Conference Coverage
![](https://cdn-uat.mdedge.com/files/s3fs-public/styles/max_width_small/public/Image/August-2018/Selim_Bernardo_J_MIN_web.jpg)
Treating sleep disorders in chronic opioid users
Continuous-positive airway pressure may not be an effective therapy for patients with sleep disorders who are using opioids.
Maggy Mitzkewich is a Clinical Nurse Specialist and Gilbert Seda is Chair of Pulmonary and Sleep Medicine, both in the Department of Pulmonary, Critical Care, and Sleep Medicine at the Naval Medical Center San Diego in California. Jason Jameson is a Senior Scientist, Leidos and Rachel Markwald is a Sleep Research Physiologist, both in the Warfighter Performance Department of the Naval Health Research Center in San Diego.
Correspondence: Maggy Mitzkewich (margaret.p.mitzkewich .mil@mail.mil)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Our study did not provide evidence that self-reported depressive and insomnia symptoms, as measured by the CES-D and ISI, can serve as useful predictors of short and long-term CPAP adherence in a sample of active-duty and retired military. OSA severity, as measured by the AHI, was the only promising predictor of CPAP adherence at 3 months.
Insomnia has been shown to improve with the use of CPAP. In a pilot study, Krakow and colleagues investigated the use of CPAP, oral appliances, or bilateral turbinectomy on patients with OSA and chronic insomnia.20 Objective measures of insomnia improved with 1 night of CPAP titration. Björnsdóttir and colleagues evaluated the long-term effects of positive airway pressure (PAP) treatment on 705 adults with middle insomnia.21 They found after 2 years of PAP treatment combined with cognitive behavioral therapy for insomnia, patients had reduced symptoms of middle insomnia. It is possible that persistent insomnia is associated with more severe OSA which was not studied in our population.22
As reported in other studies, it is possible that patients with depressive symptoms can improve with CPAP use, suggesting that depression and CPAP use are not totally unrelated. Edwards and colleagues studied the impact of CPAP on depressive symptoms in men and woman. They found that depressive symptoms are common in OSA and markedly improve with CPAP.23 Bopparaju and colleagues found a high prevalence of anxiety and depression in patients with OSA but did not influence CPAP adherence.24
The results of this study differ from some previous findings where depression was found to predict CPAP adherence.10 This may be due in part to differences in the type of instrument used to assess depression. Wells and colleagues found that baseline depressive symptoms did not correlate with CPAP adherence and that patients with greater CPAP adherence had improvement in OSA and depressive symptoms.25 Furthermore, patients with residual OSA symptoms using CPAP had more depressive symptoms, suggesting that it is the improvement in OSA symptoms that may be correlated with the improvement in depressive symptoms. Although soldiers with PTSD may have reduced CPAP adherence, use of CPAP is associated with improvement in PTSD symptoms.11,26
This study had several limitations, including a small sample size. Study patients were also from a single institution, and the majority of patients had mild-to-moderate OSA. A multicenter prospective study with a larger sample size that included more severe patients with OSA may have shown different results. The participants in this study were limited to members from the active-duty and retired military population. The findings in this population may not be transferrable to the general public. Another study limitation was that the ISI and the CES-D were only administered prior to the initiation of CPAP. If the CES-D and ISI were administered at the 3- and 12-month follow-up visits, we could determine whether short and long-term CPAP improved these symptoms or whether there was no association between CPAP adherence with insomnia and depressive symptoms. Another limitation is that we did not have access to information about potential PTSD symptomatology, which has been associated with reduced CPAP adherence and is more common in a military and veteran population.11
Continuous-positive airway pressure may not be an effective therapy for patients with sleep disorders who are using opioids.
Maximizing adherence to positive airway pressure among veterans requires implementing a team approach, setting expectations, and educating...