Dangerous Liaisons: Opioid Use and Central Sleep Apnea

When we think of sleep apnea, we usually think of obstructive sleep apnea (OSA), which involves a collapse of the tissues in the upper airway. This blocks our breathing passages until we awaken, gasping, to reclaim our breath.

Central sleep apnea (CSA) is equally problematic, but less common, and with a different cause.

What is central sleep apnea?

The signals to and from the brain’s central nervous system and the respiratory system are disrupted, delayed, or fail to be delivered because of a problem of neurology.

This means a person with CSA may simply lay quietly, not breathing, and not even trying to breathe, because there’s no direction to do so from the brain.

While CSA happens rarely (in about 1 percent of people over 40 in the United States), these numbers worsen in light of another tragic health problem: opioid use disorder (OUD).¹

What are opioids?

These are pain-relieving medications commonly taken by people with chronic conditions like cancer, or who experience acute pain following an operation or injury.

The most common forms of legal opioids are:²

• Morphine
• Oxycodone
• Hydrocodone
• Fentanyl
• Methadone

The most common forms of illegal opioids are:²

• Heroin
• Illegally made and distributed fentanyl

What to know about opioid use and addiction

People with severe pain for their chronic or acute conditions legitimately need pain relief.

However, opioids are highly addictive. Up to 19 percent of people taking prescription pain medications develop an addiction to them. A person using them may become dependent upon them in as little as a month, and chronic use leads to significant withdrawal symptoms.³

What’s even worse: People addicted to opioids, who are then denied prescriptions, will simply go to the street to purchase illegal supplies. The American Medical Association estimates that 45 percent of heroin users started out as prescription opioid users.³

OUD is described as “a problematic pattern of opioid use leading to problems or distress.” It’s now formally defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.⁴

Finally, the overprescription of opioids since the 1990s has led to quadruple the rate of drug overdose since 1999. Hence, the medical establishment now calls it “the opioid epidemic.”²

How do opioids factor into sleep breathing?

Using opioids can lead to something known as respiratory depression (another word for hypoventilation). In fact, this may be one of the most concerning side effects of opioid use after overdose.

Respiratory depression by any cause happens when the breathing rate becomes extremely slow and ineffective. The lungs fail to exchange carbon dioxide from the bloodstream from an exhale for fresh new oxygen you get when you inhale. Without adequate oxygen, the body’s tissues and cells cannot function.

During sleep, our breathing patterns are managed by the central nervous system. We count on our brain and lungs to talk to one another while we sleep because we are unable to consciously take breaths to correct our breathing patterns. Respiratory depression describes the rapid deterioration of that process we assume will work for us as we sleep.

Opioids and central sleep apnea

Chronic opioid use is now associated with the development of CSA. In other words, healthy people of all ages who take opioids regularly over long periods of time are likely to develop this serious sleep breathing disorder. Research shows that CSA occurs in about 24 percent of chronic opioid users.⁵

What’s worse, if these people then also use certain kinds of sleeping medications, it greatly worsens the severity of the CSA. What’s considered severe? A central apnea index of 5 or more events per hour.⁵

Finally, when the drive to breathe becomes compromised as we sleep, consequences include cardiac events and even death.

About narcotic-induced CSA

There are 2 categories of CSA: hypoventilation type (very slow breathing rate) and hyperventilation type (rapid breathing followed by periods without breathing).¹

Because opioids dampen the brain’s ability to initiate and regulate breathing, a chief result is narcotic-induced CSA, a form of CSA from the hypoventilation category.¹

One researcher looked at specific case studies of chronic opioid users with CSA. They found that subjects using opioids were often found deceased in their sleep. They suspect these subjects – some of them young, not at all similar to the usual older people who have CSA – may have died from a terminal apnea event related to narcotic-induced CSA.⁶

What can we do?

Many good people use opioids to treat legitimate pain. The challenges are many in preventing CSA as a result of opioid use. What can we do?

• Work with an observant, trained pain specialist in conjunction with your sleep specialist.
• Manage safe doses taken only at their prescribed frequency.
• Choose non-opioid pain medications.
• Consider alternative pain relief like massage, neurostimulation, or acupuncture.
• Seek detox if you find you’re misusing opioids.