Opioid Safety, Respiratory Compromise

When Can Sleep Be Deadly?

We all know intuitively the benefits of sleep. As the Division of Sleep Medicine at Harvard Medical School says:

It may seem obvious that sleep is beneficial. Even without fully grasping what sleep does for us, we know that going without sleep for too long makes us feel terrible, and that getting a good night’s sleep can make us feel ready to take on the world.

Popular magazines like Health have enumerated sleep’s benefits – “11 Surprising Health Benefits of Sleep”.

However, in a recent editorial in Anesthesia & Analgesia by David R. Hilliman, MBBS, FANZCA (Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia), we are reminded that sleep may also be deadly, particularly when opioids are given to patients:

Sleep is a vulnerable state for breathing. Ventilatory drive is reduced because of loss of stimulatory effects of wakefulness, accompanied by reduction in hypercapnic and hypoxic responsiveness. Sleep depresses muscle activation, reflex gain, and arousal responses … 

Opioids have complex effects on breathing that are particularly prominent (and may only be clinically evident) during sleep. They reduce upper airway muscle activation, pre-disposing to snoring and upper airway obstruction (i.e., OSA). They depress hypoxic and hypercapnic ventilatory drive, particularly in opioid-naive subjects, leading to hypoventilation.

Sleep may also be deadly, particularly when #opioids are given to patients #ptsafety Click To Tweet

Dr. Hilliman cites the 1997 consensus statement by the American Academy of Pain Medicine and American Pain Society which stated “withholding the appropriate use of opioids from a patient who is experiencing pain on the basis of respiratory concerns is unwarranted”.

The consequences of adopting this consensus statement were disastrous, writes Dr. Hilliman:

Predictably, the number of opioid prescriptions written exploded in the years that followed. Sadly, so did the number of opioid-related deaths.

While many years have passed from 1997 until now, The Joint Commission reminds us that respiratory compromise is an identified patient safety issue. As The Joint Commission recently stated in its Sentinel Event Alert, “Safe Use of Opioids in Hospitals”:

While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.

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