Sleep-Disordered Breathing and Chronic Opioid Therapy
Lifetree Clinical Research and Pain Clinic, Salt Lake City, Utah, USA. Pain Medicine
(Impact Factor: 2.3).
07/2007; 9(4):425-32. DOI: 10.1111/j.1526-4637.2007.00343.x
To assess the relation between medications prescribed for chronic pain and sleep apnea.
An observational study of chronic pain patients on opioid therapy who received overnight polysomnographies. Generalized linear models determined whether a dose relation exists between methadone, nonmethadone opioids, and benzodiazepines and the indices measuring sleep apnea.
A private clinic specializing in the treatment of chronic pain.
Polysomnography was sought for all consecutive (392) patients on around-the-clock opioid therapy for at least 6 months with a stable dose for at least 4 weeks. Of these, 147 polysomnographies were completed (189 patients declined, 56 were directed to other sleep laboratories by insurance companies, and data were incomplete for seven patients). Available data were analyzed on 140 patients.
The apnea-hypopnea index to assess overall severity of sleep apnea and the central apnea index to assess central sleep apnea.
The apnea-hypopnea index was abnormal (> or =5 per hour) in 75% of patients (39% had obstructive sleep apnea, 4% had sleep apnea of indeterminate type, 24% had central sleep apnea, and 8% had both central and obstructive sleep apnea); 25% had no sleep apnea. We found a direct relation between the apnea-hypopnea index and the daily dosage of methadone (P = 0.002) but not to other around-the-clock opioids. We found a direct relation between the central apnea index and the daily dosage of methadone (P = 0.008) and also with benzodiazepines (P = 0.004).
Sleep-disordered breathing was common in chronic pain patients on opioids. The dose-response relation of sleep apnea to methadone and benzodiazepines calls for increased vigilance.
Available from: Wan-Yu Lo
- "Sleep-disordered breathing, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), is another potential factor leading to disrupted sleep in MMT patients. Some studies showed that CSA has been reported to occur in 30–60% of MMT patients   and associated with methadone dose and concomitant benzodiazepine use . "
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ABSTRACT: Methadone maintenance therapy is an effective treatment for opiate dependence, but more than three-quarters of persons receiving the treatment report sleep quality disturbances. In this double-blind, randomized, controlled trial, we recruited 90 individuals receiving methadone for at least one month who reported sleep disturbances and had Pittsburgh Sleep Quality Index (PSQI) scores > 5. The purpose of this study was to determine whether Suan Zao Ren Tang, one of the most commonly prescribed traditional Chinese medications for treatment of insomnia, improves subjective sleep among methadone-maintained persons with disturbed sleep quality. Ninety patients were randomly assigned to intervention group (n = 45) and placebo group (n = 45), and all participants were analyzed. Compared with placebo treatment, Suan Zao Ren Tang treatment for four weeks produced a statistically significant improvement in the mean total PSQI scores (P = 0.007) and average sleep efficiency (P = 0.017). All adverse events (e.g., lethargy, diarrhea, and dizziness) were mild in severity. Suan Zao Ren Tang is effective for improving sleep quality and sleep efficiency among methadone-maintained patients with sleep complaints.
Available from: PubMed Central
- "The literature on the effect of opioids on sleep yields contradictory results, with one study demonstrating improvement in sleep quality and efficiency70 and several other studies reporting that opioids can cause inhibition of rapid eye movement and nonrapid eye movement phases of sleep.71,72 Patients receiving chronic opioid therapy also have a high prevalence of sleep apnea73,74 and hypoxemia.75 If sleep apnea is suspected, it is important to refer the patient to a sleep specialist for testing, especially if considering opioid therapy. "
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ABSTRACT: Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.
Available from: Esmaeil Akbari
- "Thus, pain management in patients with a long history of opiate use is considered to be a medical complication because the strategy of using a higher dose of opiates in such individuals is not only ineffective in alleviating their pain but could also increase their tolerance, hyperalgesia, and dependence (7, 9-11). Opioid-related side effects such as respiratory depression are also more likely to occur in these patients (12). Therefore, the use of non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) (13) and antidepressants, which have multiple analgesic mechanisms, is a logical treatment for such cases. "
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ABSTRACT: This study investigates the effectiveness of the antinociceptive effects of diclofenac, an NSAID, on the nociceptive behavior of morphine-treated rats on formalin test.
Rats were treated with morphine-containing drinking water for twenty one days, which induced morphine dependence. The antinociceptive effects of 8, 16, and 32 mg/kg doses of diclofenac were then evaluated and compared with distilled water in a formalin-based model of pain.
Diclofenac potentiated pain suppression in morphine-dependent rats during the interphase of the formalin test and reduced the pain score during phase II. The post-test analysis revealed that both 16 mg/kg (p < 0.0001) and 32 mg/kg (p < 0.0001) doses of diclofenac had a significant effect on the interphase, while 8 mg/kg (p < 0.05), 16 mg/kg (p < 0.05), and 32 mg/kg (p < 0.01) doses of diclofenac significantly affected phase II. In contrast, the antinociceptive effects of diclofenac on morphine-naïve rats were observed during phase II only with the a 32 mg/kg dose (p < 0.05).
In general, these results suggest that the long-term use of morphine in rats increases their sensitivity to the antinociceptive effects of diclofenac. Furthermore, the results support the existence of a non-opioid-dependent mechanism of pain suppression during the interphase of formalin test.
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