Opioid use continues to be widespread in the United States and Europe, despite modifications to physician prescribing guidelines. As a result, approximately 92 million Americans are prescribed opioids, with more than 12% (11.5 million) misusing their pain medications. This presents an enormous public health challenge, as chronic opioid use increases risk of addiction as well as a range of physical and mental health problems. Recently, the American Academy of Sleep Medicine released a position statement to advise physicians on the relationship between opioids and sleep.
Opioids’ Effects on Sleep
Chronic pain, rather than acute pain, represents a large number of the total opioid prescriptions written in the United States. Chronic pain negatively affects sleep, mood, and cognitive abilities. Given that many patients with chronic pain take opioids to manage their conditions, it is challenging to disentangle the effects of pain and opioid medications on sleep. To help physicians understand these complexities, the American Academy of Sleep Medicine reviewed the scientific literature about opioids and sleep. They summarized their findings in a recent position paper published in the Journal of Clinical Sleep Medicine.
The position statement highlights the risks of long-term opioid therapy on sleep. Healthy, non-opioid using individuals cycle through five different stages of sleep, with each sleep cycle lasting approximately 90 minutes. Normally, a person begins in light “alpha wave” sleep before descending into deeper “delta wave” sleep and rapid eye movement (REM) sleep, during which dreams occur. Deep sleep is necessary to repair tissues, promote immune functioning, and store up energy.
For someone taking opioids, the order and amount of time spent in these sleep stages differs. People using opioids for an extended period of time no longer cycle through the five sleep stages normally. Instead, they spend more time in light sleep and less time in deep, delta wave sleep. As a result, they may report fragmented nighttime sleep, daytime sleepiness, and chronic fatigue. These things may exacerbate chronic pain, resulting in an increased need for opioid medications.
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Opioid Use and Risk for Sleep Disorders
In addition to disrupting sleep architecture, chronic opioid use also increases a person’s risk for a variety of sleep disorders. Opioids are a central nervous system depressant, meaning that they slow activity of the brain regions responsible for breathing and heart rate. Slowed breathing is a common side effect of opioid use. For people who use opioids for extended periods of time, the American Academy of Sleep Medicine warns of the following sleep problems:
- Snoring due to slowed breathing
- Sleep-related hypoventilation, a condition in which slowed breathing during sleep can lead to an increase in blood carbon dioxide levels
- Central sleep apnea, in which the brain fails to send signals to the muscles controlling breathing. As a result, a person stops breathing for brief periods of time throughout the night.
- Obstructive sleep apnea, in which the throat muscles relax during sleep. This blocks the airway and temporarily prevents normal breathing. A person typically experiences periods with no breathing followed by gasping or choking.
Opioid-related sleep disorders can cause serious problems for patients. Conditions like snoring or sleep apnea disrupt sleep quality. This further exacerbates feelings of daytime sleepiness or fatigue. This fatigue, in turn, exacerbates the experience of pain, causing a vicious cycle of turning to more opioids for pain relief.
These sleep disorders also affect the balance of oxygen to carbon dioxide in the body. Even brief periods of apnea (stopping breathing) during sleep can have profound effects on health. All of the organs in the body rely on oxygenated blood. If carbon dioxide builds up, it can damage tissue. The brain is particularly sensitive to loss of oxygen. As a result, opioid-related sleep disorders may have significant negative effects on brain health. Over time, this may result in cognitive impairment or higher risk for cerebrovascular disease.
Treatment and Opioid Prescribing Guidelines for Physicians
In 2018, the Centers for Disease Control and Prevention released updated guidelines to aid physicians in their decision-making about prescription opioids. The guidelines recommend non-pharmacologic treatment as a first-line approach for chronic pain, lower initial doses, and use of immediate rather than extended release medications.
The recent statement from the AASM concurs with the CDC guidelines, stating that “non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred treatment options for chronic pain.” However, the position statement also acknowledges that opioids may continue to be prescribed for chronic, non-cancer pain should the benefits outweigh potential harms. Any long-term medication treatment has its own adverse consequences. Patient care decisions should always be about the best quality of service and the most comprehensive treatment a physician can offer the patient, but it is critically important to consider long-term effects. In the case of opioids, those effects include a heightened risk for sleep disorders in addition to the well-known risk of dependence and addiction.
When it comes to opioid-related sleep disorders, the best approach is to follow the CDC guidelines and minimize opioid prescriptions whenever possible. Patients should be informed of the risks of opioid therapy, including the risk of serious sleep disorders. For those who do use opioid medications over the long term, physicians should be aware of the high risk for sleep problems. Polysomnography (a sleep study) is the gold standard way to diagnose sleep disorders. While treatments such as using a CPAP or BiPAP machine are effective for sleep apnea, the best approach is to help patients reduce their dependence on opioids. Fortunately, there are effective treatments for opioid dependence.
Result-Based Treatment for Opioid Dependence
Most people who use prescription opioid medications for an extended period of time will develop some degree of physiological tolerance. This occurs because opioid receptors throughout the body become accustomed to the presence of the drug. As a result, they modulate their activity, requiring more and more of the drug to achieve the same level of activation. Some patients may also develop opioid addiction, a behavioral condition in which people begin to crave, seek and use the drug, regardless of its adverse consequences.
In most cases, the first step in effectively treating opioid dependence is a complete detoxification. Detoxification allows any remaining opioid molecules to be removed from the body, returning it to an opioid-free state. This allows the body to begin restoring its homeostatic imbalances, including sleep quality. After a period of sustained sobriety, most people’s body can achieve its prior level of physiological functioning.
Opioid withdrawal can have ramifications for the entire body, making it essential for patients to receive comprehensive medical care. Given the complexities of opioid dependence, collaboration between all medical providers — primary care physicians, sleep doctors, addiction experts, pain doctors, psychotherapists, and others who manage a patient’s health — is often the best option. Few treatment programs in the country have the expertise, reputation, and track record of positive patient outcomes that the Waismann Method Treatment Program has. It’s all encompassed collaborative and comprehensive approach to patient-centered care is the main reason for this success.
For more than two decades, the Waismann Method® has offered comprehensive detoxification and treatment services for those suffering from opioid use disorder. Unlike other treatment programs, Waismann Method® operates within a full-service accredited hospital. Thus, patients undergoing acute withdrawal through our medically assisted detox protocols have a nearly 100% success rate of achieving complete detoxification.
When people suffering from opioid use disorder seek treatment at Waismann Method® and Domus Retreat, they’re met with the respect, acceptance, and compassion they need to start the healing process. Moreover, Waismann and Domus provide individuals with personalized, compassionate and clinically excellent care they deserve. The unwavering commitment to superior care and results has helped thousands of people recover while finding new physical and emotional health.