Dr-Nicole Tang

Even if Opioids Relieve Pain, They Don’t Necessarily Improve Sleep

MedicalResearch.com Interview with:

Dr-Nicole Tang

Dr. Tang

Nicole Tang, D.Phil, C.Psychol (Reader)
Department of Psychology
Warwick Sleep and Pain Lab
University of Warwick

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Current guidelines recommend non-opioid therapy as the preferred treatment of chronic non-malignant (CNP) pain, with opioids reserved to situations “when benefits for pain and function are expected to outweigh risks” [1,10]. Whilst the effectiveness of opioid therapy is usually measured in terms of pain outcomes, less is known about its effect on day-to-day functions.

A particular function of concern to patients with chronic non-malignant pain
is the ability to get a good night’s sleep.

The current systematic review has identified a set of papers with relevant outcomes regarding the effect of opioid therapy on sleep quality and sleep architecture in CNP patients. It
extends our understanding from the drug’s respiratory depression effect in healthy
individuals to the potential risks and utility of opioid therapy for chronic non-malignant pain
patients with sleep disturbances.

Whilst the narrative synthesis and the exploratory meta-analysis of a subset of data both suggest that the use of opioid therapy is associated with an overall report of sleep quality improvement, such an improvement is not consistently replicated across studies
or substantiated by improvements in sleep parameters linked to deeper and better-sleep quality. Moreover, the improvement may be accompanied by undesirable side effects and increased daytime sleepiness that contradict with the very idea of improved
sleep quality. We are also painfully aware of the methodological limitations of the studies reviewed; their exposure to different sources of biases has heightened the risk of result inflation.

To many patients with chronic non-malignant pain, improved sleep is a top priority
when evaluating the performance of a new drug and non-drug intervention.

If we were to advance our current understanding of the
opioid-sleep relationship, future trials need to be designed with
this interdisciplinary question in mind such that validated measures
of sleep can be incorporated as an outcome measure alongside pain.

MedicalResearch.com: What should readers take away from your report?

• Evidence that taking opioids will help people with chronic pain to sleep better is limited and of poor quality
• Patients on a low to high dose of opioids reported only a small improvement in sleep quality
• Painkillers are often prescribed to manage pain that is disrupting sleep
• Effects of opioids on sleep quality were found to be poorly researched, and under-reported in previous studies
• A high dose of opioid therapy didn’t necessarily lead to better results
• The small reported improvements were not always straightforward and might be offset by excessive daytime sleepiness and increased risks of sleep apnoea which can be overseen if monitoring is not appropriate.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

  • 1. Future opioid trials should include sleep as an outcome,
    using well-validated sleep quality or architecture
  • 2. Future sleep intervention trials for CNP should include
    pain and analgesic (including opioid) use as outcomes.
  • 3. Developing a consensus as to which sleep measure(s)
    should be recommended as core outcome measure(s) in
  • 4. To identify the PSG signature of opioids both in terms of
    macro- and micro-sleep architectural changes.
  • 5. To examine the effect of long-term opioid use (>12
    months), opioid switching and opioid tapering on sleep.
  • 6. To investigate the potential opioid-sparing effect of sleep
    intervention for CNP.
  • 7. To identify the biological, psychological, and contextual
    factors that influence people’s drug preference and categorical
    judgment of sleep quality following opioid


Conflicts of interest
N.T. and H.S. are investigators on a UK-based multicentric trial,
Improving the Wellbeing of People with Opioid Treated Chronic
Pain (I-WOTCH), which involves developing a support programme
that aims to improve the everyday functioning for people living
with chronic pain and reduce their opioid use. N.T. and H.S. recently
completed a feasibility study of a hybrid cognitive behaviour
therapy for pain-related insomnia in primary care, funded by the
NIHR under its Research for Patient Benefit (RfPB) programme
(Grant Reference Number PB-PG-0213-30121). H.S. is a director of
Health Psychology Services Ltd, which in part provides psychological
treatments for those with chronic pain.

N.T. and H.S. are funded by the NIHR under its Health Technology
Assessment Programme (HTA) Programme (Grant Reference
Number 14/224/04). The views expressed are those of the author(s)
and not necessarily those of the NHS, the NIHR or the Department
of Health and Social Care. C.B. was supported by a return grant of
the SNSF (P3SMP3_151710/2) and a “Pepiniere” Grant from the
University of Lausanne Faculty of Biology and Medicine. The funders
had no role in study design, data collection and analysis, decision
to publish, or preparation of this systematic review. The
authors are grateful to Nadia Danon for her bibliographical help.

Nicole K.Y. Tang, Maria T. Stella, Ptolemy D.W. Banks, Harbinder K. Sandhu, Chantal Berna. The effect of opioid therapy on sleep quality in patients with chronic non-malignant pain: A systematic review and exploratory meta-analysis. Sleep Medicine Reviews, 2019; 45: 105 DOI: 10.1016/j.smrv.2019.03.005

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Last Updated on June 6, 2019 by Marie Benz MD FAAD