The Association of Obstructive Sleep Apnea and Chronic Pain

Christopher J. Lettieri, MD


May 24, 2013

In This Article

Treatment of Opioid-Induced Sleep-Disordered Breathing

The treatment of opioid-induced sleep disordered breathing is similar to that for other etiologies of OSA and CSA, with positive airway pressure (PAP) being the most efficacious therapeutic option. Improvement, or even resolution, of sleep-disordered breathing after cessation of medication has been frequently reported. Both oral appliances and uvulopalatopharyngoplasty (UPPP) have also been shown to be beneficial in these individuals. However, unlike in other patients with sleep apnea, apneas may be more refractory to PAP therapy among those with opioid-induced OSA.

The common coexistence of central events may require further management. Although CSA may resolve or diminish with continuous PAP (CPAP), persistent events often require bilevel PAP (BiPAP) or adaptive servoventilation (ASV).

Guilleminault and colleagues[13] found that despite adequate titration with CPAP or BiPAP, nocturnal awakenings and central apneas persisted in the majority of patients.They observed a residual apnea/hypopnea index of 13.8 ± 2.8 among their cohort. The predominance of residual events were central in nature. The authors concluded that BIPAP with a back-up rate was most effective for resolving these events. In a similar study, Farney and colleagues[15] determined that both BiPAP with back-up rate and ASV were superior to CPAP in the treatment of sleep disordered breathing associated with long-term opioid therapy.[15]

Similar to other forms of CSA, both BiPAP and ASV are more effective in ablating respiratory events and normalizing objective sleep measures than CPAP. However, no studies have compared long-term outcomes among these different treatment options.


Chronic pain and disrupted sleep are commonly associated, and they share a clear cause-and-effect relationship. Pain fragments sleep, and poor sleep worsens the pain response. The prevalence of sleep disorders and the number of patients experiencing chronic pain continue to increase. Finally, pain and sleep disorders are among the most common reason for medical care. It is important to understand these conditions and appreciate the intimate relationship they share.

It seems clear that long-term narcotic use causes, precipitates, or exacerbates sleep-disordered breathing; as the use of these agents continues to grow, so will the number of individuals with opioid-induced apnea. Prompt recognition and appropriate treatment will probably improve outcomes and quality of life. It may also reduce overall healthcare utilization and aid in controlling pain.


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