Sleep-disordered breathing in patients chronically using opioids
- Shirin Shafazand, MD, MS, FRCP(C), FCCP, FAASM
Shirin Shafazand, MD, MS, FRCP(C), FCCP, FAASM
- Associate Professor of Medicine, Division of Pulmonary Critical Care and Sleep Medicine
- University of Miami, Miller School of Medicine
Prescription opioid use for chronic non-cancer pain has increased dramatically over the past two decades. Although the prevalence and impact of respiratory depression due to opioids were at one time de-emphasized , there is now a growing appreciation for the adverse effects of chronic opioid use, including increased mortality . Emerging data also suggest that there is an increased incidence of sleep-disordered breathing (SDB) with chronic opioid use, with possible negative consequences.
Given the relatively high prevalence of both obstructive sleep apnea (OSA) and chronic pain in the general population, clinicians are likely to encounter patients with pre-existing or undiagnosed OSA who are using opioids for chronic pain. Awareness of the sleep and respiratory effects of chronic opioid use is essential in the safe management of these patients.
The effects of chronic opioid use on sleep architecture and respiration during sleep, and the diagnosis and treatment of opioid-associated SDB are reviewed here. Acute opioid use and its impact on patients with OSA in the perioperative setting are discussed separately. The respiratory and other effects of acute opioid intoxication are also reviewed separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea" and "Acute opioid intoxication in adults".)
EFFECTS OF OPIOIDS ON SLEEP AND RESPIRATION
Sleep architecture — Limited data suggest that opioids are disruptive to sleep architecture, despite their sedative effects. Acute opioid use causes more frequent shifts in sleep states, increased arousals from sleep, an increase in non-rapid eye movement (NREM) stage 2 sleep, and reductions in total sleep time, amount of slow wave (stage N3) sleep, and rapid eye movement (REM) sleep . (See "Stages and architecture of normal sleep".)
With chronic opioid use, there is a tendency for the percent time spent in REM and slow wave sleep to normalize, but there is an increase in daytime sleepiness and reported fatigue . Withdrawal from chronic opioid use may lead to insomnia, increased arousals from sleep, and rebound in REM and slow wave sleep.
- The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain 1997; 13:6.
- Manchikanti L, Helm S 2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician 2012; 15:ES9.
- Dimsdale JE, Norman D, DeJardin D, Wallace MS. The effect of opioids on sleep architecture. J Clin Sleep Med 2007; 3:33.
- Pressman MR. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications. Sleep Med Rev 2007; 11:5.
- Yue HJ, Guilleminault C. Opioid medication and sleep-disordered breathing. Med Clin North Am 2010; 94:435.
- Tangel DJ, Mezzanotte WS, White DP. Influence of sleep on tensor palatini EMG and upper airway resistance in normal men. J Appl Physiol (1985) 1991; 70:2574.
- Pattinson KT. Opioids and the control of respiration. Br J Anaesth 2008; 100:747.
- Teichtahl H, Wang D, Cunnington D, et al. Ventilatory responses to hypoxia and hypercapnia in stable methadone maintenance treatment patients. Chest 2005; 128:1339.
- Teichtahl H, Prodromidis A, Miller B, et al. Sleep-disordered breathing in stable methadone programme patients: a pilot study. Addiction 2001; 96:395.
- Farney RJ, McDonald AM, Boyle KM, et al. Sleep disordered breathing in patients receiving therapy with buprenorphine/naloxone. Eur Respir J 2013; 42:394.
- Correa D, Farney RJ, Chung F, et al. Chronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations. Anesth Analg 2015; 120:1273.
- Walker JM, Farney RJ, Rhondeau SM, et al. Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. J Clin Sleep Med 2007; 3:455.
- Wang D, Teichtahl H, Drummer O, et al. Central sleep apnea in stable methadone maintenance treatment patients. Chest 2005; 128:1348.
- Walker JM, Farney RJ. Are opioids associated with sleep apnea? A review of the evidence. Curr Pain Headache Rep 2009; 13:120.
- Mogri M, Desai H, Webster L, et al. Hypoxemia in patients on chronic opiate therapy with and without sleep apnea. Sleep Breath 2009; 13:49.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Mason M, Cates CJ, Smith I. Effects of opioid, hypnotic and sedating medications on sleep-disordered breathing in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2015; :CD011090.
- Farney RJ, Walker JM, Boyle KM, et al. Adaptive servoventilation (ASV) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain. J Clin Sleep Med 2008; 4:311.
- Guilleminault C, Cao M, Yue HJ, Chawla P. Obstructive sleep apnea and chronic opioid use. Lung 2010; 188:459.
- Javaheri S, Harris N, Howard J, Chung E. Adaptive servoventilation for treatment of opioid-associated central sleep apnea. J Clin Sleep Med 2014; 10:637.
- Javaheri S, Malik A, Smith J, Chung E. Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med 2008; 4:305.
- Ramar K, Ramar P, Morgenthaler TI. Adaptive servoventilation in patients with central or complex sleep apnea related to chronic opioid use and congestive heart failure. J Clin Sleep Med 2012; 8:569.
- Troitino A, Labedi N, Kufel T, El-Solh AA. Positive airway pressure therapy in patients with opioid-related central sleep apnea. Sleep Breath 2014; 18:367.
- Reddy R, Adamo D, Kufel T, et al. Treatment of opioid-related central sleep apnea with positive airway pressure: a systematic review. J Opioid Manag 2014; 10:57.
- Shapiro CM, Chung SA, Wylie PE, et al. Home-use servo-ventilation therapy in chronic pain patients with central sleep apnea: initial and 3-month follow-up. Sleep Breath 2015; 19:1285.
- Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med 2015; 373:1095.
- Bouillon T, Bruhn J, Roepcke H, Hoeft A. Opioid-induced respiratory depression is associated with increased tidal volume variability. Eur J Anaesthesiol 2003; 20:127.
- EFFECTS OF OPIOIDS ON SLEEP AND RESPIRATION
- Sleep architecture
- Respiratory control
- RISK FACTORS
- CLINICAL FEATURES
- Patient selection for polysomnography
- Diagnostic criteria
- Lowering the opioid dose
- Concomitant drugs
- Positive airway pressure therapy
- Supplemental oxygen
- FOLLOW-UP AND MONITORING
- SUMMARY AND RECOMMENDATIONS