Pain Medications May Cause Sleep Apnea

According to at least one study, sleep disordered breathing, including sleep apnea, was common among users of opioid pain medications for chronic pain. The study, published in the journal Pain Medicine, showed that up to three-quarters of users of opioid pain medications suffered from sleep apnea, nearly 10 times the rate in the general population.

Although many of the sufferers had obstructive sleep apnea, up to a third of them suffered from central sleep apnea. In addition, the researchers found that there was a dose-dependent effect of certain opioid pain medications on the severity of central sleep apnea. Methadone and benzodiazepines had dose-dependent relationships with the severity of central sleep apnea.

Unfortunately, pain medication and sleep apnea have a vicious cyclical relationship. Sleep apnea sufferers often see less effect from pain relievers, which may trigger them to move on to stronger opioid medication for chronic pain, which then will increase the severity of their sleep apnea. As sleep apnea worsens, people suffer an increased risk of heart attack, stroke, and other potentially deadly health consequences.

If you are taking chronic pain medication or if you have chronic pain that you are considering medication for, you should be evaluated for sleep apnea so that you can receive appropriate treatment to reduce the risks associated with this vicious cycle.

To learn more about sleep apnea and sleep apnea treatments, please contact a local sleep dentist today.

Shocking the Low Road for Central Sleep Apnea

Central sleep apnea is rarer than obstructive sleep apnea. In obstructive sleep apnea, the tissues of the airway collapse, closing the airway, preventing air from entering. CPAP and oral appliance therapy treat sleep apnea by keeping the airway open, but are of limited value for central sleep apnea. In central sleep apnea, the brain stops sending signals telling the body to breathe. CPAP is used for central sleep apnea, and it can be helpful because it ensures there is always some amount of fresh air in the lungs that can partly keep the blood oxygenated. But even for patients that tolerate the treatment, it can only improve the condition, not fully treat it.

Now researchers at Ohio State University think they may have found a good solution to the problem. Similar to the tongue shocker for obstructive sleep apnea, they have invented a pacemaker-like device targeted at the diaphragm. When this device senses that the sleeper has stopped breathing, it shocks the diaphragm, stimulating it to function.

Currently, the device is being tried on one patient, but if it works, it may be the long-sought best treatment option for central sleep apnea.

If you are looking for a successful sleep apnea treatment, talk to a local sleep dentist today to learn the full range of options available.

Can Carbon Dioxide help treat central and mixed sleep apnea? Should CO2 be added to CPAP Flow to Treat Central Sleep Apnea & Cheyne-Stokes Breathing?

Patients with central and mixed sleep apnea are different than obstructive sleep apnea patients. There has been work done with increased dead space in CPAP units and addition or carbon dioxide to treat central sleep apnea and Cheye-Stokes breathing. It is actually a build-up in CO2 that cause awakening and breathing in all apnea patients.

If Carbon Dioxide can be judiciously supplied to these patients it could solve the problems of central sleep apnea and emerging central apnea in patients treated with CPAP or Oral Appliances.

It may also explain why appliances like the TAP that limit opening seem more effective in some patients than Herbsts, Suad,, or Somnomed appliances. Appliances that allow easier oral opening and breating are more likely to have decreased CO2 levels.

Remember, it is the rise in CO2 (carbon dioxide) that turns on the drive to breathe.

PROBLEMS WITH PURE SLEEP appliance

I received a phone call from Scott about problems from his Pure Sleep Appliance. I would like to thank him for voluntaring this info for my blog. See below and them my commentary.

My name is Scott Kizzia. I bought a Puresleep device about a year ago to alleviate a snoring problem. After approximately nine or ten months I started having some pain in my jaw and a little difficulty opening my mouth fully, especially early in the morning. As time progressed, it continued to get worse to the point that it was painful to put the devise in my mouth. Additionally, the pain opening my mouth fully was such that I could no longer eat items that required a fully open mouth such as a sandwich. I have recently reset my Puresleep devise where the forward movement of my jaw has been decreased and my jaw problem has gotten somewhat better. I still can not open my mouth wide enough to eat many larger items, but the pain has subsided noticeably.

Scott Kizzia
Centerville, TX

Scott has graciously sent me this e-mail for publicatin on my sleep blogs. The principle behind pure sleep is sound but not necessarily safe for an over the counter appliance. The FDA in the past would have prevented sales of such a device but has suspened any and all regulation that I know of.

Oral appliances can cause tooth movement and bite changes. The American Academy of Sleep Medicine Reccomended that dentists experience in treating TMJ disorders utilize oral appliances to treat sleep apnea.

The real danger is that sleep apnea diagnosis is not made leaving patienbts at greatly increase risk or heart attack , stroke and motor vehicle accidents. I fear it is only a matter of time until we see late night ads from attorneys looking for accident victims when the driver used pure sleep appliances.

In addition patients like Scott can suffer irreparable damage from unsupervised use of orthopeic appliances. The FDA has abdicated it's role in protecting the public.
dentists are often guilty of abicating their legal responsibilities by fitting patients with oral appliances for treating snoring and sleep apnea without adequate follow-up.

The symptoms Scott describes may be a Close-Lock of the TM Joint disc. Please, if you think you have sleep apnea see a qualified sleep physician and utilize CPAP. If you want a CPAP alternative find a dentist with training in Dental Sleep Meicine and always have a follow-up sleep test with the appliance. Additional information on TMJ disorders can be found at www.ihateheadaches.org

Dentists are not legally qualified to diagnose the presence or absence of sleep apnea. A few dentists may have the required medical expertise but diagnosis is still not within the scope of their dental licensce.

RAPID MAXILLARY EXPANSION TO TREAT SLEEP APNEA IN CHILDREN

wHEN SLEEP APNEA OCCURS IN YOUNG CHILDREN REMOVAL OF TONSILS AND ADENOIDS IS THAT BLOCK THE AIRWAY IS USUALLY THE FIRST LINE OF TREATMENT.

a SECOND APPROACH IS RAPID MAXILLARY EXPANSION TO INCREASE NASAL AIRWAY AND AND TONGUE SPACE IN THE MOUTH. a PAPER PRESENTED AT THE AMERICAN ACADEMY OF DENTAL SLEEP MEDICINE SUGGESTED THAT rem SHOULD PROCEED SURGICAL INTERVENTION TO REDUCE POST-OPERATIVE RISKS.

3% OF CHILDREN SUFFER FROM SLEEP APNEA AND OVER 10% SNORE. THIS MAY PARTIALLY DUE TO THE FACT THAT FEWER TONSILLECTOMIES ARE BEING DONE. iDEALLY WITH PROPER MANAGEMENT EARLY TREATMENT OF SLEEP APNEA MAY PROVIDE A LIFETIME CURE OF THE PROBLEM. tHIS IS IMPORTANT BECAUSE UP TO 60% OF PATIENTS REFUSE CPAP.

SOME OF THE PROBLEMS ASSOCIATES WITH SLEEP APNEA IN CHILDREN INCLUDE POOR SCHOOL PERFORMANCE, DAYTIME SLEEPINSS, HYPERACTIVITY AND INNATEN5TIVENESS IN SCHOOL AS WELL AS BEHAVIORAL DISORDERS. hYPERACTIVITY AND ADHD CAN BE PREDICTED WITH UP TO 70% ACCURACY BASED ON SLEEP PATTERNS ALONE.

cLUES TO PROBLEMS WITH SLEEP APNEA IN CHILDREN INCLUDE SNORING, MOUTHBREATHING,ENURESIS, ENLARGED TONSILS AND/OR ADENOIDS, LARGE TOUNGUES, DROOLING AND A SMALL JAW OR RETROGNATHIA.

Oral Appliances and Sleep Study results. What are my options

QUESTION: I have a dental appliance that works great. I sleep soundly, my mental alertness has increased since changing from the CPAP. The problem is I had a sleep study and it did not go well. There were a lot of noises that woke me up. The leads kept pulling my body hair so I never really could relax enough to sleep well. Is the sleep study the end all be all for determining the effectiveness of a dental appliance? I can't go back to using a CPAP. Do I have any recourse for insisting on using the dental appliance?

ANSWER: There are actually several questions. First, like many patients you feel great with the appliance and symptoms have been resolved. When you said the sleep study did not go well you discussed problems with the study not your results. Did they still show you have sleep apnea and if so how severe?

Important considerations are the apnea hypopnea index and oxygen nadir. Think of the sleep test as a opportunity to continue to improve the effectiveness of your oral appliance. It sounds like it was not an ideal situation , sometimes sleep medication can help for study night. The only way to know treatment is successful is a sleep study but it is posible to do home studies. I prefer to use a lab study because your appliance can be titrated uring the night for improved quality of treatment but this means your expert in Dental Sleep Medicine has taught the lab how to titrate appliances.

Some sleep labs are very negative about oral appliances and only offer CPAP. This is an example of poor medical treatment. Stuies have shown that the majority of patients reject CPAP. Oral appliances are a safe and effective treatment and it is medically-legally incumbent that all options are offered. For severe apnea oral appliances are an alternative when CPAP is not tolerated or refused by the patient. MANY PATIENTS CAN CONBINED POSITIONAL TREATMENT WITH ORAL APPLIANCE THERAPY AND VASTLY IMPROVE RESULTS. Frequently an oral appliance can be combined with nasal surgery to reduce turbinates or correct deviated septums improving results. I suggest that patients avoid labs and physicians that are completely negative about oral appliances. These labs often have financial intreasts in CPAP treatment. I would also suggest patients avoid dentists who are not careful in doing follow-up sleep studies with physicians your health is always the primary concern. The I HATE CPAP site is sometimes seen as being negative about CPAP but that is certainly not the case. CPAP is excellent treatment and highly effective, when used. The I HATE CPAP site is interested in insuring that patients who do not tolerate CPAP find effective alternatives.

I would suggest you continue to work to improve the results you obtained with your appliance. You are definitively better with some treatment than no treatment but your health is at stake.

QUESTION ABOUT THE PILLAR PROCEDURE

Question: What do you think of the pillar procedure?

Answer: The pillar procedure is not effective for treating blockage at the base of the tongue where almost all obstructive apnea occurs. If you have sleep apnea the pillar procedure alone will almost never cure it and you will still need CPAP or an appliance. I would not suggest this procedure for patients who have sleep apnea. This may be be considered for patients with simple snoring only especially if the frequency of the snoring suggests it is specifically from the soft palate. Otherwise, it would seem to be a surgery looking for a problem it can cure. It will rarely, if ever be an apnea cure and then only in the mildest cases.

IS MY SLEEP APNEA CAUSED BY NASAL CONGESTION?

QUESTION: Hi. I'm 18 years old and I've had moderate sleep apnea (45-50 apnea episodes per night) for almost 2 years now. It seems to be caused by nightly congestion and I was wondering if other patients have had this same specific issue. Thanks.

ANSWER: THERE IS A PROCESS CALLED THE NASAL CYCLE WHERE ONE SIDE OF THE NOSE CLOSES DURING SLEEP AND YOU BREATHE THRU THE OTHER SIDE . IT CHANGES SIDES EVERY 60-90 MINUTES. WHEN WE WAKE FROM AN APNEA EPISODE WE MAY FEEL THAT THIS IS DUE TO NASAL CONGESTION WHERE IT IS ACTUALLYA NORMAL PART OF THIS CYCLE.

IF THERE IS A LARGER NASAL AIRWAY ON ONE SIDE THAN THE OTHER THAN WHEN THE SMALL SIDE CLOSES WE DO WELL BECAUSE THE LARGER AIRWAY SIDE IS OPEN. WHEN THE LARGER AIRWAY SIDE SWELLS UP WE NOW NEED TO BREATHE THRU THE MORE CONSTRICTED AIRWAY.

IT IS POSTULATED THAT THE NASAL AIRWAY CYCLE IS HEALTH BECAUSE IT PROMOTES THE MOVEMENT OF OUR BODY FROM SIDE TO SIDE DURING SLEEP.

BELOW IS FROM WIKIPEDIA:
"The nasal cycle is the alternating obstruction of the nostrils in humans. It is a physiological congestion of the nasal concha due to selective activation of one half of the autonomic nervous system by the hypothalamus. It should not be confused with pathological nasal congestion. The nasal cycle was first described by the German physician Richard Kayser in 1895."
"Later on in 1927 Heetderks[2] speaks about alternating turgescence of the inferior turbinates in 80% of a normal population. The turbinates in one fossa filled up while the opposite turbinates decongested. This cycle, which is controlled by the autonomic nervous system as described above, had a mean duration of two and a half hours. He further observed and documented that the turbinates in the dependent nasal fossa filled when the patient was in the lateral decubitus position. Some postulate that this alternating positional obstruction has the purpose of causing a person to turn from one side to the other while sleeping. The nasal cycle is an alternating one, with the total resistance in the nose remaining constant. In patients with a fixed septal deviation and intermittent nasal obstruction, the interplay of the nasal cycle becomes evident; the sensation of obstruction frequently mirrors the congestion phase."

AN ARTICLE IN CNS Spectr. 2007;12(8):625-634 by David S. Shannahoff-Khalsa, BA discusses how this autonomic phenomenon can have psychiatric implications if only one side is stimulated. The abstract and link to this interesting topic is below: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1163

Research advances have led to three methods for selectively activating one half of the autonomic nervous system in humans. The first method is an ancient yogic technique called unilateral forced nostril breathing (UFNB) that employs forced breathing through only one nostril while closing off the other. The second method works by stimulation of an autonomic reflex point on the fifth intercostal space near the axilla. The most recent method employs unilateral vagus nerve stimulation (VNS) via the mid-inferior cervical branch and requires surgical implantation of a wire and pacemaker. UFNB is non-invasive and seems to selectively activate the ipsilateral branch of the sympathetic nervous system with a possible compensation effect leading to contralateral VNS. UFNB and VNS have been employed to treat psychiatric disorders. While UFNB has been studied for its potential effects on the endogenous ultradian rhythms of the autonomic and central nervous system, and their tightly coupled correlates, VNS has yet to be studied in this regard. This article reviews these three methods and discusses their similarities, putative mechanisms, their studied effects on the endogenous autonomic nervous system and central nervous system rhythms, and their implications for the treatment of psychiatric disorders.

WHY IS THIS IMPORTANT IN REGARDS TO SLEEP APNEA: THE CYCLE CAN BE DISRUPTED BY APNEA AND IF THE NASAL CYCLE TENDS TO ALWAYS AWAKEN THE BODY WHEN THE SAME SYMPATHETIC AND PARASYMPATHTIC INNERVATIONS IT COULD CREAT A HOST OF PROBLEMS INCLUDING HORMONE REGULATION.

An interesting section of this article deals with an ancient Yogi technique that can effect the nasal cycle and other autonomic phenomenon.