Chronic Pain and Sleep Apnea

In 2006, my daughter, Janice Montbriand, and I did a pilot study on selected chronic pain patients looking for sleep apnea. We found a high incidence of nocturnal oxygen desaturations in these cases. Methadone classically has also been known to induce sleep apnea. Now a cases series of people on other opioids has been published:

Sleep Breath. 2008 Sep 20. [Epub ahead of print] Opioid-associated central sleep apnea: a case series. Alattar MA, Scharf S

abstract

  • Epworth Scales levels 7 – 21
  • CSA [Central Sleep Apnea] was defined as apnea-hypopnea index (AHI) more than 5 per hour with >/=50% central events yet their AHI ranged from 28.4-106 per hour.
  • “Bilevel (BLV) titration was done to determine settings and all patients were followed for at least 6 months on nocturnal BLV.”
  • “Four of the patients were treated with chronic BLV ventilation with settings ranging 12-16 cm H(2)O (inspiratory positive airway pressure)/4-8 cm H(2)O (expiratory positive airway pressure) with backup rate of 12-16.”
  • “Among the four patients who used BLV treatment for at least 6 months, Epworth scores improved (by 4, 12, 5, and 9, respectively).”
  • “CONCLUSION: Treatment of opioid-associated CSA with BLV corrected nocturnal hypoxemia and reduced sleep fragmentation. Randomized controlled trials, with objective measures of daytime function, are recommended in opioid-induced CSA patients. “

Comment – Our sleep lab won’t even do opioid cases unless they stop their opioids – something I consider not practical. It looks like opioid related sleep apnea might be a sleeping giant, pun not intended. Private labs will do sleep studies but I have never seen a Bilevel titration done. Heck, I have one case who can’t keep his mask on when he lies on his side – any suggestions?

Anyone with practical experience would be appreciated…

Addendum:

It has now been suggested that:

“Sleep-disordered breathing is not an uncommon finding in patients with long-term opioid users with recent studies estimating a dose-related1 prevalence of 30% to 90%.”2-4

However ref 1 was:

1. Farney RJ, Walker JM, Cloward TV, Rhondeau S.
Sleep-disordered breathing associated with long-term opioid therapy. Chest. 2003;123:632–639.

They discuss THREE CASES:

  • “A 35-year-old woman (height, 155 cm; weight, 87 kg; body mass index [BMI], 36; and neck circumference, 39 cm) presented with chronic fatigue; poor sleep quality; generalized discomfort; back, right hip, and feet pain; restless legs syndrome; frequent nocturia; snoring; and witnessed apneas. Previous diagnoses included depression and gastroesophageal reflux. Medications included the following: hydrocodone, 7.5 mg tid; time-release morphine sulfate, 15 mg bid; tramadol, 50 mg at bedtime; sertraline; nefazadone; amitriptyline; alprazolam, 0.5 mg; celecoxib; and omeprazole. Baseline polysomnography revealed obstructive respiratory disturbances…”
    This case is complicated by the fact she could have had it pre-treatment given her BMI and the fact alprazolam was used concomitantly.
  • Case 2 – on methadone known to cause sleep apnea
  • Case 3 – known sleep apnea, morbidly obese (BMI 51), type II diabetes, only worsening of sleep apnea rather than cuasing sleep apnea while on opioids

2. Teichtahl H, Prodromidis A, Miller B, Cherry G, Kronborg I. Sleep-disordered breathing in stable methadone programme patients: a pilot study. Addiction (Abingdon, England). 2001;96:395–403

– Groan – a methadone study only

3. 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;3:455–461.

This study is TERRIBLE – chronic pain is aften associated with disordered breathing

This might not be surprising considering sleep disordered breathing is very common in people with fibromyaglia. canada goose sale damen canada goose sale damen

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4 Responses to Chronic Pain and Sleep Apnea

  1. Joe says:

    My company makes a combination sleep mask sound muffling pillow combination called the Dreamhelmet. I was recently diagnosed with sleep apnea. I thought I could never get used to sleeping hooked up to an air pump and a nose mask, but I have actually adapted to it quite readily.

    I had been using the Dreamhelmet for years previously, and I have found that wearing the Dreamhelmet over the the straps that hold the CPAP mask actually helps keep them in place in any sleeping position.

  2. admin says:

    If this Dreamhelmet works – that would be great. Site is :
    http://www.dreamhelmet.com/styles1.html

  3. Michael says:

    The last study I looked at compared people with chronic pain on opiates with “the general population” as the control.

    I think this is an absolute logical mistake! They need to compare people with chronic pain on opiates, with people with chronic pain not on opiates as the control!

    I havre had insominia and chronic pain since at least 1984. I never took prescription meds until the pain got worse, memory failed, etc. in 1998. Never took opiates until 2004 (2x 5mg vicodin day.) Finally started Fentanyl in around 2006.

    W/o opiates I sleep 2.5-6 hours per night, even with Lunesta, Lyrica, Savella, Naproxen, etc. With the Fentanyl patch, when I am balanced (I am almost always under medicated – docs are so afraid of these meds) I can sleep 10 hours, which is what I need for pain management.

    Twice in the past 3 years I have thought my pain was gone for about 3-5 days – when I was adequately medicated and plateaued (blood levels) on the patch. The pain comes roaring back though when I reduce the opiates. It averages about 8 per day, with a range of 7-9 by the end of the day. Nothing else really helps mmuch.

    Cheers!
    Michael

  4. Michael says:

    Link:

    American Academy of Pain Medicine (2007, September 11). Pain Patients At Risk For Sleep Apnea. ScienceDaily. Retrieved November 19, 2009, from http://www.sciencedaily.com­ /releases/2007/09/070906104140.htm

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