Looking both ways before crossing the street: Assessing the benefits and risk of opioids in treating patients at risk of sleep disordered breathing for pain and dyspnea

Mellar P. Davis, MD, FCCP, FAAHPM; Bertrand Behm, MD; Diwakar Balachandran, MD

doi:10.5055/jom.2017.0385

Authors

Mellar P. Davis, MD, FCCP, FAAHPM
Bertrand Behm, MD
Diwakar Balachandran, MD

DOI:

https://doi.org/10.5055/jom.2017.0385

Keywords:

sleep, apnea, sleep disordered breathing, obstructive sleep apnea, central sleep apnea, opioid

Abstract

Opioids adversely influence respiration in five distinct ways. Opioids reduce the respiratory rate, tidal volume, amplitude, reflex responses to hypercapnia and hypoxia, and arousability related necessary for respiratory adaptive responses. Opioids cause impairment of upper pharyngeal dilator muscles leading to obstructive apnea. Opioids cause complex sleep disordered breathing (SDB) consisting of central sleep apnea and obstructive sleep apnea. Clinically opioids worsen preexisting SDB. Recent studies have shown increased morbidity and mortality in patients receiving opioids for chronic noncancer pain and chronic obstructive pulmonary disease, which appear to be related to cardiovascular events, not overdose. Both patient populations are at risk for sleep disordered breathing and increased risk for adverse cardiovascular events on opioids for dyspnea or pain. This review discusses the influence of opioids on respiration and SDB and will review the adverse respiratory and cardiovascular effects of opioid use in at risk populations. Recommendations regarding management will follow as a summary.

Author Biographies

Mellar P. Davis, MD, FCCP, FAAHPM

Director of Palliative Medicine, Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania

Bertrand Behm, MD

Faculty, Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania

Diwakar Balachandran, MD

Associate Professor, Director, Sleep Center, Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas

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