Sleep-Disordered Breathing and Chronic Opioid Therapy

Webster, Lynn R.; Choi, You Yeon; Desai, Himanshu; Webster, Linda; Grant, Brydon J. B.

doi:10.1111/j.1526-4637.2007.00343.x

Cited by 278 publications

(212 citation statements)

References 13 publications

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“…Although the lethal dosage of benzodiazepine agonists is usually as much as hundreds of hypnotic doses, it drops by an extraordinary degree after moderate ingestions of alcohol [54,55]. Combinations of narcotics and hypnotics, especially with the addition of alcohol and other sedatives, may slow breathing [56]. There are no established safe dose ranges for combinations of hypnotics, sedatives, and narcotics.…”

Section: The Causality Of Hypnotics Effects On Mortalitymentioning

confidence: 99%

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Kripke

2015

Drug Saf

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Sleeping pills, more formally defined as hypnotics, are sedatives used to induce and maintain sleep. In a review of publications for the past 30 years, descriptive epidemiologic studies were identified that examined the mortality risk of hypnotics and related sedative-anxiolytics. Of the 34 studies estimating risk ratios, odds ratios, or hazard ratios, excess mortality associated with hypnotics was significant (p \ 0.05) in 24 studies including all 14 of the largest, contrasted with no studies at all suggesting that hypnotics ever prolong life. The studies had many limitations: possibly tending to overestimate risk, such as possible confounding by indication with other risk factors; confusing hypnotics with drugs having other indications; possible genetic confounders; and too much heterogeneity of studies for meta-analyses. There were balancing limitations possibly tending towards underestimates of risk such as limited power, excessive follow-up intervals with possible follow-up mixing of participants taking hypnotics with controls, missing dosage data for most studies, and over-adjustment of confounders. Epidemiologic association in itself is not adequate proof of causality, but there is proof that hypnotics cause death in overdoses; there is thorough understanding of how hypnotics euthanize animals and execute humans; and there is proof that hypnotics cause potentially lethal morbidities such as depression, infection, poor driving, suppressed respiration, and possibly cancer. Combining these proofs with consistent evidence of association, the great weight of evidence is that hypnotics cause huge risks of decreasing a patient's duration of survival. Key PointsMost sleeping pills e.g., benzodiazepines and ''Z'' benzodiazepine agonists (like eszopiclone) are associated with early death, and they most probably cause serious increases in mortality.Benzodiazepine agonist sleeping pills and diphenhydramine should not be prescribed for insomnia, except in long-term controlled trials and hospice care.

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Section: The Causality Of Hypnotics Effects On Mortalitymentioning

confidence: 99%

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Kripke

2015

Drug Saf

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“…Longterm opioid therapy predisposes patients to development of an irregular breathing pattern with central apneas during sleep in a dose-dependent manner and is contraindicated in patients with preexisting central sleep apnea. 22,23 After a treatment trial, the achieved beneficial effects are weighed against ADRs. The most important adverse events and clinical considerations of first-line drugs and opioids are summarized in Table 2.…”

Section: Pharmacotherapy For Npmentioning

confidence: 99%

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Haanpää¹,

Gourlay

Kent

et al. 2010

Mayo Clinic Proceedings

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The efficacy of drugs for neuropathic pain has been established in randomized controlled trials that have excluded patients with comorbid conditions and those taking complex medications. However, patients with neuropathic pain frequently present with complex histories, making direct application of this evidence problematic. Treatment of neuropathic pain needs to be individualized according to the cause of the pain, concomitant diseases, medications, and other individual factors. Tricyclic antidepressants (TCAs), gabapentinoids, selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line choices; if needed, combination therapy may be used. When a new drug is added, screening for potential drug interactions is recommended. The TCAs have anticholinergic adverse effects and may cause orthostatic hypotension. They should be avoided or used cautiously in patients with cardiac conduction disturbances or arrhythmias. Patients who lack cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine and have a weaker analgesic response to tramadol. A combination of several serotoninergic drugs may lead to serotonin syndrome. Risk of gastrointestinal tract bleeding is increased in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially when combined with nonsteroidal anti-inflammatory drugs. Dose adjustment may be needed in patients with renal or hepatic impairment. Depending on the drug, the dose is reduced or the dosage interval lengthened. Slow titration and careful follow-up are needed. No drug is absolutely safe during pregnancy and lactation. Particular care must be exercised during the first trimester when drug dose should be as low as possible. Individual weighing of benefits and risks should guide therapeutic decisions.Mayo Clin Proc. 2010;85(3)(suppl):S15-S25 ADR = adverse drug reaction; BP = blood pressure; CKD = chronic kidney disease; CYP = cytochrome P450; ECG = electrocardiogram; EM = extensive metabolizer; GFR = glomerular filtration rate; MI = myocardial infarction; NP = neuropathic pain; NSAID = nonsteroidal anti-inflammatory drug; OR = odds ratio; PM = poor metabolizer; RCT = randomized controlled trial; SNRI = selective noradrenergic reuptake inhibitor; TCA = tricyclic antidepressant; UM = ultrarapid metabolizer From Rehabilitation ORTON,

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“…CBT includes specific skill acquisition (relaxation therapy, stress management, cognitive restructuring) followed by skill consolidation and rehearsal, and relapse training. 36 It is important for the practitioner to identify qualified CBT therapists in the community to whom they may refer these complex patients.…”

Section: Complementary and Alternative Medicine (Cam)mentioning

confidence: 99%

“…35 If sleep apnea is suspected, referral to a sleep center for testing is important, especially if a patient is prescribed opiates related to risk of respiratory depression. 36,37 Assessment of function. Continuing opioid therapy should be determined, in part, by improvement in function after opioids have been prescribed or dosage increased.…”

mentioning

confidence: 99%

Treating Pain in Addicted Patients: Recommendations from an Expert Panel

Cheatle

Comer

Wunsch³

et al. 2014

Population Health Management

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Clinicians may face pragmatic, ethical, and legal issues when treating addicted patients. Equal pressures exist for clinicians to always address the health care needs of these patients in addition to their addiction. Although controversial, mainly because of the lack of evidence regarding their long-term efficacy, the use of opioids for the treatment of chronic pain management is widespread. Their use for pain management in the addicted population can present even more challenges, especially when evaluating the likelihood of drug-seeking behavior. As the misuse and abuse of opioids continues to burgeon, clinicians must be particularly vigilant when prescribing chronic opioid therapy. The purpose of this article is to summarize recommendations from a recent meeting of experts convened to recommend how primary care physicians should approach treatment of chronic pain for addicted patients when an addiction specialist is not available for a referral. As there is a significant gap in guidelines and recommendations in this specific area of care, this article serves to create a foundation for expanding chronic pain guidelines in the area of treating the addicted population. This summary is designed to be a practical how-to guide for primary care physicians, discussing risk assessment, patient stratification, and recommended therapeutic approaches. (Population Health Management 2014;17:79-89)

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Sleep-Disordered Breathing and Chronic Opioid Therapy

Abstract: 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.

Cited by 278 publications

References 13 publications

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Treating Pain in Addicted Patients: Recommendations from an Expert Panel

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