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Chronic opioid therapy can alter sleep architecture and increase the risk for sleep-disordered breathing, and this is a critical point primary care physicians and other providers need to know, according to a new (AASM) position statement.

Screening and testing can help identify patients using chronic opioids who are at risk for sleep problems, and treatment can improve their health and well-being, said Ilene Rosen, MD, MS, of the University of Pennsylvania, and co-authors.

"Although the best therapeutic option for opioid-associated sleep-disordered breathing may be withdrawal of opioids, providers are often faced with the challenge of effectively managing the underlying disorder while also ensuring patient safety, which requires collaborative care," they wrote in . Treatments like positive airway pressure therapy can offer effective solutions for chronic pain patients on opioids, they added.

Pain and sleep often co-exist in "a vicious cycle," noted co-author Nisha Aurora, MD, MHS, of the Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

"Poor sleep highlights pain. It makes pain worse and makes you more sensitized to pain, and you might take more opioids to alleviate that pain," she explained. "But the opioids can cause more sleep problems and, therefore, your sleep is worse. And, therefore, the pain is worse. And you take more opioids, and it just keeps going," she told MedPage Today.

"There's a large population on opioids chronically and there are a lot of issues with sleep going unnoticed," Aurora pointed out. "If we can make sleep better, if people can make better executive decisions, deal better with insomnia, and take care of their sleep-disordered breathing, their pain might get better. Their ability to wean down their medications might be better."

Regular, chronic opioid use can reduce sleep efficiency and disrupt sleep stage distribution. Its effects appear to be dose-dependent and lead to poor sleep quality and daytime sleepiness. Chronic opioid use also has been linked to sleep-disordered breathing, including snoring or more severe respiratory problems like sleep-related hypoventilation, central sleep apnea, and obstructive sleep apnea.

It's essential to identify which patients on chronic opioids are at risk for sleep problems, noted Gilles Lavigne, DMD, PhD, of the University of Montreal, Canada, who was not involved with the AASM position paper. "We need to know who is at risk for breathing depression, who is at risk for ongoing sleep apnea," he told MedPage Today. "It's not one-size-fits-all; some patients have more risk, and this is an area that needs more research."

This is especially important because some physicians have interpreted the on chronic opioids to mean they should stop prescribing or abruptly taper opioids for chronic pain patients, despite the agency's guideline clarification in 2019, Lavigne observed. "Now, some people are saying we went too far, we did some harm."

There also are cases where opioids and sleep work together well, such as patients with severe, refractory restless leg syndrome, but these are "typically lower doses" of opioids, Aurora noted.

At the in September, Jean Wong, MD, of the University of Toronto, and co-authors looked at about 200 Canadian chronic pain patients taking opioids and found that almost 60% had sleep-disordered breathing. "This is higher than the general population," said Wong, who was not involved with the AASM position paper. About "20% of these patients had central sleep apnea -- much higher than the prevalence in the general population, which is less than 1%," she told MedPage Today.

"We found for sleep-disordered breathing: the and daytime oxygen saturation," Wong added. "We also found that the and daytime oxygen saturation were predictive of central sleep apnea."

Addressing sleep problems with opioid patients in primary care is a "good place to start," Aurora noted.

"The first thing primary care physicians can do is to ask questions about sleep in general, both night and daytime symptoms," Aurora said. "It can be as simple as: How is your sleep? Do you suffer from insomnia? Does anybody tell you that you snore? Do they tell you that you're holding your breath during sleep? Do you feel refreshed when you get up in the morning? Are you sleepy during the day?"

Asking questions like these "can point you in the direction if a patient on chronic opioid therapy needs further evaluation or may need to be referred to a sleep physician," she added. "There needs to be a team approach when dealing with chronic opioid therapy."

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