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.
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- 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