Chronic Opioid Use and Sleep
Oftentimes, an anesthesia provider’s role involves helping patients with long-term pain management.1 In fact, some anesthesia professionals specialize in managing chronic pain or do research to develop effective treatments for chronic pain.2 Patients with long-lasting pain may take various types of drugs, including opioids.3 Chronic opioid use is accompanied by several side effects, such as tolerance and dependence, and recent research has focused on opioids’ effects on sleep.4 Before prescribing opioids for long-term use, anesthesia providers should be familiar with the effects of chronic opioid use, the definition of sleep apnea and the relationship between opioid therapy and sleep difficulties.
Adverse effects of long-term opioid therapy include constipation, tolerance, endocrinopathies, sleep disorders, cognitive effects, respiratory depression, overdose and addiction.5 Data show a higher risk of overdose and death with increased daily opioid doses, particularly above the equivalent of 100 milligrams of oral morphine per day.5 While extended-release or long-acting formulations may be beneficial for patients using opioids for long periods of time, they may be associated with a higher risk for abuse due to their large dosages.5 Long-term opioid use can lead to hypogonadism, immunosuppression and increased risk of myocardial infarction.6 In addition, patients who use opioids frequently may develop tolerance and hyperalgesia (pain sensitivity), and may be at risk for complications during acute anesthesia.3 Though many patients may not develop opioid use disorder (OUD), the physical dependence from long-term opioid use can complicate attempts to wean off or discontinue opioid use.7 Evidently, chronic opioid use has many acute and long-lasting effects on a patient’s body.
Opioids cause breathing to slow and become irregular,8 and this effect continues throughout chronic use.9 Apnea, which is temporary cessation of breathing, can be a risk for patients who use opioids over long periods of time.9 Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts.10 It is marked by loud snoring and exhaustion even after a full night’s sleep.10 The three main types of sleep apnea are obstructive sleep apnea (OSA), the most common form that occurs when throat muscles relax; central sleep apnea (CSA), which occurs when the brain does not send proper signals to the muscles that control breathing; and complex sleep apnea syndrome, also known as treatment-emergent central sleep apnea, which occurs when someone has both OSA and CSA.10 The general population has a high prevalence of OSA, which often goes undiagnosed.9
The combination of opioid use and potential for sleep apnea can create dangerous sleep issues for opioid-maintained patients.8 According to Pattinson, there had been few studies on the effects of opioids on breathing during sleep in humans when he wrote his review in 2008.8 Since then, however, many researchers have investigated the effects of opioids on respiration and sleep quality. Van Ryswyk and Antic’s review found a clear link between opioid use and sleep-disordered breathing (SDB), which affects the majority of chronic opioid users in a dose-dependent fashion.11 Chowdhuri and Javaheri suggest that opioid-related SDB is related to binding to the pre-Bötzinger complex, hypoglossal nerve nucleus and chemoreceptor sites.12 Ventilatory instability is especially prominent in opioid users during non-rapid eye movement (non-REM) sleep.12 Chronic opioid users are also predisposed to CSA and, to a lesser extent, OSA.11 Indeed, a review by Correa et al. showed that overall prevalence of CSA in patients taking chronic opioids was 24 percent.13 Opioid-related SDB is associated with poor sleep quality14 and risks of respiratory depression and even death.15 For patients who already have OSA, chronic opioid use may confer greater mortality risk.16 Treatments for opioid-related SDB, CSA and OSA include cognitive behavioral therapy, medication, positive airway pressure (PAP), oral devices and adaptive servo-ventilation (ASV).11,14 However, more research is needed to evaluate long-term outcomes of PAP and ASV.11,12 Also, there are limited data available on perioperative management of patients with opioid-related sleep apnea.13
Anesthesia providers who care for patients with chronic pain must be familiar with long-term opioid use and its consequences. Opioids can cause issues ranging from constipation to tolerance and psychological addiction. Chronic opioid use is also related to breathing issues during sleep, such as SDB, CSA and OSA, all of which can increase risk for respiratory depression and mortality. Further research is needed to establish the long-term effects of mechanical ventilation as a solution for opioid-related sleep issues.
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2.American Society of Anesthesiologists. Types of Pain: Chronic Pain. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/pain-management/types-of-pain/chronic/.
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10.Mayo Clinic. Sleep apnea. Diseases & Conditions July 25, 2018; https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631.
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13.Correa D, Farney RJ, Chung F, Prasad A, Lam D, Wong J. Chronic Opioid Use and Central Sleep Apnea: A Review of the Prevalence, Mechanisms, and Perioperative Considerations. Anesthesia & Analgesia. 2015;120(6):1273–1285.
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16.Chowdhuri S, Wiitala W, Ratz D, Davis J. Sleep Apnea and Prescription Opioid Use in U.S. Veterans: Results from a National Database. B63. My Way: OSA Outpatient Models of Care: American Thoracic Society; 2016:A4182.