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Abstract
Sleep health is an important factor across several physical and mental health disorders, and a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during OUD recovery. The goal of this narrative review is to collate the literature on sleep, opioid use, and OUD as a means of identifying therapeutic targets to improve OUD treatment outcomes. Sleep disturbance is common and often severe in persons with OUD, especially during opioid withdrawal, but also in persons on opioid maintenance therapies. There is ample evidence that sleep disturbances including reduced total sleep time, disrupted sleep continuity, and poor sleep quality often accompany negative OUD treatment outcomes. Sleep disturbances are bidirectionally associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving. This constellation of outcome variables represents a more comprehensive appraisal of the quality of life and quality of recovery than is typically assessed in OUD clinical trials. To date, there are very few clinical trials or experimental studies aimed at improving sleep health in OUD patients, either as a means of improving stress, affect, and craving outcomes, or as a potential mechanistic target to reduce opioid withdrawal and drug use behaviors. As such, the direct impact of sleep improvement in OUD patients is largely unknown, yet mechanistic and clinical research suggests that therapeutic interventions that target sleep are a promising avenue to improve OUD treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Eckert DJ, Yaggi HK. Opioid Use Disorder, Sleep Deficiency, and Ventilatory Control: Bidirectional Mechanisms and Therapeutic Targets. Am J Respir Crit Care Med 2022; 206:937-949. [PMID: 35649170 PMCID: PMC9801989 DOI: 10.1164/rccm.202108-2014ci] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 05/31/2022] [Indexed: 01/07/2023] Open
Abstract
Opioid use continues to rise globally. So too do the associated adverse consequences. Opioid use disorder (OUD) is a chronic and relapsing brain disease characterized by loss of control over opioid use and impairments in cognitive function, mood, pain perception, and autonomic activity. Sleep deficiency, a term that encompasses insufficient or disrupted sleep due to multiple potential causes, including sleep disorders, circadian disruption, and poor sleep quality or structure due to other medical conditions and pain, is present in 75% of patients with OUD. Sleep deficiency accompanies OUD across the spectrum of this addiction. The focus of this concise clinical review is to highlight the bidirectional mechanisms between OUD and sleep deficiency and the potential to target sleep deficiency with therapeutic interventions to promote long-term, healthy recovery among patients in OUD treatment. In addition, current knowledge on the effects of opioids on sleep quality, sleep architecture, sleep-disordered breathing, sleep apnea endotypes, ventilatory control, and implications for therapy and clinical practice are highlighted. Finally, an actionable research agenda is provided to evaluate the basic mechanisms of the relationship between sleep deficiency and OUD and the potential for behavioral, pharmacologic, and positive airway pressure treatments targeting sleep deficiency to improve OUD treatment outcomes.
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Affiliation(s)
- Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - H. Klar Yaggi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
- Clinical Epidemiology Research Center, Veterans Administration Connecticut Healthcare System, West Haven, Connecticut
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3
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Winkelman JW. Treating Severe Refractory and Augmented Restless Legs Syndrome. Chest 2022; 162:693-700. [DOI: 10.1016/j.chest.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 10/18/2022] Open
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Langstengel J, Yaggi HK. Sleep Deficiency and Opioid Use Disorder: Trajectory, Mechanisms, and Interventions. Clin Chest Med 2022; 43:e1-e14. [PMID: 35659031 PMCID: PMC10018646 DOI: 10.1016/j.ccm.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Opioid use disorder (OUD) is a chronic and relapsing brain disease characterized by loss of control over opioid use and impairments in cognitive function, mood, pain perception, and autonomic activity. Sleep deficiency, a term that encompasses insufficient or disrupted sleep due to multiple potential causes, including sleep disorders (eg, insomnia, sleep apnea), circadian disruption (eg, delayed sleep phase and social jet lag), and poor sleep quality (eg, sleep fragmentation, impaired sleep architecture), is present in greater than 75% of patients with OUD. This article focuses on highlighting bidirectional mechanisms between OUD and sleep deficiency and points toward promising therapeutic targets.
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Affiliation(s)
- Jennifer Langstengel
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA
| | - H Klar Yaggi
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, USA.
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5
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Huerta J, Taleu H, Norton R, Gries H, Yun P, Lam D. Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children. J Clin Sleep Med 2022; 18:695-701. [PMID: 34823651 PMCID: PMC8883104 DOI: 10.5664/jcsm.9582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The Snoring, Trouble Breathing, Un-Refreshed (STBUR) screening questionnaire has been validated in identifying pediatric surgical patients with symptoms of sleep-disordered breathing who may be at risk of perioperative respiratory adverse events. We sought to assess the performance of the STBUR questionnaire when adjusting for potential confounders such as patient comorbidities or surgical service. METHODS This was a retrospective cohort study of children aged 2-18 years undergoing elective procedures under general anesthesia over a 3-month period. Procedure specialties included general surgery, urology, orthopedic surgery, neurosurgery, plastic surgery, otolaryngology, dentistry, and gastroenterology. Preoperative STBUR questionnaire responses and perioperative respiratory adverse events were documented prospectively. Multivariate logistic regression was used to quantify associations between preoperative questionnaire responses, other potential risk factors (including age, sex, surgical specialty, comorbidities), and risk of perioperative respiratory adverse events. RESULTS Of 555 children, 17% had a positive STBUR screen. The prevalence of perioperative respiratory adverse events with a positive questionnaire screen was significantly greater than with a negative screen (29% vs 9%, respectively; P < .001). A positive questionnaire screen was associated with a significantly increased risk of a perioperative respiratory adverse event (adjusted odds ratio 3.47 [95% confidence interval 1.53-7.84], P = .003). CONCLUSIONS A positive screen on the STBUR questionnaire was associated with a 3.5-fold increased risk of perioperative respiratory adverse events in pediatric surgical patients. The STBUR questionnaire should be considered as a routine preoperative screening tool in children undergoing elective procedures. CITATION Huerta J, Taleu H, Norton R, Gries H, Yun P, Lam D. Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children. J Clin Sleep Med. 2022;18(3):695-701.
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Affiliation(s)
- Javier Huerta
- Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Hannah Taleu
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Rene Norton
- Nursing Professional Practice, Oregon Health and Science University, Portland, Oregon
| | - Heike Gries
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Philip Yun
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Derek Lam
- Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
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Wasey W, Saleh S, Manahil N, Mohammed A, Wasey N. Anterior Cervical Discectomy and Fusion: A Hidden Etiology of Obstructive Sleep Apnea. Cureus 2022; 14:e22185. [PMID: 35308725 PMCID: PMC8925988 DOI: 10.7759/cureus.22185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/23/2022] Open
Abstract
Obstructive Sleep Apnea (OSA), a common variant of sleep-disordered breathing, is characterized by repeated complete or partial collapse of upper airways during sleep, leading to oxyhemoglobin desaturations. The obstruction may be iatrogenically induced in patients undergoing Anterior Cervical Discectomy and Fusion (ACDF). Damage to the pharyngeal plexus during the procedure may predispose to a new collapse of the upper airway, and the placement of the hardware for the fusion may lead to further narrowing of the upper airway. Literature does not exist associating this possible etiology prospectively. The association of ACDF and OSA has only been retrospectively documented by Guiilleminault and associates. We are reporting a case of a 49-year-old female who was evaluated pre and post surgery and established the evidence of worsening OSA in a patient who underwent ACDF.
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Yawning and airway physiology: a scoping review and novel hypothesis. Sleep Breath 2022; 26:1561-1572. [DOI: 10.1007/s11325-022-02565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/14/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
Abstract
Background and purpose
Yawning is a stereotypical complex muscular movement and is commonly executed by most vertebrates. In seconds, the entire airway is fully dilated and surrounding muscles are powerfully stretched, most prominently around the pharynx. To date, yawning has been rarely studied, and as of yet there is no consensus on its main function.
Material and methods
To investigate a mechanical airway function for yawning, a literature search was conducted to relate the frequency of yawning and obstructive airway conditions.
Results
The results show that changes in obstructive airway conditions and alteration of the frequency of yawning are temporally related.
Interpretation
These relationships, however, cannot be interpreted as causal, nor can they be extrapolated to explain the function of yawning. Yet airway management and yawning share many physiological characteristics. We therefore propose a novel hypotheses: yawning plays a significant role in airway physiology by muscle repositioning and widening the airway lumen, thereby securing long-term oxygenation.
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Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med 2022; 18:647-652. [PMID: 34672945 PMCID: PMC8805010 DOI: 10.5664/jcsm.9730] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 02/03/2023]
Abstract
Opioids are widely prescribed for pain management, and it is estimated that 40% of adults in the United States use prescription opioids every year. Opioid misuse leads to high mortality, with respiratory depression as the main cause of death. Animal and human studies indicate that opioid use may lead to sleep-disordered breathing. Opioids affect control of breathing and impair upper airway function, causing central apneas, upper airway obstruction, and hypoxemia during sleep. The presence of obstructive sleep apnea (OSA) increases the risk of opioid-induced respiratory depression. However, even if the relationship between opioids and central sleep apnea is firmly established, the question of whether opioids can aggravate OSA remains unanswered. While several reports have shown a high prevalence of OSA and nocturnal hypoxemia in patients receiving a high dose of opioids, other studies did not find a correlation between opioid use and obstructive events. These differences can be attributed to considerable interindividual variability, divergent effects of opioids on different phenotypic traits of OSA, and wide-ranging methodology. This review will discuss mechanistic insights into the effects of opioids on the upper airway and hypoglossal motor activity and the association of opioid use and obstructive sleep apnea. CITATION Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.
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Affiliation(s)
- Carla Freire
- Johns Hopkins Sleep Disorders Center, Baltimore, Maryland
- Otolaryngology Department, University of São Paulo, Sao Paulo, Brazil
| | - Luiz U. Sennes
- Otolaryngology Department, University of São Paulo, Sao Paulo, Brazil
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Ahmed A, Anand AN, Shah I, Yakah W, Freedman SD, Thomas R, Sheth SG. Prospective evaluation of sleep disturbances in chronic pancreatitis and its impact on quality of life: a pilot study. Sleep Breath 2022; 26:1683-1691. [PMID: 34981297 DOI: 10.1007/s11325-021-02541-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/13/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022]
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Zha S, Yang H, Yue F, Zhang Q, Hu K. The influence of acute morphine use on obstructive sleep apnea: A systematic review and meta-analysis. J Sleep Res 2021; 31:e13523. [PMID: 34806800 DOI: 10.1111/jsr.13523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/23/2021] [Accepted: 11/08/2021] [Indexed: 12/01/2022]
Abstract
The present study was conducted to systematically evaluate the acute effect of morphine on obstructive sleep apnea (OSA). The PubMed, Embase, Cochrane Library, Clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), and Wan-Fang databases were searched for randomised controlled trials studying the influence of morphine on OSA published up to May 24, 2021. The Cochrane risk of bias tool was used to assess study quality and meta-analysis was performed on the included clinical trial results to quantify the impact of morphine on various sleep and respiratory parameters. Three studies (n = 132 patients) were ultimately examined. There were no significant differences between patients with OSA taking morphine and placebo/non-opioids with respect to the sleep Apnea-Hypopnea Index (mean difference [MD] 1.78, 95% confidence interval [CI] -2.41, 5.98; p > 0.05); Oxygen Desaturation Index (MD 1.49, 95% CI -3.21, 6.19; p > 0.05); Obstructive Sleep Apnea Index (MD 0.83, 95% CI -2.08, 3.75; p > 0.05); Hypopnea Index (MD -0.01, 95% CI -2.64, 2.63; p > 0.05); lowest oxygen saturation (MD 0.68, 95% CI -4.50, 5.86; p > 0.05); or sleep oxygen saturation >90% (MD 0.10, 95% CI -1.14, 1.34; p > 0.05). In conclusion, a single dose of 30 or 40 mg morphine does not have a significant effect on sleep or respiratory outcomes compared to placebo in patients with OSA, challenging the orthodoxy that opioids worsen OSA.
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Affiliation(s)
- Shiqian Zha
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Haizhen Yang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fang Yue
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qingfeng Zhang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ke Hu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
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Saito K, Takamatsu Y. Periodic breathing in patients with stable obstructive sleep apnea on long-term continuous positive airway pressure treatment: a retrospective study using CPAP remote monitoring data. Sleep Breath 2021; 26:1181-1191. [PMID: 34651259 PMCID: PMC9418282 DOI: 10.1007/s11325-021-02510-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/21/2021] [Accepted: 10/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate the rate of periodic breathing (PB) and factors associated with the emergence or persistence of PB in patients with obstructive sleep apnea (OSA) by continuous positive airway pressure (CPAP) remote monitoring data. METHODS This was a retrospective cohort study on 775 patients who had used the same model CPAP machine for at least 1 year as of September 1, 2020. The data were analyzed online using the dedicated analysis system. Using exporter software, average apnea/hypopnea index (AHI), average central apnea index (CAI), and average the rate of PB time (PB%) were cited. RESULTS Among 618 patients analyzed (age 61.7 ± 12.2 years, male 89%, BMI 27.2 ± 4.9), the average duration of CPAP use was 7.5 ± 4.0 years. The median PB% in stable patients was low at 0.32%, and only 149 patients (24%) had a PB% above 1%. Multiple regression analysis of factors for the development of PB showed that the most important factor was atrial fibrillation (Af) with a coefficient of 0.693 (95% CI; 0.536 to 0.851), followed by QRS duration with a coefficient of 0.445 (95% CI; 0.304 to 0.586), followed by history of heart failure, male sex, comorbid hypertension, obesity, and age. The average PB% for paroxysmal Af was significantly lower than that for persistent and permanent Af. CONCLUSIONS The median PB% in stable patients on CPAP treatment was low at 0.32%, with only 24% of patients having PB% ≥ 1%. Persistent Af and an increase in QRS duration were found to be important predictors of increased PB%. CLINICAL TRIAL REGISTRATION UMIN000042555 2021/01/01.
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Affiliation(s)
- Kimimasa Saito
- Saito Naika Kokyukika, Mie Sleep Clinic, Ise-shi, 519-0502, Japan.
| | - Yoko Takamatsu
- Saito Naika Kokyukika, Mie Sleep Clinic, Ise-shi, 519-0502, Japan
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Brief report: Cannabis and opioid use disorder among heart failure admissions, 2008-2018. PLoS One 2021; 16:e0255514. [PMID: 34591847 PMCID: PMC8483306 DOI: 10.1371/journal.pone.0255514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/16/2021] [Indexed: 01/08/2023] Open
Abstract
Background In the United States, both cannabis use disorder (CUD) and opioid use disorder (OUD) have increased in prevalence. The prevalence, demographics, and costs of CUD and OUD are not well known in heart failure (HF) admissions. This study aimed to use a national database to examine the prevalence, demographics, and costs associated with CUD and OUD in HF. Methods This study used the National Inpatient Sample from 2008 to 2018 to identify all primary HF admissions with and without the co-diagnosis of OUD or CUD using International Classification for Diagnosis, diagnosis codes. Demographics, costs, and trends were examined. Results Between 2008 and 2018, we identified 11,692,995 admissions for HF of which 84,796 (0.8%) had a co-diagnosis of CUD only, and 67,137 (0.6%) had a co-diagnosis of OUD only. The proportion of HF admissions with CUD significantly increased from 0.3% in 2008 to 1.3% in 2018 (p<0.001). The proportion of HF admissions with OUD significantly increased from 0.2% in 2008 to 1.1% in 2018 (p<0.001). Patients admitted with HF and either CUD or OUD were younger, more likely to be Black, and from lower socioeconomic backgrounds (p<0.001, all). HF admissions with OUD or CUD had higher median costs compared to HF admissions without associated substance abuse diagnoses ($8,611 vs. $8,337 for CUD HF and $10,019 vs. $8,337 for OUD HF, p<0.001 for both). Conclusions Among discharge records for HF, CUD and OUD are increasing in prevalence, significantly affect underserved populations and are associated with higher costs of stay. Future research is essential to better delineate the cause of these increased costs and create interventions, particularly in underserved populations.
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13
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Dufort A, Samaan Z. Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations. Drugs Aging 2021; 38:1043-1053. [PMID: 34490542 PMCID: PMC8421190 DOI: 10.1007/s40266-021-00893-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
With the aging population, an increasing number of older adults (> 65 years) will be affected by problematic opioid use and opioid use disorder (OUD), with both illicit and prescription opioids. Problematic opioid use is defined as the use of opioids resulting in social, medical or psychological consequences, whereas OUD is a form of problematic use that meets diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Problematic use of opioids by older adults is associated with a number of pertinent adverse effects, including sedation, cognitive impairment, falls, fractures and constipation. Risk factors for problematic opioid use in this population include pain, comorbid medical illnesses, concurrent alcohol use disorder and depression. Treatment of OUD consists of acute detoxification and maintenance therapy. At this time, there have been no randomized controlled trials examining the effectiveness of pharmacological interventions for OUD in this population, with recommendations based on data from younger adults. Despite this, opioid agonist therapy (OAT) is recommended for both stages of treatment in older adults with OUD. Buprenorphine is recommended as a first line agent over methadone in the older adult population, due to a more favourable safety profile and relative accessibility. Use of methadone in this population is complicated by risk of QT interval prolongation and respiratory depression. Available observational data suggests that older adults respond well to OAT and age should not be a barrier to treatment. Further research is required to inform treatment decisions in this population.
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Affiliation(s)
- Alexander Dufort
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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Selvanathan J, Waseem R, Peng P, Wong J, Ryan CM, Chung F. Simple screening model for identifying the risk of sleep apnea in patients on opioids for chronic pain. Reg Anesth Pain Med 2021; 46:886-891. [PMID: 34373347 DOI: 10.1136/rapm-2020-102388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is an increased risk of sleep apnea in patients using opioids for chronic pain. We hypothesized that a simple model comprizing of: (1) STOP-Bang questionnaire and resting daytime oxyhemoglobin saturation (SpO2); and (2) overnight oximetry will identify those at risk of moderate-to-severe sleep apnea in patients with chronic pain. METHOD Adults on opioids for chronic pain were recruited from pain clinics. Participants completed the STOP-Bang questionnaire, resting daytime SpO2, and in-laboratory polysomnography. Overnight oximetry was performed at home to derive the Oxygen Desaturation Index. A STOP-Bang score ≥3 or resting daytime SpO2 ≤95% were used as thresholds for the first step, and for those identified at risk, overnight oximetry was used for further screening. The Oxygen Desaturation Index from overnight oximetry was validated against the Apnea-Hypopnea Index (≥15 events/hour) from polysomnography. RESULTS Of 199 participants (52.5±12.8 years, 58% women), 159 (79.9%) had a STOP-Bang score ≥3 or resting SpO2 ≤95% and entered the second step (overnight oximetry). Using an Oxygen Desaturation Index ≥5 events/hour, the model had a sensitivity of 86.4% and specificity of 52% for identifying moderate-to-severe sleep apnea. The number of participants who would require diagnostic sleep studies was decreased by 38% from Step 1 to Step 2 of the model. CONCLUSION A simple model using STOP-Bang questionnaire and resting daytime SpO2, followed by overnight oximetry, can identify those at high risk of moderate-to-severe sleep apnea in patients using opioids for chronic pain. TRIAL REGISTRATION NUMBER NCT02513836.
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Affiliation(s)
- Janannii Selvanathan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Rida Waseem
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Philip Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada .,Institute of Medical Science, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
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Tadjalli A, Seven YB, Sharma A, McCurdy CR, Bolser DC, Levitt ES, Mitchell GS. Acute morphine blocks spinal respiratory motor plasticity via long-latency mechanisms that require toll-like receptor 4 signalling. J Physiol 2021; 599:3771-3797. [PMID: 34142718 DOI: 10.1113/jp281362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/15/2021] [Indexed: 12/22/2022] Open
Abstract
KEY POINTS While respiratory complications following opioid use are mainly mediated via activation of mu opioid receptors, long-latency off-target signalling via innate immune toll-like receptor 4 (TLR4) may impair other essential elements of breathing control such as respiratory motor plasticity. In adult rats, pre-treatment with a single dose of morphine blocked long-term facilitation (LTF) of phrenic motor output via a long-latency TLR4-dependent mechanism. In the phrenic motor nucleus, morphine triggered TLR4-dependent activation of microglial p38 MAPK - a key enzyme that orchestrates inflammatory signalling and is known to undermine phrenic LTF. Morphine-induced LTF loss may destabilize breathing, potentially contributing to respiratory side effects. Therefore, we suggest minimizing TLR-4 signalling may improve breathing stability during opioid therapy. ABSTRACT Opioid-induced respiratory dysfunction is a significant public health burden. While respiratory effects are mediated via mu opioid receptors, long-latency off-target opioid signalling through innate immune toll-like receptor 4 (TLR4) may modulate essential elements of breathing control, particularly respiratory motor plasticity. Plasticity in respiratory motor circuits contributes to the preservation of breathing in the face of destabilizing influences. For example, respiratory long-term facilitation (LTF), a well-studied model of respiratory motor plasticity triggered by acute intermittent hypoxia, promotes breathing stability by increasing respiratory motor drive to breathing muscles. Some forms of respiratory LTF are exquisitely sensitive to inflammation and are abolished by even a mild inflammation triggered by TLR4 activation (e.g. via systemic lipopolysaccharides). Since opioids induce inflammation and TLR4 activation, we hypothesized that opioids would abolish LTF through a TLR4-dependent mechanism. In adult Sprague Dawley rats, pre-treatment with a single systemic injection of the prototypical opioid agonist morphine blocks LTF expression several hours later in the phrenic motor system - the motor pool driving diaphragm muscle contractions. Morphine blocked phrenic LTF via TLR4-dependent mechanisms because pre-treatment with (+)-naloxone - the opioid inactive stereoisomer and novel small molecule TLR4 inhibitor - prevented impairment of phrenic LTF in morphine-treated rats. Morphine triggered TLR4-dependent activation of microglial p38 MAPK within the phrenic motor system - a key enzyme that orchestrates inflammatory signalling and undermines phrenic LTF. Morphine-induced LTF loss may destabilize breathing, potentially contributing to respiratory side effects. We suggest minimizing TLR-4 signalling may improve breathing stability during opioid therapy by restoring endogenous mechanisms of plasticity within respiratory motor circuits.
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Affiliation(s)
- Arash Tadjalli
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
| | - Yasin B Seven
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
| | - Abhisheak Sharma
- Department of Pharmaceutics, University of Florida, Gainesville, FL, USA
| | | | - Donald C Bolser
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physiological Sciences, University of Florida, Gainesville, FL, USA
| | - Erica S Levitt
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Pharmacology and Therapeutics, University of Florida, Gainesville, FL, USA
| | - Gordon S Mitchell
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.,Department of Physical Therapy, University of Florida, Gainesville, FL, USA
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16
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Gavidia R, Emenike A, Meng A, Jansen EC, Hershner S, Goldstein C, Fetterolf J, Dunietz GL. The influence of opioids and nonopioid central nervous system active medications on central sleep apnea: a case-control study. J Clin Sleep Med 2021; 17:55-60. [PMID: 32964833 DOI: 10.5664/jcsm.8826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVES Opioids are known to contribute to central sleep apnea (CSA), but the influence of nonopioid central nervous system active medications (CNSAMs) on CSA remains unclear. In light of the hypothesized impact of nonopioid CNSAMs on respiration, we examined the relationships between the use of opioids only, nonopioid CNSAMs alone, and their combination with CSA. METHODS Among all adults who underwent polysomnography testing at the University of Michigan's sleep laboratory between 2013 and 2018 (n = 10,606), we identified 212 CSA cases and randomly selected 300 controls. Participants were classified into four groups based on their medication use: opioids alone, nonopioid CNSAMs only, their combination, and a reference group, including those who did not use any of these medications. We defined CSA as a binary outcome and as a continuous variable using central apnea index data. Logistic and linear regression were used to examine associations between medication use, CSA diagnosis, and central apnea index. RESULTS Study participants included 58% men, and mean age was 50 (± 14 standard deviation years. Nearly half of the study participants did not use opioids or nonopioid CNSAMs, 6% used opioids alone, 27% nonopioid CNSAMs alone, and 16% used a combination of these medications. In adjusted analyses, opioids-only users had a nearly twofold increase in CSA odds, whereas those who used a combination of opioids and nonopioid CNSAMs had fivefold higher odds of CSA relative to the reference group. In contrast, the use of nonopioid CNSAMs alone had protective associations with CSA. CONCLUSIONS This report showed increased odds of CSA, particularly among patients with sleep complaints who were prescribed opioids in combination with nonopioid CNSAMs compared with those who did not use any of these medications.
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Affiliation(s)
- Ronald Gavidia
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Amara Emenike
- Tallahassee Memorial Hospital Sleep Disorders Center, Tallahassee, Florida
| | - Anran Meng
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Erica C Jansen
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Shelley Hershner
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Cathy Goldstein
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Judy Fetterolf
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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17
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A Pilot Crossover Trial of Sleep Medications for Sleep-disturbed Methadone Maintenance Patients. J Addict Med 2021; 14:126-131. [PMID: 30870203 DOI: 10.1097/adm.0000000000000531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Problems with sleep are a common and detrimental occurrence among individuals who receive methadone maintenance for opioid use disorder (OUD). METHODS We enrolled ten methadone-maintained persons with insomnia (60% female, mean age 40) in a double-blind trial using actigraphy to confirm daily sleep reports. After a no-medication week to establish baseline sleep patterns, each participant received 1 week each of mirtazapine (30 mg), zolpidem (sustained-release 12.5 mg), mirtazapine (30 mg IR) plus zolpidem (10 mg), and placebo, with a washout week between each medication week. Study medication order was randomized so that the order of each 1-week medication treatment was different for each participant, but all participants received all 4 regimens. RESULTS We found that mirtazapine alone improved total sleep (mean 23 minutes), sleep latency (mean 23 minutes), and sleep efficiency (mean 3%), surpassing the other regiments. CONCLUSIONS This pilot work suggests that mirtazapine is worthy of further testing as a sleep aid for persons with OUD receiving methadone maintenance.
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18
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Towards the endotyping of the sleep-pain interaction: a topical review on multitarget strategies based on phenotypic vulnerabilities and putative pathways. Pain 2021; 162:1281-1288. [PMID: 33105436 DOI: 10.1097/j.pain.0000000000002124] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022]
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19
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Ahmad A, Ahmad R, Meteb M, Ryan CM, Leung RS, Montandon G, Luks V, Kendzerska T. The relationship between opioid use and obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev 2021; 58:101441. [PMID: 33567395 DOI: 10.1016/j.smrv.2021.101441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/11/2020] [Accepted: 10/27/2020] [Indexed: 12/26/2022]
Abstract
We conducted a systematic review to address limited evidence suggesting that opioids may induce or aggravate obstructive sleep apnea (OSA). All clinical trials or observational studies on adults from 1946 to 2018 found through MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Databases were eligible. We assessed the quality of the studies using published guidelines. Fifteen studies (six clinical trials and nine observational) with only two of good quality were included. Fourteen studies investigated the impact of opioids on the presence or severity of OSA, four addressed the effects of treatment for OSA in opioid users, and none explored the consequences of opioid use in individuals with OSA. Eight of 14 studies found no significant relationship between opioid use or dose and apnea-hypopnea index (AHI) or degree of nocturnal desaturation. A random-effects meta-analysis (n = 10) determined the pooled mean change in AHI associated with opioid use of 1.47/h (-2.63-5.57; I2 = 65%). Three of the four studies found that continuous positive airway pressure (CPAP) therapy reduced AHI by 17-30/h in opioid users with OSA. Bilevel therapy with a back-up rate and adaptive servo-ventilation (ASV) without mandatory pressure support successfully normalized AHI (≤5) in opioid users. Limited by a paucity of good-quality studies, our review did not show a significant relationship between opioid use and the severity of OSA. There was some evidence that CPAP, Bilevel therapy, and ASV alleviate OSA for opioid users, with higher failure rates observed in patients on CPAP in opioid users.
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Affiliation(s)
- Aseel Ahmad
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Ontario, Canada
| | - Randa Ahmad
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Ontario, Canada
| | - Moussa Meteb
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Clodagh M Ryan
- University of Toronto, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
| | - Richard S Leung
- University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gaspard Montandon
- University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Sciences, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada
| | - Vanessa Luks
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; University of Ottawa, Ontario, Canada.
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20
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Freire C, Pho H, Kim LJ, Wang X, Dyavanapalli J, Streeter SR, Fleury-Curado T, Sennes LU, Mendelowitz D, Polotsky VY. Intranasal Leptin Prevents Opioid-induced Sleep-disordered Breathing in Obese Mice. Am J Respir Cell Mol Biol 2020; 63:502-509. [PMID: 32603263 DOI: 10.1165/rcmb.2020-0117oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Respiratory depression is the main cause of morbidity and mortality associated with opioids. Obesity increases opioid-related mortality, which is mostly related to comorbid obstructive sleep apnea. Naloxone, a μ-opioid receptor blocker, is an effective antidote, but it reverses analgesia. Like humans with obesity, mice with diet-induced obesity hypoventilate during sleep and develop obstructive sleep apnea, which can be treated with intranasal leptin. We hypothesized that intranasal leptin reverses opioid-induced sleep-disordered breathing in obese mice without decreasing analgesia. To test this hypothesis, mice with diet-induced obesity were treated with morphine at 10 mg/kg subcutaneously and with leptin or placebo intranasally. Sleep and breathing were recorded by barometric plethysmography, and pain sensitivity was measured by the tail-flick test. Excitatory postsynaptic currents were recorded in vitro from hypoglossal motor neurons after the application of the μ-opioid receptor agonist [D-Ala2, N-MePhe4, Gly-ol]-enkephalin and leptin. Morphine dramatically increased the frequency of apneas and greatly increased the severity of hypoventilation and obstructive sleep apnea. Leptin decreased the frequency of apneas, improved obstructive sleep apnea, and completely reversed hypoventilation, whereas morphine analgesia was enhanced. Our in vitro studies demonstrated that [D-Ala2, N-MePhe4, Gly-ol]-enkephalin reduced the frequency of excitatory postsynaptic currents in hypoglossal motoneurons and that application of leptin restored excitatory synaptic neurotransmission. Our findings suggest that intranasal leptin may prevent opioid respiratory depression during sleep in patients with obesity receiving opioids without reducing analgesia.
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Affiliation(s)
- Carla Freire
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lenise J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xin Wang
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Jhansi Dyavanapalli
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Stone R Streeter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomaz Fleury-Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - Luiz U Sennes
- Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - David Mendelowitz
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Selvanathan J, Peng PWH, Wong J, Ryan CM, Chung F. Sleep-disordered breathing in patients on opioids for chronic pain. Reg Anesth Pain Med 2020; 45:826-830. [PMID: 32928994 DOI: 10.1136/rapm-2020-101540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/23/2020] [Accepted: 07/02/2020] [Indexed: 11/03/2022]
Abstract
The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain.
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Affiliation(s)
- Janannii Selvanathan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Philip W H Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada .,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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22
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Montgomery LS. Pain management with opioids in adults. J Neurosci Res 2020; 100:10-18. [PMID: 32770580 DOI: 10.1002/jnr.24695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/18/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Given the ubiquitous nature of opioids in the treatment of pain, it is an interesting paradox that this class of medications also represents one of the least understood components of clinical pain medicine. For many years, there has been intense interest in the mechanisms of opioid activity, but this has not resulted in a corresponding increase in convincing clinical data. This review focuses primarily on the evidence surrounding the long-term use of opioids in chronic pain, but discussions of this research are often conflated with the very different data governing acute and cancer-related pain, where evidence of efficacy is clearer. It is therefore important to clarify the evidence-based indications for opioid therapy. There remains very little evidence that opioids improve function or quality of life beyond 3 months in people with chronic pain conditions. In all three patient populations, the development of tolerance, dependence, hyperalgesia and withdrawal are key phenomena that affect the patient experience, and in particular the decision to remain on opioids in the long term. This is a common thread that connects the opioid literature in all of these spheres, and justifies the burgeoning interest in these phenomena in the basic science literature. There is an urgent need to address these negative consequences of opioid use, in order to maximize the therapeutic benefit that opioids can offer.
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Affiliation(s)
- Lori S Montgomery
- Departments of Family Medicine and Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, Calgary, AB, Canada
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23
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Cantero C, Adler D, Pasquina P, Uldry C, Egger B, Prella M, Younossian AB, Poncet A, Soccal-Gasche P, Pepin JL, Janssens JP. Adaptive Servo-Ventilation: A Comprehensive Descriptive Study in the Geneva Lake Area. Front Med (Lausanne) 2020; 7:105. [PMID: 32309284 PMCID: PMC7145945 DOI: 10.3389/fmed.2020.00105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/09/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Use of adaptive servo-ventilation (ASV) has been questioned in patients with central sleep apnea (CSA) and chronic heart failure (CHF). This study aims to detail the present use of ASV in clinical practice. Methods: Descriptive, cross-sectional, multicentric study of patients undergoing long term (≥3 months) ASV in the Cantons of Geneva or Vaud (1,288,378 inhabitants) followed by public or private hospitals, private practitioners and/or home care providers. Results: Patients included (458) were mostly male (392; 85.6%), overweight [BMI (median, IQR): 29 kg/m2 (26; 33)], comorbid, with a median age of 71 years (59–77); 84% had been treated by CPAP before starting ASV. Indications for ASV were: emergent sleep apnea (ESA; 337; 73.6%), central sleep apnea (CSA; 108; 23.6%), obstructive sleep apnea (7; 1.5%), and overlap syndrome (6; 1.3%). Origin of CSA was cardiac (n = 30), neurological (n = 26), idiopathic (n = 28), or drug-related (n = 22). Among CSA cases, 60 (56%) patients had an echocardiography within the preceding 12 months; median left ventricular ejection fraction (LVEF) was 62.5% (54–65); 11 (18%) had a LVEF ≤45%. Average daily use of ASV was [mean (SD)] 368 (140) min; 13% used their device <3:30 h. Based on ventilator software, apnea-hypopnea index was normalized in 94% of subjects with data available (94% of 428). Conclusions: Use of ASV has evolved from its original indication (CSA in CHF) to a heterogeneous predominantly male, aged, comorbid, and overweight population with mainly ESA or CSA. CSA in CHF represented only 6.5% of this population. Compliance and correction of respiratory events were satisfactory. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04054570.
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Affiliation(s)
- Chloé Cantero
- Division of Pulmonary Diseases, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Dan Adler
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | | | - Christophe Uldry
- Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Bernard Egger
- Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Maura Prella
- Division of Pulmonary Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alain Bigin Younossian
- Division of Pulmonary Diseases and Intensive Care, La Tour Hospital, Geneva, Switzerland
| | - Antoine Poncet
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Center for Clinical Research and Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | - Paola Soccal-Gasche
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Jean-Louis Pepin
- Inserm U1042 Unit, HP2 Laboratory, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Paul Janssens
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Respiratory Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
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24
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25
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Kölliker-Fuse/Parabrachial complex mu opioid receptors contribute to fentanyl-induced apnea and respiratory rate depression. Respir Physiol Neurobiol 2020; 275:103388. [PMID: 31953234 DOI: 10.1016/j.resp.2020.103388] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/05/2019] [Accepted: 01/13/2020] [Indexed: 12/19/2022]
Abstract
Overdoses caused by the opioid agonist fentanyl have increased exponentially in recent years. Identifying mechanisms to counter progression to fatal respiratory apnea during opioid overdose is desirable, but difficult to study in vivo. The pontine Kölliker-Fuse/Parabrachial complex (KF/PB) provides respiratory drive and contains opioid-sensitive neurons. The contribution of the KF/PB complex to fentanyl-induced apnea was investigated using the in situ arterially perfused preparation of rat. Systemic application of fentanyl resulted in concentration-dependent respiratory disturbances. At low concentrations, respiratory rate slowed and subsequently transitioned to an apneustic-like, 2-phase pattern. Higher concentrations caused prolonged apnea, interrupted by occasional apneustic-like bursts. Application of CTAP, a selective mu opioid receptor antagonist, directly into the KF/PB complex reversed and prevented fentanyl-induced apnea by increasing the frequency of apneustic-like bursting. These results demonstrate that countering opioid effects in the KF/PB complex is sufficient to restore phasic respiratory output at a rate similar to pre-fentanyl conditions, which could be beneficial in opioid overdose.
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26
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Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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27
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Rosen IM, Aurora RN, Kirsch DB, Carden KA, Malhotra RK, Ramar K, Abbasi-Feinberg F, Kristo DA, Martin JL, Olson EJ, Rosen CL, Rowley JA, Shelgikar AV. Chronic Opioid Therapy and Sleep: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med 2019; 15:1671-1673. [PMID: 31739858 PMCID: PMC6853382 DOI: 10.5664/jcsm.8062] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 01/23/2023]
Abstract
None There is a complex relationship among opioids, sleep and daytime function. Patients and medical providers should be aware that chronic opioid therapy can alter sleep architecture and sleep quality as well as contribute to daytime sleepiness. It is also important for medical providers to be cognizant of other adverse effects of chronic opioid use including the impact on respiratory function during sleep. Opioids are associated with several types of sleep-disordered breathing, including sleep-related hypoventilation, central sleep apnea (CSA), and obstructive sleep apnea (OSA). Appropriate screening, diagnostic testing, and treatment of opioid-associated sleep-disordered breathing can improve patients' health and quality of life. Collaboration among medical providers is encouraged to provide high quality, patient-centered care for people who are treated with chronic opioid therapy.
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Affiliation(s)
- Ilene M. Rosen
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - R. Nisha Aurora
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Kelly A. Carden
- Saint Thomas Medical Partners - Sleep Specialists, Nashville, Tennessee
| | - Raman K. Malhotra
- Sleep Medicine Center, Washington University School of Medicine, St. Louis, Missouri
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jennifer L. Martin
- Veteran Affairs Greater Los Angeles Healthcare System, North Hills, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Eric J. Olson
- Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carol L. Rosen
- Department of Pediatrics, Case Western Reserve University, University Hospitals - Cleveland Medical Center, Cleveland, Ohio
| | | | - Anita V. Shelgikar
- University of Michigan Sleep Disorders Center, University of Michigan, Ann Arbor, Michigan
| | - American Academy of Sleep Medicine Board of Directors
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Sleep Medicine, Atrium Health, Charlotte, North Carolina
- Saint Thomas Medical Partners - Sleep Specialists, Nashville, Tennessee
- Sleep Medicine Center, Washington University School of Medicine, St. Louis, Missouri
- Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
- Millennium Physician Group, Fort Myers, Florida
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Veteran Affairs Greater Los Angeles Healthcare System, North Hills, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
- Department of Pediatrics, Case Western Reserve University, University Hospitals - Cleveland Medical Center, Cleveland, Ohio
- Wayne State University, Detroit, Michigan
- University of Michigan Sleep Disorders Center, University of Michigan, Ann Arbor, Michigan
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28
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Baillargeon J, Singh G, Kuo YF, Raji MA, Westra J, Sharma G. Association of Opioid and Benzodiazepine Use with Adverse Respiratory Events in Older Adults with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2019; 16:1245-1251. [PMID: 31104504 PMCID: PMC6812171 DOI: 10.1513/annalsats.201901-024oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/15/2019] [Indexed: 12/31/2022] Open
Abstract
Rationale: Older adults with chronic obstructive pulmonary disease (COPD) are at substantially increased risk for medication-related adverse events. Two frequently prescribed classes of drugs that pose a particular risk to this patient group are opioids and benzodiazepines. Research on this topic has yielded conflicting findings.Objectives: The purpose of this study was to examine, among older adults with COPD, whether: 1) independent or concurrent use of opioid and benzodiazepine medications was associated with hospitalizations for respiratory events, and 2) this association was exacerbated by the presence of obstructive sleep apnea (OSA).Methods: We conducted a case-control study of Medicare beneficiaries aged ≥66 years, who were diagnosed with COPD in 2013, using the 5% national Medicare database. Cases (n = 3,232) were defined as patients hospitalized for a primary COPD-related respiratory diagnosis in 2014 and were matched with up to two control subjects (n = 6,247) on index date, age, sex, socioeconomic status, comorbidity, presence of OSA, COPD medication, and COPD complexity.Results: In comparison to the referent (no opioid or benzodiazepine use), opioid use alone (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.52-1.97), benzodiazepine use alone (aOR, 1.42; 95% CI, 1.21-1.66), and concurrent opioid/ benzodiazepine use (aOR, 2.32; 95% CI, 1.94-2.77) in the 30 days before the event/index date were all associated with an increased risk of hospitalization for a respiratory condition. Risk of hospitalization was higher with concurrent opioid and benzodiazepine use when compared with use of either medication alone. There was no statistically significant interaction between OSA and either of the drugs, alone or in combination. However, the adverse respiratory effects of concurrent opioid and benzodiazepine use were increased in patients with a high degree of COPD complexity. All of the above findings persisted using exposure windows that extended to 60 and 90 days before the event/index date.Conclusions: Among older adults with COPD, use of opioid and benzodiazepine medications alone or in combination were associated with increased adverse respiratory events. The adverse effects of these medications were not exacerbated in patients with COPD-OSA overlap syndrome. However, the adverse impact of dual opioid and benzodiazepine was greater in patients with high-complexity COPD.
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Affiliation(s)
- Jacques Baillargeon
- Department of Preventive Medicine and Community Health
- Sealy Center on Aging, and
| | - Gurinder Singh
- Internal Medicine Residency Program, San Joaquin General Hospital, French Camp, California
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
| | - Mukaila A. Raji
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
| | - Jordan Westra
- Department of Preventive Medicine and Community Health
| | - Gulshan Sharma
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
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29
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Abstract
Migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicranias are each reported as intrinsically related to sleep. Chronic migraine, chronic tension-type headache, and medication overuse headache may cause sleep disturbance. Otherwise, both headache and sleep disorder may be manifestations of a same systemic dysfunction. There is a vicious cycle linking sleep disorders and migraine. The poor quality or poor duration of sleep could be a trigger of migraine attack and migraineurs with poor sleep reported a higher headache frequency. Moreover, coping behaviors of migraineurs (e.g., going to sleep early to relieve migraine attacks) can be factors precipitating and perpetuating sleep disturbances themselves. During cluster headache, patients report a poor quality of sleep correlated with the amount of daylight. In particular, it was demonstrated that melatonin levels have influences on cluster headache attacks. Concerning the pathophysiology of hypnic headache, it has been hypothesized a possible role of obstructive sleep apnea in triggering nocturnal attacks: an increased number of apnea episodes has been reported in hypnic headache patients, but a lack of a temporal correlation of headache attacks with the drop of oxygen saturation has been observed. Tension-type headache is the most common headache with sleep dysregulation (lack of sleep or oversleeping) frequently reported as a triggering factor for acute attacks: management of sleep disturbances seems crucial in this form of headache.
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Affiliation(s)
- Luigi Ferini-Strambi
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology-Sleep Disorders Centre, Milan, Italy.
- "Vita-Salute" San Raffaele University, Milan, Italy.
| | - Andrea Galbiati
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology-Sleep Disorders Centre, Milan, Italy
- "Vita-Salute" San Raffaele University, Milan, Italy
| | - Romina Combi
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
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Tang NK, Stella MT, Banks PD, Sandhu HK, Berna C. The effect of opioid therapy on sleep quality in patients with chronic non-malignant pain: A systematic review and exploratory meta-analysis. Sleep Med Rev 2019; 45:105-126. [DOI: 10.1016/j.smrv.2019.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/13/2019] [Accepted: 03/14/2019] [Indexed: 12/21/2022]
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Opioid Use and Outcomes in Hospitalized Older Patients With Heart Failure Receiving and Not Receiving Hospice Referrals. Am J Ther 2019; 27:e356-e365. [PMID: 31145140 DOI: 10.1097/mjt.0000000000000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of opioids is associated with poor outcomes. Less is known about this association in patients with heart failure (HF) and whether it varies by the receipt of hospice care. METHODS Of the 7467 patients hospitalized for HF without previous opioid use, 124 received discharge opioids. We matched 123 of these patients with 123 not receiving opioids based on their propensity scores for opioid use, thus assembling a matched cohort of 246 patients balanced on 30 baseline characteristics (mean age, 76 years, 60% women, and 11% African American). We repeated the process in hospice (n = 155; 20 received opioids) and nonhospice (n = 7298; 104 received opioids) subgroups, thus assembling 2 matched cohorts of 22 and 208 patients, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) associated with opioid use were estimated from matched cohorts. RESULTS During 8.6 (median, 1.4) years of follow-up, all-cause mortality occurred in 80% and 68% of matched patients in the opioid and nonopioid groups, respectively (HR, 1.49; 95% CI, 1.11-1.99; P = 0.008). There was evidence of heterogeneity in this association between hospice and nonhospice patients (P for interaction, 0.027). Among matched hospice and nonhospice patients, HRs (95% CIs) for mortality were 6.37 (2.06-19.69; P = 0.001) and 1.42 (1.03-1.96; P = 0.035), respectively. HRs (95% CIs) for 30-day and 1-year mortality were 1.98 (1.06-3.70; P = 0.033) and 1.72 (1.18-2.49; P = 0.004), respectively. HRs (95% CIs) for all-cause, HF, and non-HF readmissions were 1.31 (0.97-1.76; P = 0.079), 1.03 (0.71-1.49; P = 0.866), and 1.75 (1.05-2.91; P = 0.031), respectively. Readmission associations were similar among matched nonhospice patients. There was no readmission among matched hospice patients receiving opioids. CONCLUSIONS In older patients with HF, opioid use is associated with a higher risk of mortality, which is greater in the hospice subgroup, and a higher risk of non-HF readmission in the nonhospice subgroup.
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Isono S, Nozaki-Taguchi N, Hasegawa M, Kato S, Todoroki S, Masuda S, Iida N, Nishimura T, Noto M, Sato Y. Contact-free unconstraint respiratory measurements with load cells under the bed in awake healthy volunteers: breath-by-breath comparison with pneumotachography. J Appl Physiol (1985) 2019; 126:1432-1441. [DOI: 10.1152/japplphysiol.00730.2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Rate of respiration is a fundamental vital sign. Accuracy and precision of respiratory rate measurements with contact-free load cell sensors under the bed legs were assessed by breath-by-breath comparison with the pneumotachography technique during two different dynamic breathing tasks in 16 awake human adults resting on the bed. The subject voluntarily increased and decreased the respiratory rate between 4 and 16 breaths/min ( n = 8) and 10 and 40 breaths/min ( n = 8) at every 2 breaths in 6 different lying postures such as supine, left lateral, right lateral, and 30, 45, and 60° sitting postures. Reciprocal phase changes of the upper and lower load cell signals accorded with the respiratory phases indicating respiratory-related shifts of the centroid along the long axis of the bed. Bland-Altman analyses revealed 0.66 and 1.59 breaths/min standard deviation differences between the techniques (limits of agreement: −1.22 to 1.36 and −2.96 to 3.30) and 0.07 and 0.17 breaths/min fixed bias differences (accuracy) (confidence interval: 0.04 to 0.10 and 0.12 to 0.22) for the mean respiratory rates of 10.5 ± 3.7 and 24.6 ± 8.9 breaths/min, respectively, regardless of the body postures on the bed. Proportional underestimation by this technique was evident for respiratory rates >40 breaths/min. Sample breath increase up to 10 breaths improved the precision from 1.59 to 0.26 breaths/min. Abnormally faster and slower respirations were accurately detected. We conclude that contact-free unconstraint respiratory rate measurements with load cells under the bed legs are accurate and may serve as a new clinical and investigational tool. NEW & NOTEWORTHY Four load cells placed under the bed legs successfully captured a centroid shift during respiration in human subjects lying on a bed. Breath-by-breath comparison of the breaths covering a wide respiratory rate range by pneumotachography confirmed reliability of the contact-free unconstraint respiratory rate measurements by small standard deviations and biases regardless of body postures. Abnormally faster and slower respirations were accurately detected. This technique should be an asset as a new clinical and investigational tool.
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Affiliation(s)
- Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Makoto Hasegawa
- Department of Anesthesiology, Chiba University Hospital, Chiba, Japan
| | - Shinichiro Kato
- Department of Anesthesiology, Chiba University Hospital, Chiba, Japan
| | - Shinsuke Todoroki
- Functional Technology Department, Section 4, R&D Division Electronic Device and Component, Manufacturing Headquarters and Engineering Headquarters, MinebeaMitsumi, Fukuroi, Japan
| | - Shigemi Masuda
- Functional Technology Department, Section 4, R&D Division Electronic Device and Component, Manufacturing Headquarters and Engineering Headquarters, MinebeaMitsumi, Fukuroi, Japan
| | - Norihito Iida
- Sensing Device Business Unit, Electronic Device Division, Electronic Device and Component Manufacturing Headquarters, MinebeaMitsumi, Fujisawa, Japan
| | - Toshiaki Nishimura
- Sales Planning Office, Bed Sensor Product Management Division, MinebeaMitsumi, Tokyo, Japan
| | - Masatoshi Noto
- Sensing Device Business Unit, Electronic Device Division, Electronic Device and Component Manufacturing Headquarters, MinebeaMitsumi, Fujisawa, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
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Marshansky S, Mayer P, Rizzo D, Baltzan M, Denis R, Lavigne GJ. Sleep, chronic pain, and opioid risk for apnea. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:234-244. [PMID: 28734941 DOI: 10.1016/j.pnpbp.2017.07.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/15/2017] [Accepted: 07/15/2017] [Indexed: 01/21/2023]
Abstract
Pain is an unwelcome sleep partner. Pain tends to erode sleep quality and alter the sleep restorative process in vulnerable patients. It can contribute to next-day sleepiness and fatigue, affecting cognitive function. Chronic pain and the use of opioid medications can also complicate the management of sleep disorders such as insomnia (difficulty falling and/or staying asleep) and sleep-disordered breathing (sleep apnea). Sleep problems can be related to various types of pain, including sleep headache (hypnic headache, cluster headache, migraine) and morning headache (transient tension type secondary to sleep apnea or to sleep bruxism or tooth grinding) as well as periodic limb movements (leg and arm dysesthesia with pain). Pain and sleep management strategies should be personalized to reflect the patient's history and ongoing complaints. Understanding the pain-sleep interaction requires assessments of: i) sleep quality, ii) potential contributions to fatigue, mood, and/or wake time functioning; iii) potential concomitant sleep-disordered breathing (SDB); and more importantly; iv) opioid use, as central apnea may occur in at-risk patients. Treatments include sleep hygiene advice, cognitive behavioral therapy, physical therapy, breathing devices (continuous positive airway pressure - CPAP, or oral appliance) and medications (sleep facilitators, e.g., zolpidem; or antidepressants, e.g., trazodone, duloxetine, or neuroleptics, e.g., pregabalin). In the presence of opioid-exacerbated SDB, if the dose cannot be reduced and normal breathing restored, servo-ventilation is a promising avenue that nevertheless requires close medical supervision.
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Affiliation(s)
- Serguei Marshansky
- CIUSSS du Nord de l'Île de Montréal, Hôpital Sacré-Cœur, Québec, Canada; Hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal (CHUM), Faculté de Médecine, Université de Montréal, Québec, Canada
| | - Pierre Mayer
- Hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal (CHUM), Faculté de Médecine, Université de Montréal, Québec, Canada
| | - Dorrie Rizzo
- Jewish General, Université de Montréal, Montréal, Québec, Canada
| | - Marc Baltzan
- Faculty of Medicine, McGill University, Mount Sinai Hospital, Montréal, Canada
| | - Ronald Denis
- CIUSSS du Nord de l'Île de Montréal, Hôpital Sacré-Cœur, Québec, Canada
| | - Gilles J Lavigne
- CIUSSS du Nord de l'Île de Montréal, Hôpital Sacré-Cœur, Québec, Canada; Faculty of Dental Medicine, Université de Montréal, Department of Stomatology, CHUM, Montréal, Québec, Canada.
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34
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Slawek DE, Lu TY, Hayes B, Fox AD. Caring for Patients With Opioid Use Disorder: What Clinicians Should Know About Comorbid Medical Conditions. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175890 DOI: 10.1176/appi.prcp.20180005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Opioid use disorder (OUD) is a growing problem, with opioid‐involved overdose deaths quadrupling since 1999 in the United States. This article reviews comorbid medical conditions related to OUD, starting with complications of behaviors associated with opioid use (e.g., injection drug use), followed by conditions stemming from the direct effects of opioids (e.g., hypogonadism). HIV and hepatitis C virus (HCV) are common infections in people with OUD, and treatment for these conditions can be safely provided regardless of ongoing substance use. Complications of drug injection, such as HIV, HCV, skin and soft tissue infections, and infective endocarditis, may be prevented through provision of sterile syringes and supervised injection facilities. Rare, life‐threatening bacterial infections may present with signs and symptoms that mimic intoxication, such as malaise or stupor, and should be assessed in patients with fever or positive blood cultures. In addition, chronic opioid exposure can lead to hypogonadism, opioid‐induced hyperalgesia, sleep‐disordered breathing, and potentially increased risk of cardiovascular disease and neurocognitive impairment. Pharmacotherapies for OUD (buprenorphine, methadone, and naltrexone) are safe and effective and their adverse opioid effects can be managed in clinical practice. Awareness of OUD‐associated medical conditions and their treatments is an important step in improving the health and wellness of people with OUD.
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Affiliation(s)
| | - Tiffany Y. Lu
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Benjamin Hayes
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Aaron D. Fox
- Department of MedicineAlbert Einstein College of MedicineBronxNY
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35
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Tomazini Martins R, Carberry JC, Gandevia SC, Butler JE, Eckert DJ. Effects of morphine on respiratory load detection, load magnitude perception, and tactile sensation in obstructive sleep apnea. J Appl Physiol (1985) 2018; 125:393-400. [DOI: 10.1152/japplphysiol.00065.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pharyngeal and respiratory sensation is impaired in obstructive sleep apnea (OSA). Opioids may further diminish respiratory sensation. Thus protective pharyngeal neuromuscular and arousal responses to airway occlusion that rely on respiratory sensation could be impaired with opioids to worsen OSA severity. However, little is known about the effects of opioids on upper airway and respiratory sensation in people with OSA. This study was designed to determine the effects of 40 mg of MS-Contin on tactile sensation, respiratory load detection, and respiratory magnitude perception in people with OSA during wakefulness. A double-blind, randomized, crossover design (1 wk washout) was used. Twenty-one men with untreated OSA (apnea/hypopnea index = 26 ± 17 events/h) recruited from a larger clinical study completed the protocol. Tactile sensation using von Frey filaments on the back of the hand, internal mucosa of the cheek, uvula, and posterior pharyngeal wall were not different between placebo and morphine [e.g., median (interquartile range) posterior wall = 0.16 (0.16, 0.4) vs. 0.4 (0.14, 1.8) g, P = 0.261]. Similarly, compared with placebo, morphine did not alter respiratory load detection thresholds for nadir mask pressure detected = −2.05 (−3.37, −1.55) vs. −2.19 (−3.36, −1.41) cmH2O, P = 0.767], or respiratory load magnitude perception [mean ± SD Borg scores during a 5 resistive load (range: 5–126 cmH2O·l−1·s−1) protocol = 4.5 ± 1.6 vs. 4.2 ± 1.2, P = 0.347] but did reduce minute ventilation during quiet breathing (11.4 ± 3.3 vs. 10.7 ± 2.6 l/min, P < 0.01). These findings indicate that 40 mg of MS-Contin does not systematically impair tactile or respiratory sensation in men with mild to moderate, untreated OSA. This suggests that altered respiratory sensation to acute mechanical stimuli is not likely to be a mechanism that contributes to worsening of OSA with a moderate dose of morphine.NEW & NOTEWORTHY Forty milligrams of MS-Contin does not alter upper airway tactile sensation, respiratory load detection thresholds, or respiratory load magnitude perception in people with obstructive sleep apnea but does decrease breathing compared with placebo during wakefulness. Despite increasing concerns of harm with opioids, the current findings suggest that impaired respiratory sensation to acute mechanical stimuli with this dose of MS-Contin is unlikely to be a direct mechanism contributing to worsening sleep apnea severity in people with mild-to-moderate disease.
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Affiliation(s)
- Rodrigo Tomazini Martins
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Jayne C. Carberry
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Simon C. Gandevia
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane E. Butler
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Danny J. Eckert
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
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36
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Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research. Addict Behav 2018; 83:5-17. [PMID: 29174666 DOI: 10.1016/j.addbeh.2017.11.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/02/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.
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37
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Bryce TN. Opioids should not be prescribed for chronic pain after spinal cord injury. Spinal Cord Ser Cases 2018; 4:66. [PMID: 30083395 DOI: 10.1038/s41394-018-0095-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/11/2018] [Accepted: 05/13/2018] [Indexed: 11/09/2022] Open
Abstract
Most people with spinal cord injury (SCI) have chronic pain and effective treatments have not been identified. Within the first two decades of the 21st century, opioids have been commonly prescribed in an attempt to manage pain after SCI, however, the risks and absence of benefit of opioids have become more apparent as opioid crises have developed around the world. This perspective is an argument for why opioids should no longer be prescribed to treat chronic pain after SCI.
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Affiliation(s)
- Thomas N Bryce
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
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38
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Chakravorty S, Vandrey RG, He S, Stein MD. Sleep Management Among Patients with Substance Use Disorders. Med Clin North Am 2018; 102:733-743. [PMID: 29933826 PMCID: PMC6289280 DOI: 10.1016/j.mcna.2018.02.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Sleep and substance use disorders commonly co-occur. Insomnia is commonly associated with use and withdrawal from substances. Circadian rhythm abnormalities are being increasingly linked with psychoactive substance use. Other sleep disorders, such as sleep-related breathing disorder, should be considered in the differential diagnosis of insomnia, especially in those with opioid use or alcohol use disorder. Insomnia that is brief or occurs in the context of active substance use is best treated by promoting abstinence. A referral to a sleep medicine clinic should be considered for those with chronic insomnia or when another intrinsic sleep disorder is suspected.
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Affiliation(s)
- Subhajit Chakravorty
- Department of Psychiatry, Perelman School of Medicine, Corporal Michael J. Crescenz VA Medical Center, MIRECC, 2nd Floor, Postal Code 116, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
| | - Ryan G Vandrey
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Sean He
- Post-baccalaureate studies program, College of Liberal Arts and Professional Studies, University of Pennsylvania, 3440 Market Street Suite 100, Philadelphia, PA 19104, USA; Department of R & D, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Michael D Stein
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
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Danish N, Edaki O, Fehr BS, Khawaja IS. A Case of an Opioid-Induced Sleep Disorder. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180511-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Nagappa M, Weingarten TN, Montandon G, Sprung J, Chung F. Opioids, respiratory depression, and sleep-disordered breathing. Best Pract Res Clin Anaesthesiol 2017; 31:469-485. [DOI: 10.1016/j.bpa.2017.05.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/10/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
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Congenital central hypoventilation syndrome: An overview of etiopathogenesis, associated pathologies, clinical presentation, and management. Auton Neurosci 2017; 210:1-9. [PMID: 29249648 DOI: 10.1016/j.autneu.2017.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/10/2017] [Accepted: 11/12/2017] [Indexed: 12/19/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS), known colloquially as Ondine's curse, is a rare disorder characterized by impaired autonomic control of breathing during sleep from the loss of vagal input and diminished sensitivity of CO2 receptors in the medulla. CCHS correlates to the malformation of the neural crest located in the brainstem; this consequently affects the loss of sensitivity of CO2 chemoreceptors, bringing about hypoventilation during sleep. The primary cause of CCHS is the mutation of the paired-like homeobox PHO2XB gene, found in 90% of the patients. This mutation not only affects breathing but also drives neurological abnormalities such as autonomic and neurocognitive dysfunction. Though typically congenital, there have been late-onset (i.e., acquired) cases reported. It is vital for physicians and clinicians to be able to diagnose CCHS due to its similar presentation to other syndromes and disorders, which may cause it to be misdiagnosed and may account for its deleterious effects. CCHS can lead to a constellation of symptoms, and consideration of diseases that present concomitantly with CCHS affords us a better understanding of the etiology of this illness. Although a rare syndrome, we aim to review the current literature to emphasize the pathogenesis, etiology, clinical presentation, symptoms, diagnosis, and current treatment methods of CCHS for clinicians to better identify and understand this condition.
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43
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Morley JE, Sanford A, Bourey R. Sleep Apnea: A Geriatric Syndrome. J Am Med Dir Assoc 2017; 18:899-904. [DOI: 10.1016/j.jamda.2017.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
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Gromov K, Kjærsgaard-Andersen P, Revald P, Kehlet H, Husted H. Feasibility of outpatient total hip and knee arthroplasty in unselected patients. Acta Orthop 2017; 88:516-521. [PMID: 28426262 PMCID: PMC5560215 DOI: 10.1080/17453674.2017.1314158] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The number of patients who are suitable for outpatient total hip and knee arthroplasty (THA and TKA) in an unselected patient population remains unknown. The purpose of this prospective 2-center study was to identify the number of patients suitable for outpatient THA and TKA in an unselected patient population, to investigate the proportion of patients who were discharged on the day of surgery (DOS), and to identify reasons for not being discharged on the DOS. Patients and methods - All consecutive, unselected patients who were referred to 2 participating centers and who were scheduled for primary THA and TKA were screened for eligibility for outpatient surgery with discharge to home on DOS. If patients did not fulfill the discharge criteria, the reasons preventing discharge were noted. Odds factors with relative risk intervals for not being discharged on DOS were identified while adjusting for age, sex, ASA score, BMI and distance to home. Results - Of the 557 patients who were referred to the participating surgeons during the study period, 54% were potentially eligible for outpatient surgery. Actual DOS discharge occurred in 13-15% of the 557 patients. Female sex and surgery late in the day increased the odds of not being discharged on the DOS. Interpretation - This study shows that even in unselected THA and TKA patients, same-day discharge is feasible in about 15% of patients. Future studies should evaluate safety aspects and economic benefits.
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Affiliation(s)
- Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark.,Correspondence:
| | - Per Kjærsgaard-Andersen
- Departement of Orthopedic Surgery, Vejle Hospital, Vejle;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Peter Revald
- Departement of Orthopedic Surgery, Vejle Hospital, Vejle;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
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Lyons PG, Snyder A, Sokol S, Edelson DP, Mokhlesi B, Churpek MM. Association Between Opioid and Benzodiazepine Use and Clinical Deterioration in Ward Patients. J Hosp Med 2017; 12:428-434. [PMID: 28574532 PMCID: PMC5695213 DOI: 10.12788/jhm.2749] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications. OBJECTIVE To determine the association between opioid and benzodiazepine administration and clinical deterioration. DESIGN Observational cohort study. SETTING 500-bed academic urban tertiary-care hospital. PATIENTS All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were "comfort care" status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded. MEASUREMENTS The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score. RESULTS In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P < 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16- 1.45; P < 0.001). CONCLUSION Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434.
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Affiliation(s)
- Patrick G. Lyons
- Washington University School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, St. Louis, MO
| | - Ashley Snyder
- The University of Chicago Medicine, Department of Medicine, Section of Hospital Medicine, Chicago, IL
| | - Sarah Sokol
- The University of Chicago Medicine, Department of Pharmaceutical Services, Chicago, IL
| | - Dana P. Edelson
- The University of Chicago Medicine, Department of Medicine, Section of Hospital Medicine, Chicago, IL
| | - Babak Mokhlesi
- The University of Chicago Medicine, Department of Medicine, Section of Pulmonary and Critical Care Medicine, Chicago, IL
| | - Matthew M. Churpek
- The University of Chicago Medicine, Department of Medicine, Section of Pulmonary and Critical Care Medicine, Chicago, IL
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Balachandran DD, Bashoura L, Faiz SA. Sleep-Related Breathing Disorders and Cancer. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0182-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn MA. The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients. THE JOURNAL OF PAIN 2017; 18:360-365. [DOI: 10.1016/j.jpain.2016.11.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/01/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
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Abstract
PURPOSE OF REVIEW Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management? RECENT FINDINGS Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies. This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.
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Affiliation(s)
- Eric S Hsu
- Comprehensive Pain Center, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Kim S, Slaven JE, Ang DC. Sustained Benefits of Exercise-based Motivational Interviewing, but Only among Nonusers of Opioids in Patients with Fibromyalgia. J Rheumatol 2016; 44:505-511. [PMID: 27909084 DOI: 10.3899/jrheum.161003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Given the known side effects of opioids and their potential effects on cognition, we sought to evaluate the benefits of motivational interviewing (MI) to promote physical activity on 2 subsets of participants with fibromyalgia (FM): nonusers and users of opioids. METHODS This was a secondary data analysis of a 36-week randomized controlled trial to assess the efficacy of MI to promote physical activity among participants with FM. Participants were randomized to 1 of 2 treatment arms: 6 phone-based MI sessions (n = 107) or 6 sessions of FM self-management instructions [attention control (AC), n = 109]. The primary outcomes were changes in physical function (Medical Outcomes Study Short Form-36), pain severity (Brief Pain Inventory), global FM symptom severity (Fibromyalgia Impact Questionnaire), and the amount of light to moderate physical activity (LMPA) from baseline to each followup visit. At study entry, subjects were categorized as opioid nonusers versus users. Repeated measures ANOVA was used to assess treatment effects adjusting for potential confounders. RESULTS Of the 216 participants, 145 (67%) were nonusers and 71 (33%) were opioid users. Among nonusers, MI was associated with improved physical function, reduced pain severity, and global FM severity, and increased LMPA at 6-month followup. Among opioid users, there were no significant differences in any outcome measures between the MI and AC groups. CONCLUSION Exercise-based MI was associated with sustained clinical benefits 6 months after completion of therapy, but only for those who were not taking opioids.
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Affiliation(s)
- Sunghye Kim
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA.,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine
| | - James E Slaven
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA.,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine
| | - Dennis C Ang
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA. .,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine.
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