Are Sleep Apnea Treatment Adherence and Opioid Therapy for Pain Related?

man sleeping with CPAP machine, sleep apnea
Are patients with newly diagnosed sleep apnea who are prescribed opioids inclined to attend a sleep clinic and follow treatment recommendations?

People with newly diagnosed sleep apnea who were prescribed opioid therapy for chronic pain were less likely to attend a sleep clinic for sleep apnea treatment and to adhere to sleep apnea therapy, according to research published in the Journal of Clinical Sleep Medicine.

Despite evidence confirming the association among chronic pain, opioids, and sleep apnea, current therapeutic modalities for sleep apnea treatments in this patient population have not yet been pragmatically evaluated. Researchers sought to determine whether patients receiving opioid therapy for noncancer pain with newly diagnosed sleep apnea both followed treatment recommendations and attended sleep clinic reviews.

Researchers conducted a planned, post-hoc analysis of data from a multicenter, prospective cohort study (Op-Safe; identifier NCT02513836) that included adults taking opioid medications for chronic pain for ≥3 months.

Participants underwent in-laboratory level 1 polysomnography to diagnose sleep apnea. Technologists scored results, and 2 sleep physicians reviewed them. Sleep apnea was defined as an apnea-hypopnea index (AHI) ≥5 events/h of sleep. Persons with AHI ≥10 or with AHI ≥5 and Epworth sleepiness scale >10 were recommended for sleep clinical review.

Of the 332 eligible patients, 61.4% (n=204) completed polysomnography. Within this group, 59% had AHI ≥5 and were diagnosed with sleep apnea. Mean age was 56(±12) years, and mean body mass index was 29.5(±6) kg/m2. Median morphine milligram equivalents (MME) for AHI ≥5 and central apnea index (CAI) ≥5 was 75 mg/d and 172.5 mg/d, respectively.

Sleep clinic review was recommended in 57.5% (n=69) of patients. Of those patients, 43.5% attended a consultation with a sleep physician and agreed to treatment; the remaining patients refused either the consultation or positive airway pressure (PAP) therapy after consultation.

Persons who attended the consultation had significantly higher Epworth sleepiness scale (11±4.8 vs 7.8±5) and CAI (4.8 vs 0.9; P <.05 for both) compared with persons who did not attend the consultation. No significant difference in other demographics, including sex, age, body mass index, and MME, and sleep parameters, were noted.

Among those individuals who attended the sleep clinic, 66.7% were recommended for PAP therapy, including continuous positive airway pressure, auto-adjustable positive airway pressure, bi-level positive airway pressure, and adaptive servo ventilation (ASV). All adherent patients experienced a mean reduction in AHI.

Positional therapy was initiated in 3 patients after consultation with a sleep physician. Five patients only had a dose reduction in opioids, with baseline AHI and CAI scores of 49(±26) and 31.9(±13) events/h, respectively. Median MME was 270 mg/d.

Study limitations include potential selection bias among the Op-Safe participants who completed polysomnography, a lack of standardization of treatment regimens because of the pragmatic nature of the trial, and a lack of information on whether opioid and benzodiazepine dose reduction recommendations were implemented.

“Over 50% of participants on opioids for chronic pain from the [Op-Safe] trial… declined attendance for sleep clinic review or treatment,” the researchers concluded. “Of those who pursued PAP therapy, adherence was similar to the general population at 1 year and was proven to be effective in abolishing sleep apnea.”

Future studies should explore the factors that influence this population’s lack of engagement with sleep health providers, as well as barriers to adherence to PAP therapy.


Wasef S, Mir S, Ryan C, et al. Treatment for patients with sleep apnea on opioids for chronic pain: results of the OpSafe trial. Published online December 31, 2020. J Clin Sleep Med. doi: 10.5664/jcsm.9064