Are opiates (opioid medications) suitable for treating sleep disturbances?

Opiates Are Not Recommended for Sleep Disturbances

Opioid medications are not recommended for treating sleep disturbances due to their potential to worsen sleep quality, induce sleep-disordered breathing, and create dependence. 1, 2

Why Opioids Are Problematic for Sleep

• Opioids are known central nervous system respiratory depressants that can significantly disrupt sleep architecture and breathing patterns during sleep 1
• They can cause a combination of obstructive apneas and central sleep-disordered breathing, with 75-85% of patients treated with opioids developing at least mild sleep apnea 1
• Chronic opioid use creates a bidirectional negative relationship with sleep - opioids disrupt sleep quality and poor sleep may influence opioid use, creating a feed-forward cycle 2
• Opioids cause relaxation of the tongue and upper airway muscles, which may exacerbate airway obstruction during sleep 1

Recommended First-Line Approaches for Sleep Disturbances

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is recommended as first-line treatment for insomnia 1
• Sleep hygiene education including regular morning/afternoon exercise, daytime bright light exposure, and avoiding heavy meals, alcohol, and nicotine near bedtime 1
• Physical activity has been shown to improve sleep quality in clinical trials 1
• Psychosocial interventions including psychoeducational therapy and supportive expressive therapy 1

Short-Term Pharmacological Options (When Necessary)

• For short-term insomnia (<4 weeks) with severe daytime impairment, a short course of hypnotic medication may be considered 1
• Short-acting benzodiazepines or newer non-benzodiazepine medications (e.g., zaleplon, zolpidem) are preferred options for short-term treatment 1
• The lowest effective dose should be used for the shortest period possible 1

Special Considerations for Specific Populations

Cancer Patients

• For cancer patients with sleep disturbances, the main focus should be to alleviate/treat underlying causes (e.g., pain) 1
• In palliative care settings, refractory insomnia may be managed with short-acting benzodiazepines (lorazepam), non-benzodiazepines (zolpidem), or sedating antidepressants (trazodone, mirtazapine) 1
• Mirtazapine may be especially effective in patients with both depression and anorexia 1

Older Adults

• Benzodiazepines should be avoided in older patients and those with cognitive impairment due to their potential to cause decreased cognitive performance 1
• Antihistamines should be used cautiously due to risk of daytime sedation and delirium, especially in older patients and those with advanced cancer 1

Medications to Avoid for Sleep Disturbances

• Opioids are not recommended due to respiratory depression, sleep architecture disruption, and potential for dependence 1, 2, 3
• Barbiturates should not be used for managing sleep disturbances 1
• Long-acting benzodiazepines are problematic due to half-lives longer than 24 hours and accumulation with multiple doses 1
• Over-the-counter antihistamines or herbal substances (e.g., valerian, melatonin) are not recommended for chronic insomnia due to relative lack of efficacy, safety data, and potential for rebound insomnia 1
• Antipsychotics are not recommended as first-line treatment for insomnia due to metabolic side effects 1

Risks of Using Opioids for Sleep

• Development of sleep-disordered breathing, including both obstructive and central sleep apnea 1, 3
• Disruption of normal sleep architecture 2, 3
• Potential for tolerance, dependence, and withdrawal symptoms that further worsen sleep 4, 5
• Withdrawal from opioids is associated with significant sleep disturbances that can persist for weeks 4
• Opioids can cause daytime sedation, cognitive impairment, and reduced quality of life 3

In summary, opioids should not be used to treat sleep disturbances due to their negative effects on sleep architecture, breathing during sleep, and high potential for dependence. Non-pharmacological approaches like CBT and sleep hygiene should be first-line treatments, with short-term use of specific sleep medications only when necessary.