort of walk further or sort of do more gardening, do you think that that would be something that would be… A: I'd take anything…’ Participant 8

Quote 24: ‘I think if it was, if the, somebody had sat down with the patient and talked, and said, look we’ve had these morphine based tablets on trials and it seems to be working but we need more people to try it, would you be willing to, and if, if you're in pain and, anything … anything to help me breathe I, I’d do it, yeah.' Participant 5

Quote 25: ‘Q: Do you think that there will be anything that we’ve talked about so far or anything else that might stop you from taking morphine if you found that it was helpful to you? A: None, nothing whatsoever.' Participant 7

Quote 26: ‘It’s just another medicine that does me a lot of good when the time's right.' Participant 6

Medical associations

Quote 27: ‘Funnily enough the doctors have various ideas about these things.’ Participant 3

Quote 28: ‘He (GP) give me a morphine tablet… and he said “Don’t use ‘em if you can avoid it” he said “but just keep” he said “have” he said “if you feel really bad” he said “just take one.” ‘ Participant 10

Quote 29: ‘But he (the GP) were blaming the morphine for all this (symptoms).’ Participant 6

Medication use in CHF

Knowledge, information and polypharmacy

Participants reported that other people expressed astonishment about the high number of drugs administered and the amount of information about them (Quote 1).

Knowledge about the use of medications was variable, with half of the participants clearly understanding the reason for medications and how to manage polypharmacy (Quote 2). However, half were happy to take medication as prescribed without understanding and were dependent on partners or others (Quotes 3 and 4). Most had read patient information leaflets at some point, but found them alarming, confusing or unhelpful.

Faith in the medical community

There was an uncomplaining acceptance of the number of tablets as a necessary part of their condition associated with a trusting faith in their doctors and nurses. Some participants rationalised their lack of knowledge about medication as part of their trust in the medical profession, being deferential to the knowledge of the healthcare professional (Quotes 5–7). Respect, trust or faith in the clinical community was expressed by all participants.

Role of symptoms in CHF

Pain, cough and breathlessness are all potential therapeutic targets for opioids. However, participants in this study perceived opioids as only being relevant for the relief of pain. Five identified breathlessness as their most troublesome symptom coupled with pain in three participants (Quote 8).

Some participants minimised the severity of their illness, attributing their symptoms to other comorbidities or, in particular, their age (Quote 9). Two showed ‘optimistic fatalism’ as things had been worse for them in the past or others were worse off than they were. Symptom variability was prominent (Quote 10), and an ‘every day at a time’ attitude was employed, limiting the ability to plan ahead.

Loss of role and function

Loss of role and function was described by most respondents. Activities such as dancing, gardening or others previously enjoyed (or anticipated for retirement) had been limited or lost (Quotes 11 and 12). The loss of the ability to enjoy family events (eg, playing with grandchildren), to drive or to play an active perceived ‘male’ role such as ‘do it yourself’ home improvements were highlighted. The variability of symptoms made planning for recreation and tasks such as shopping difficult (Quote 10). These functional limitations result in reliance on others and associated frustration and loss of role (Quotes 13 and 14).

Adaptation

Commonplace lifestyle adaptations accompanied a stoical attitude relating to the deteriorating ability to perform daily activities (Quotes 15 and 16).

Perception of others

Distressing symptoms were amplified by the reaction of those witnessing them (Quote 17), finding that receiving attention intended to be helpful merely made them feel more self-conscious and embarrassed which in turn made the symptoms worse.

Prior morphine experience

We have divided prior encounters with morphine-like medicines into: direct (involving self), direct (involving family or friends) and indirect (media/television).

Direct experience involving self

The direct patient experience of morphine was difficult to clarify where recall was a problem. Four participants remembered receiving injected opioids during myocardial infarction (MI) or surgery. Three had received oral opioids for arthritic pain or angina. Opioid use was generally viewed positively, particularly for MI pain (Quote 18).

Experience from observation of use in others

Experience of opioid use often came from observing others, usually for cancer pain management, and was commented on positively (Quote 19). Only one participant had experience of non-pain opioid use: for breathlessness in a relative with chronic obstructive pulmonary disease. He had another relative taking opioids for cancer pain and did not recognise the morphine used for breathlessness as the same ‘powerful stuff’ used to treat cancer pain (participant 5).

Indirect experience

Participants volunteered fewer observations on morphine use in the media although one participant gained knowledge through being an avid reader. Another commented on the negative media portrayal of morphine, which was contrary to his experience (Quote 20).

Morphine attitudes, concerns and anxieties

Associated adverse effects with opioids

Addiction, tolerance and side effects were issues mentioned, although only by a minority of four (Quote 21). One participant had found morphine very effective for MI pain, but was concerned that it would mask signs of further problems (Quote 22). He was reassured, however, by the doctor's explanation about dose–pain titration and the careful cardiac monitoring. The most commonly mentioned adverse effects, sleep and loss of concentration, were highlighted by one participant saying it had made someone that he had seen in hospital become ‘unrational’ (participant 1) and another referring to it as ‘dope’ (participant 4). Nausea, constipation and light-headedness were also mentioned by participants.

Consideration for the use of opioid medicines in healthcare

Most participants identified morphine as a painkiller in accidents, battlefields, cancer or painful conditions including arthritis, often described as ‘killing’ the pain. Three participants mentioned use as a sedative. None knew of its use in heart failure. Two participants commented on morphine's usefulness, if used appropriately. Six people mentioned that morphine could be helpful at the end of life, but did not appear to think that a person would have to be dying in order to benefit from it. Only one participant considered morphine to be something that should be restricted to very serious situations only (participant 3). Another (participant 6) commented that one did not have to be seriously ill to try morphine and two others (participants 2 and 5) even suggested that morphine could be used to prolong or preserve life.

Attitudes to the terminology of morphine

Most responders found ‘morphine’ acceptable as a term, but commented that acceptance may be less in the general population.

Attitudes to opioid prescription in CHF

Nearly all the respondents would favour a trial of morphine if recommended by a doctor, with the benefits outweighing any potential side effects, in small doses initially for pain or breathlessness (Quotes 23–26). However, there was a perception by four participants that not all doctors were happy to prescribe morphine (Quotes 27–29). One participant had been prescribed oral morphine for his angina by his general practitioner, but was told not to take the tablets ‘unless you could not avoid it’, only if his pain was ‘really bad’ and only to ‘just take one’. No repeat prescription was issued, although the morphine tablets were effective.

Discussion

Limitations

This single centre, single sex, single ethnic group study reflects the local experience of men with CHF in the UK; we recognise that health beliefs about opioids may vary between communities. Qualitative studies do not aim to produce results that can apply to a wide population,19 ,20 and therefore purposively sample the relevant participants. We sampled patients with symptoms of CHF and continued recruiting until thematic saturation was reached. Thematic saturation occurred after 10 patients which, given the preponderance of men in the recruitment setting, led to only men being included. Further study should take this into account when planning both sampling and recruitment.

Patients known to have symptoms of CHF were asked to participate, with over half of those approached agreeing to take part: the approach and response may have excluded some patients with negative experiences, perhaps less willing to volunteer information in an interview if they had problems with morphine before. In addition, those taking part may have positive narratives to tell about morphine. Interestingly, the majority of the participants wished to be interviewed in order to contribute to CHF research rather than because the topic was morphine, particularly because there was also an emphasis on the overall daily lived experience of CHF. Although the question of acceptability of morphine was posed hypothetically, some of these men did have prior experience of being offered morphine (four intravenously and three orally) and could respond in the context that this was a real possibility.

Medication use in CHF

Polypharmacy can be burdensome to patients and they devise routines to maintain concordance, often involving a partner.21 The men in our sample good-humouredly accepted the large number of medicines as necessary to maintain their remaining quality of life. The level of knowledge varied, as did their information needs.

For most of the respondents, the predominant attitude was one of ‘the doctor knows best’. Advanced disease, cognitive impairment, comorbidities and complex medication regimes can lead to dependence on professionals. This may also result from the experience of acute life-threatening hospital admissions followed by physician-guided stabilisation or from the development of supportive relationships with the healthcare team in people with chronic illness, reflected by the many positive references to the doctors and HFNS.

Patient information sheets included with medication were found to be unhelpful or counterproductive, consistent with other researchers' findings that some CHF patients were alarmed by package inserts, particularly the lists of contraindications and by the dose they had been prescribed.22

Symptomatic CHF

In keeping with published reports, we found that many patients considered their increasing age might be as problematic as the disease process.22 Participants volunteered few symptoms related to CHF, but breathlessness, cough and chest pain were prominent, in keeping with previous studies.22 ,23 Stoicism was a strong, repeated theme and this attitude may protect patients from considering advancing disease. Previous studies of the importance of a positive outlook for maintaining a good quality of life in men have yielded conflicting results.24,,26 Perceiving others to be in a worse condition, the so-called ‘downward comparison’, allows patients to maintain self-esteem.

Stoicism could be viewed as a form of disavowal, a ‘selective perceptual blindness to unpleasant facts’.27 Although thought of as a form of denial and thus a negative trait,28 Buetow et al29 suggest disavowal to be a useful coping strategy between avoidance and acceptance. Patients thus acknowledge the reality of their situation, but to palliate the emotional burden they dissociate this awareness from its personal impact. Alternatively, such stoicism may merely indicate acceptance and realisation that they are unable to alter outcome.

Variability in symptoms was a feature in the daily lives of some participants, again mirrored in other published work.30 A consequence was withdrawal from planned activities leading to a sense of loss of functional capabilities or of role. The contraction of living in people with symptoms of CHF has previously been described, but again in a predominantly male sample of CHF patients.24 ,31 ,32 Discontinued activities in our study included dancing, gardening, ‘do it yourself’ activities and driving. Very restricted participants found it difficult to complete activities of daily living, leading to reliance on others and a consequent loss of personal identity within the family and wider community. Our participants felt that their condition caused worry and apprehension for both themselves and their family. There was guilt at partners undertaking traditionally male roles. The impact of CHF on men and their families should be explored further by including partners' opinions. Fear of being a burden on loved ones is consistently stated as a major concern in those with serious illness, which is confirmed in this study.33

Prior morphine experience

In general, the previous experience of morphine use was positive. Most experience was for cancer pain and very few knew that opioids could be used for non-pain symptoms in diseases other than cancer. Better education or awareness of the use of morphine for cancer pain might lead to greater acceptance.

Interestingly, the participant who had seen beneficial effects of morphine used for breathlessness and cancer pain assumed that the cancer pain morphine was the stronger drug. Unfortunately, the types and doses of morphine are not known in these two clinical situations, but his insight appears to be that cancer pain necessitates strong analgesics as it is likely to be severe, whereas troublesome breathlessness does not necessarily require such radical intervention. It would be interesting to explore this hierarchy further. Less information came from the indirect experience of patients through media, television or further reading.

Morphine attitudes, concerns and anxieties

Despite many participants having taken morphine in the past, few volunteered morphine-related adverse events. A few participants referred to addiction and acknowledged illicit use, but appeared to be able to put this in context of balancing potential benefits. Fear of experiencing side effects was low. However, this may have been because many of them had experienced effective relief during previous frightening and painful acute events for themselves, or had seen the benefit in the management of severe pain in cancer or other conditions in someone they cared for.

The majority noted the use of morphine at the end of life, but recognised that it could be employed earlier in their illness. Several commented they did not think they had reached ‘that stage yet’ in keeping with six of the participants having NYHA class II CHF, but only one participant in our study commented that morphine use should be restricted to very serious situations. The potential use of morphine in our group was not exclusively associated with cancer, advanced disease, imminent death or by illicit non-prescriptive use in contrast to the views regarding morphine use in cancer patients for pain management.34 Our CHF group appeared to be a different type of consumer: the participants had symptoms, but not at the point where end of life considerations were urgently needed. Perhaps the timing of the interviews, allowing relatively early consideration of morphine in the trajectory of an illness, allowed acceptance: leaving discussion to a very advanced stage carries the inference that opioids can only be used at the end of life. Conversely, it may be that CHF patients genuinely do view morphine in a different light to cancer patients because they have already had a different experience. If your initial experience of morphine is in the context of an acute ‘rescue’ from a serious cardiac event, it may be less associated with imminent death and dying than it is for people with cancer, perhaps reflected in the finding that the term ‘morphine’ itself was universally accepted in our sample.

However, if these CHF patients appeared to be less phobic of morphine than cancer patients, there was a suggestion that at least one prescriber was not, despite the patient finding morphine use acceptable. Even when morphine was successfully employed in severe symptomatic angina as for one of our respondents, the impression was received that the drug was a last resort. No studies are published about cardiologists' opioid prescribing, suggesting an avenue for future research. However, there is much qualitative research in oncologists and other healthcare professionals who can hold negative misconceptions of the use of opioids.2 ,35 ,36 Initial findings from a Canadian clinicians' study confirm their serious fears regarding opioid prescribing for breathlessness,37 especially respiratory depression. Results from a large chronic breathlessness pharmacovigilance study suggest these fears appear to be unfounded in that there were no episodes of opioid-related hospital admission or respiratory depression.38

Would the patients with CHF in our sample be prepared to take morphine? Despite the polypharmacy, the general consensus was that morphine would be acceptable if prescribed and monitored by a trusted healthcare professional, assessed for net benefit. Clear information-giving and discussion between patients, carers and involved healthcare professionals is advised to maximise patient knowledge and concordance. HFNSs may be the best professionals to co-ordinate this process.

Given the participants' perception of physician opiophobia, in keeping with the Canadian studies, it would appear that targeted education and reassurance regarding the safety and potential benefit is needed. Further work to explore the particular anxieties among these physicians would be useful.

Conclusions

As found by other researchers, we found that people with CHF adopted a stoical attitude to limitations despite suffering losses. Patients coped with their changing physical state by adaptation, avoidance or reduction in physical activity. Therefore, interventions for breathlessness would be welcome, especially if this allowed participation in activities no longer possible.

This work provides a first piece of the picture about how people with CHF feel about taking opioids. We acknowledge this is a snapshot, and different responses may be given in response to these questions elsewhere. However, these data demonstrate that we should not extrapolate published work in people with cancer; participants did talk about the use of opioids in those who were dying, but this was not a major theme. In general, the use of morphine seemed to be seen in a positive light, perhaps because participants had associated morphine with life-threatening cardiac events from which they had made a good recovery. However, there was little understanding that opioids could be used for breathlessness as well as for pain in CHF, with the possibility of a hidden hierarchy of therapy if used for non-pain symptoms.

Although clinicians were not interviewed, participants in this study commented that prescribers were cautious about opioids. There is a need to understand physicians' concerns about the use of opioids for breathlessness in the management of chronic disease, and for reassurance and education regarding the risks of treatment. Patients clearly sense when their doctor has reservations about a treatment, and as trust in the prescriber was important in their willingness to try morphine, measures that can help clinicians prescribe appropriately with confidence should be encouraged.

Are people with CHF opiophobic? This small sample of male patients with symptoms did not appear to be so. Morphine for symptom relief would be acceptable despite their concurrent polypharmacy if recommended and prescribed by a trusted clinician and carefully monitored.

Acknowledgments

We thank the patients for participating, and Professor John Cleland and staff at Academic Cardiology for help with recruitment.

References

Footnotes

  • This is a reprint of a paper that first appeared in BMJ Supportive & Palliative Care, 2012, Volume 2, pages 29–35.

  • Funding This study was supported by a Clinical Fellowship Research Grant through the Hull York Medical School, UK. The funder remained separate to the research process and development of the submission.

  • Competing interests None.

  • Ethics approval Hull & East Yorkshire REC (number 08/H1304/B).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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