PURPOSE: Patients using chronic opioids are at risk for exceptionally complex and potentially lethal disorders of breathing during sleep such as central or obstructive apneas and hypoxemia. The putative respiratory sparing effect of buprenorphine-naloxone underlies its routine use for withdrawal therapy. We report the results of a care process model in which patients undergoing inpatient opioid detoxification using buprenorphine-naloxone were routinely assessed with comprehensive polysomnography.
METHODS: Beginning November 2010 and without applying any specific selection criteria, each adult patient admitted for therapy of opioid dependence was examined by a sleep medicine clinician. Unless medically unstable, attended polysomnography was performed after beginning sublingual buprenorphine-naloxone. Standard clinical, demographic, sleep and respiratory data were recorded. Respiratory events were classified as apnea (central or obstructive) or hypopnea. Severity was categorized by the apnea/hypopnea index (AHI) as None (AHI < 5/hr), Mild (AHI ≥ 5 to < 15/hr), Moderate (≥ 15 to < 30/hr) and Severe (AHI > 30/hr). The presence of ataxic respiratory patterns and degree of hypoxemia was assessed.
RESULTS: 19 females and 8 males were studied. Mean age: 33.4 years (19-62). Mean BMI 25.5 kg/m2 (17-41). Mean AHI (total group): 19.7/hr. At least mild sleep apnea was present in 55.5% (15/27). Severity categories: Mild 25.9% (7/27), Moderate 14.8% (4/27), and severe 14.8% (4/27). Central apnea index: 8.3/hr. Obstructive apnea index: 3.5/hr. Hypopnea index: 8.3/hr. 14 patients (2 without apnea) had hypoxemia (>10% of sleep below SpO2 of 90%).
CONCLUSIONS: Clinically significant SDB and/or hypoxemia was frequently encountered in patients receiving buprenorphine-naloxone. A carry-over effect of previous opioids cannot be excluded. The protective ceiling effect of buprenorphine-naloxone on respiratory control may be lowered due to drug interactions, principally GABAergic compounds. The presence of serious SDB would not have been anticipated in most cases based upon the usual clinical profile of patients with obstructive sleep apnea.
CLINICAL IMPLICATIONS: The risk for SDB with buprenorphine-naloxone may be under-recognized. Further studies are needed to assess the prevalence and define risk factors for SDB in these patients.
DISCLOSURE: The following authors have nothing to disclose: Robert Farney, Vanita Jain, Amanda McDonald, Theodore Wander, Michael Coudreaut, James Walker
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