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Opioid Medications and Sleep Health - A Few Considerations 

 

By Admin

 

Opiate and synthetic opiate drugs are used regularly to treat pain, but have a number of potential side effects that some patients prefer to avoid. One of those side effects is the disruption of sleep patterns that are important for daily functioning and optimal health. According to the American Academy of Sleep Medicine (AASM), patients and medical providers need to be aware that opiate and synthetic opiate use can interfere with sleep by reducing sleep efficiency and increasing the risk of disorders like sleep apnea. Given that pain is also likely to disrupt sleep, it can be difficult for healthcare providers to balance treatment of pain with potential side effects of pain medications, and this is particularly relevant for patients already diagnosed with a sleep disorder. The AASM  position statement on opioids and sleep, published in 2019, emphasizes the need for more awareness of this issue, particularly for healthcare providers. According to the statement, “collaboration among primary care providers, pain medicine specialists, and sleep specialists“ is needed to achieve a more effective means of opiate maintenance and moderation among patients with sleep problems. Thus, in order to keep patient informed of these risks and in control of their decisions regarding opiate and synthetic opiate prescriptions, more rigorous screening and diagnostic testing is needed not only to determine the risks of sleep-related complications, but also to ensure that the best decisions are made for the treatment of pain alongside any sleep disorders already present. 

 

Defining the Terms: Opiates and Opioids

According to the Centers for Disease Control and Prevention (CDC) website, opiate drugs are defined as natural opioids, such as opium, morphine, and codeine. This means that opiate drugs are those that are found naturally within the opium poppy plant, normally processed from the opium gum found within the poppy itself. Opioids, on the other hand, is an umbrella term that includes opiates as well as synthetic or partially synthetic (semisynthetic) opiates. Some common synthetic opiates (opioids) include methadone and fentanyl, while popular medications such as oxycodone (Oxycontin), hydromorphone (Dilaudid), and buprenorphine (suboxone and subutex) are considered semisynthetic opioids. 

 

All opioids bind to the opiate receptors in the nervous system and brain. According to the National Institutes of Health, opioid receptors are part of the endogenous opioid system, which is the body's system for regulating pain and reward messages. The body produces substances similar to opioid drugs called endogenous opioids, which act as endorphins, and this is what opioid drugs mimic when they enter the body, fitting into the receptors already there for such effects. 

 

Side Effects

The National Institutes of Health list the following side effects for opioid drugs. 

 

Cognitive Effects

  • Inability to focus
  • Memory problems
  • Slow reflexes
  • Slow thinking

 

General Physical Effects

  • Itching and sweating
  • Drowsiness
  • Sleep problems
  • Respiratory depression (usually during sleep)

 

Gastrointestinal Effects

  • Nausea and vomiting 
  • Constipation

 

Effects of Prolonged Use

  • Increased sensitivity to pain
  • Reduced testosterone levels - which can result in lower energy or sex drive
  • Tolerance - i.e. the need for higher dosages for the same effect
  • Physical dependence - symptoms of withdrawal when the medication is stopped
  • Psychological addiction - often manifested in cravings or fear of not having the medication or drug

 

Withdrawal Symptoms

When used for an extended period of time, opioids can become extremely addictive, both physically and psychologically, causing strong cravings that some people find too intense to resist. This is why maintenance and moderation is important for long-term use. The following is a list of some common symptoms experienced after stopping opioid use, often experienced for a period of two to three weeks following withdrawal.

 

  • Muscle pain
  • Anxiety
  • Irritability
  • Nausea and vomiting
  • Diarrhea
  • Tremors or convulsions
  • Depression
  • General discomfort

 

Contraindications

Opioids can be dangerous if taken with alcohol or certain drugs such as antidepressants, anxiety medications such as benzodiazepines, and sleeping pills. There is also some evidence that antibiotics can increase the chance for physical or mental dependence.

 

The Opiate Epidemic and its Consequences

According to the Department of Health and Human Services, opioid use has boomed in the last decade, with nearly 92 million Americans using prescription opioids and 11.5 million people misusing them. In a 12-month period ending in June of 2020, over 48,000 deaths were attributed to opiate drugs other than methadone. And during the same time period, 10 million Americans misused prescription opiates. This problem has increased alongside the sleep apnea epidemic and there are some parallels, particularly for older patients dealing with chronic pain or taking medications prescribed for surgery or other medical procedures. Because opioids are so prevalent, their effects on sleep architecture have become a concern for those who take them and those who must prescribe them.

 

Opioids and Sleep

Generally, patients experiencing chronic or lasting pain will also have difficulty sleeping, but pain medications can sometimes reduce the pain and increase sleep problems. While the effects of opioid drugs on sleep can vary depending on the patient and the drug or medication being taken, some of the most common complaints involve increased sleep latency and time awake after sleep onset. In some cases, opioids can disrupt or even block access to rapid eye movement (REM) sleep and the more restorative stages of non-REM sleep. Since every patient reacts somewhat uniquely to specific medications, it can be difficult to tell which prescription for pain will have a significant effect on sleep or health in general. Dosages are also important, as well as the frequency of intake. All these considerations must be made by the prescribing physician, and often, a period of trial and error is conducted to determine the extent of the benefits or possible side effects of one drug over another.

 

Opioids and Sleep Apnea

Generally, patients experiencing chronic or lasting pain will also have difficulty sleeping. But studies have found that opioid use has the potential to further disrupt sleep by reducing sleep efficiency. And because these drugs also tend to cause respiratory depression, they are of particular concern for those diagnosed with sleep apnea or other forms of sleep-related breathing disorders. Central Sleep Apnea (CSA) is also common among patients taking opioid medications, and this includes those already diagnosed with obstructive sleep apnea, the more common sleep apnea condition. In one study published in the Journal of Clinical Sleep Medicine, 46 percent of patients treated for pain had some form of sleep disordered breathing, many of them with CSA, and the risk level was positively correlated with the amount or dosages prescribed. Unfortunately, in some cases these kinds of effects can impede CPAP therapy, causing it to be ineffective. 

 

Because of the complex relationship between pain, sleep, and respiration, this area of treatment can be difficult. While opiates and opioids can contribute to sleep problems, they can also be an effective treatment for severe or chronic pain. In addition, opiate or opioid medications are sometimes prescribed for restless legs syndrome (RLS), a common comorbid condition among patients with sleep apnea. Some patients with severe or chronic pain, or those with restless leg conditions, may find opiates much more effective than other therapies. 

 

Alternative Pain Treatments

For those who wish to use an alternative to opioid medications, the following list of options may be available to treat your specific condition:

 

Over-the-counter Medications - For those experiencing mild or recurrent pain, some over-the-counter medications can be effective without the side effects common to opioids. Some examples include Tylenol (acetaminophen), Motrin (ibuprofen), and Aleve (naproxen). Each is used regularly for pain, but results may vary. Consult your primary healthcare provider if you are not sure which medication may be the best for you.

 

Non-opioid Prescription Medications - Some prescription medications may also be used to manage pain. Neurontin (gabapentin) is sometimes prescribed to manage nerve pain. Corticosteroids are used to treat pain from inflammation, and some types of antidepressants can help with long-term or chronic pain. A new type of drug called AMPAkines has also shown some promise in both pain treatment and sleep apnea symptoms. And some studies have shown that cannabis and cannabinoids can relieve or mitigate pain without many of the side effects associated with opioids. 

 

Physical Therapy - Physical medicine and rehabilitation can help patients in both the reduction of pain and improved tolerance over time, often using exercise programs, water therapies like heat and whirlpools, and deep-muscle massage to apply pressure to an affected area. 

 

Relaxation and Posture - Along with physical therapy, techniques for relaxation and posture can do a lot for long-term and chronic pain, especially when paired with biofeedback methods of heart rate and breathing control. 

 

Acupuncture and Pressure Points - Acupuncture and pressure points can do a lot for pain and have a longstanding reputation for the effective treatment of both acute and chronic pain. Pressure applied to areas of nerve or muscle pain can also help to relax the area and treat the cause of the discomfort. 

 

Injections or Nerve Blocks - Injections with anesthetics or other medications is an option when pain is constant or difficult to endure. Physicians can inject types of numbing medication that blocks or reduces pain. This is usually an option when the source of the pain is very clear and accessible, such as a pinched nerve or spinal vertebrae.

 

Radio Waves and Electric Signals - Also called radiofrequency ablation, radio waves can be inserted with a needle and used to direct a current toward a problem area. In the same manner, low-voltage electric signals can be directed with rods or pads to stimulate nerves short circuit the pain signals. These methods can last for a few days to several months, depending on the type of pain involved. 

 

Spinal Cord Stimulation - For severe and chronic pain, sometimes a pacemaker-like device called a spinal cord stimulator (SCS) is inserted into the body to release signals that mask the pain with other sensations. Usually, the device is inserted into the lower back and attached with wires to the spine. 

 

Pain Pumps - Another type of implant, pain pumps allow patients to control the release of medications by pushing a button. Similar to an SCS, the pain pump is attached to the spine but releases medication rather than physical stimulation. These devices are usually used in cases of severe pain from cancer or other debilitating conditions. 

 

Surgery - Surgery is an option In situations where other treatments are not available or have proved ineffective. Usually, this option is reserved for those patients with serious conditions such as abnormalities in the body, chronic conditions, or pain due to late-stage cancer or cancer treatment. These types of surgeries will usually require considerable follow-up care and maintenance over a period of time. 

 

Other Considerations

Some of these treatments can have lasting effects, while others can provide temporary relief while a more stable, long-term plan is considered. Statements made by groups like the AASM have focused not only on the potential side effects of opioid drugs, but on complications associated with sleep and sleep disorders, and especially when used by patients with sleep disordered breathing, which can be a dangerous combination. As the AASM stresses repeatedly in its statement, it is of vital importance for both patients and providers to be aware that opiate and synthetic opiate use is associated with “changes in sleep architecture” as well as “an increased risk of respiratory depression during sleep.” By prioritizing these considerations, providers should be able make well-informed, long-term treatment plans that attend to pain as well as the sleep health and general health needs of their patients. 

 

 

Sources

AASM.org - Rising prevalence of sleep apnea in U.S. threatens public health - https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/

Anesthesia and Analgesia - https://pubmed.ncbi.nlm.nih.gov/25988636/

Anesthesiology - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784658/

Brainreference.com - https://www.brainreference.com/ampakines-review/Centers for Disease Control and Prevention - Guideline for Prescribing Opioids for Chronic Pain - https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Drugs - https://pubmed.ncbi.nlm.nih.gov/28616844/

Evidence Based Complementary and Alternative Medicine - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676441/

Journal of Clinical Sleep Medicine - AASM Position Statement on Opioids - https://jcsm.aasm.org/doi/10.5664/jcsm.8062

Journal of Clinical Sleep Medicine - Effects of Opioids on Sleep and Breathing - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106938/

Journal of Clinical Sleep Medicine - Sleep Disordered Breathing and Chronic Respiratory Failure in Patients with Chronic Pain on Long Term Opioid Therapy - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106937/

Medical Clinics of North America - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289280/

Molecularbrain.biomedicine.com - https://molecularbrain.biomedcentral.com/articles/10.1186/s13041-021-00757-y

National Center for Complementary and Integrative Health - https://www.nccih.nih.gov/health/cannabis-marijuana-and-cannabinoids-what-you-need-to-know

National Institutes of Health - https://www.nih.gov/news-events/nih-research-matters/how-opioid-drugs-activate-receptors

ScienceDaily - https://www.sciencedaily.com/releases/2020/04/200427140508.htm