Clonidine for adhd

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mnc2006

mnc2006

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Hi, I practice in UK and am a child psychiatrist. Our general guidelines suggest stimulants as first line. Atomox as second line. Clonidine as third line. How does it work in the U.S.? And how effective is colonising for adhd?
 
The US isn't as regimented about guidelines. People usually use clonidine/guanfacine to address impulsivity and, to some extent, hyperactivity. The drugs are useful adjuncts for that purpose, but obviously nowhere near as effective as stimulants. In my limited experience, I have difficulty distinguishing the effects of alpha-2 agonists from placebo effect in any given patient, but on a population level, I'd say that most people have experienced some benefit - so I guess I might say that the magnitude of the effect is mild enough so that I'm never sure if it's real or placebo, but the frequency of the effect is common enough so that I doubt that it's placebo. I feel like I'd usually use clonidine/guanfacine in a patient who has had a partial response to a stimulant but is still having residual impulsivity.
 
Clonidine definitely is not as good as stimulants. I see it used mainly for kids that are so incredibly hyperactive that they need to be "knocked out" somewhat. Have also seen it used for it's sedative side effect for sleep in kids with ADHD. Finally I've seen it used for aggression/impulsivity when the kid really needs to be knocked out during the day.
 
I've noticed that parents can be somewhat confused when told to give a dose in the morning before school to help with attention/alertfulness and then one at night to help with sleep.
 
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I rarely seen Clonidine by itself work well for the ADHD pt though in some rare cases I've seen it work very very very well. Again rare-I'm talking less than 5 cases total.

For ADHD, I've seen better success with Clonidine with stimulant augmentation. E.g. the pt is already on the maximum dosage of a stimulant and they only have some improvement and need much more. It also helps with lowering BP that could've been significantly elevated by the stimulant.

I have seen good success with Clonidine with opioid-addicted patients experiencing strong cravings to use opioids. It can cut down the cravings. I figured this out about 2 years ago before this article was published.
http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2014.14081014

Which brings me to a point. A lot of studies come out after many clinicians figure something out but those same clinicians are too lazy or busy to do the study to show the profession the practice works. I state my prescribing of the Clonidine for opioid addiction not to pat myself on the back but to criticize myself for not pushing myself to do a study that would be far more useful to the community.

My fellowship PD told me (and I went through the same intellectual transition) that as a practicing physician you will start noticing a lot of trends that are not yet published and many will become published later on by other doctors that made the same discovery independent of you. E.g. he told me he noticed a lot of Wellbutrin pts became hypertensive but no one sat down and did the work to get it into a study for years and then get it added to the list of side effects.

He mentioned that some of the most brilliant and highly-published people are simply those that can get the article done and many doctors cannot fathom even publishing a paper.

Almost all physicians are people of brilliance to discover things and I've seen so many that have a notion I find brilliant but so few of them have the time or diligence to actually get some of these ideas tested and then published.

IMHO the incredible and unfortunate over-reliance of use of multiple choice tests in testing and ranking medical students has contributed to this phenomenon.
 
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What is crags inter-tater reliability? Is it ok to prescribe powerful psychotropic drugs to children based in thus statistic?
 
I prefer guanfacine because it's better tolerated. Have found it to be helpful for impulsivity and especially in cases where there's a trauma history or significant anxiety component. For a 'pure' ADHD I don't think it'd be my goto unless there's someone with 0 inattention and lots of hyperactivity.
 
Same ^ here.

I use tenex in the daytime and clonidine for sleeping mostly. I rarely have patients who can tolerate sedation in the daytime with clonidine.

In US, stimulants in one family, then the second family are the first and second lines of treatment, then atomoxetine, tenex, clonidine. My experience is that stimulants of either type (methylphenidates or amphetamines) help with all sxs in most patients if they can tolerate them. Atomoxetine seems to only help inattentive type sxs and Tenex, clonidine only help hyper/ impulsive sxs., so I may need to combine them if they have combined-type adhd. I also add tenex if we cannot raise stimulant doses due to tolerability in order to calm down the hyperactivity if needed or if the child has tics/Tourette's.
 
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Thanks for this. Heard that Guanfacine is coming to UK in the near future. So we will be doing some experimenting as well. I know Clonidine has been used for trauma+ADHD. Personally I have not tried that. Here they go for atomox
 
mnc2006 said:
Thanks for this. Heard that Guanfacine is coming to UK in the near future. So we will be doing some experimenting as well. I know Clonidine has been used for trauma+ADHD. Personally I have not tried that. Here they go for atomox
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I think you may be thinking about Prazosin for PTSD. You don't have guanfacine in UK? It's an old alpha agonist used for blood pressure that has been generic for years. You may be thinking about the extended release form called Intuniv in the US. Also, we have extended release Clonidine (Kapvay). We also have clonidine patches that can be used for 5 days. I don't like patches on kids as they can usually pull them off.
 
milesed said:
I think you may be thinking about Prazosin for PTSD. You don't have guanfacine in UK? It's an old alpha agonist used for blood pressure that has been generic for years. You may be thinking about the extended release form called Intuniv in the US. Also, we have extended release Clonidine (Kapvay). We also have clonidine patches that can be used for 5 days. I don't like patches on kids as they can usually pull them off.
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Prazosin seems to be somewhat of a regional thing and definitely a VA thing. I've seen clonidine used for PTSD hyper-arousal symptoms and for PTSD related nightmares. I'm more comfortable using prazosin, but I wouldn't be surprised if the poster above really did mean clonidine.

http://archpsyc.jamanetwork.com/article.aspx?articleid=483030
 
Doctor Bagel said:
Prazosin seems to be somewhat of a regional thing and definitely a VA thing. I've seen clonidine used for PTSD hyper-arousal symptoms and for PTSD related nightmares. I'm more comfortable using prazosin, but I wouldn't be surprised if the poster above really did mean clonidine.

http://archpsyc.jamanetwork.com/article.aspx?articleid=483030
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I think prazosin is more of a VA thing because there's more evidence for it than clonidine. I've used both for this purpose, but I like prazosin better because it has a longer half-life and more flexible dosing (you can relieve nightmares with 1-2mg, which doesn't drop the blood pressure as much as 0.1mg of clonidine).
 
shan564 said:
I think prazosin is more of a VA thing because there's more evidence for it than clonidine. I've used both for this purpose, but I like prazosin better because it has a longer half-life and more flexible dosing (you can relieve nightmares with 1-2mg, which doesn't drop the blood pressure as much as 0.1mg of clonidine).
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Yeah, weren't the main prazosin studies VA studies? Anecdotally I've had mixed results with prazosin, and I think I've probably prescribed it to almost all my PTSD patients. It's hard to get the dosage to the right amount, and I'm probably not as aggressive with that as I should be.
 
Prazosin is a VA thing. Almost every female patient I've seen in the local jail has PTSD, and so many men too I've seen there have also been abused. I ave seen a very high success rate with Prazosin in eliminating nightmares.
 
We use Prazosin in CMHC. I see some benefit, but only in about 50% of those trying it for re-experiencing sxs of ptsd.
 
I use prazosin a lot, I'd say somewhere around 50% of my patients benefiting is about right. All things considered that's not too bad.

I have tried clonidine for people who couldn't take or did not find prazosin effective. It's never worked. Propranolol has sometimes been helpful.

I did give an adult patient with ADHD clonidine. He had a hx of methamphetamine use disorder, didn't want to chance it with a stimulant, and didn't find either bupropion or atomoxetine effective. Surprisingly he found clonidine helpful for attentional and hyperactivity sxs.
 
Interesting commentary. I have definitely used clonidine for ADHD and definitely seen it be beneficial. I particularly use it in kids who have had in utero substance exposure to alcohol or methamphetamine who simply haven't tolerated stimulants at even micro-dosages because they send them into aggressive rages or make them irritable and intolerable. I have several handfuls of kids who have done quite well on clonidine as monotherapy for ADHD (e.g., young children, children with in utero substance exposure), but I tend to use it adjunctively. That said, I typically use Tenex over clonidine because it is less sedating, but in a kid with insomnia who hasn't benefitted from melatonin, I might go with clonidine first.

I also tend to use alpha agonists in very young children with ADHD when they're not going to tolerate a stimulant--say 3 and 4-year olds who are so hyperactive that they are exhibiting language delay and can't work with a speech therapist because they're bouncing off the walls like a ping pong ball. 0.25mg of Tenex can be your friend, and it can be quite effective. Give them even a milligram of methylphenidate, and you run the risk of seeing dilated pupils, hyperactivity and aggression. Clonidine and Tenex are also helpful for tics, whereas stimulants can be the exact opposite.

If you look at meta-analyses, clonidine actually has a decent effect size of 0.58 in the treatment of ADHD.

http://www.ncbi.nlm.nih.gov/pubmed/10596256

Prazosin is extremely effective for nightmares, and I found that working in a trauma-focused residential treatment center that I rarely came across an adolescent where I couldn't get them sleeping and get rid of their nightmares with it in short-order. I have seen Tenex and clonidine both be effective for hyperarrousal during the day for adolescents with PTSD, but I don't tend to use prazosin for this given its limited half-life.

Just one man's experience as a child psych. I like the alpha agonists and use them regularly.
 
Information Underload said:
Interesting commentary. I have definitely used clonidine for ADHD and definitely seen it be beneficial. I particularly use it in kids who have had in utero substance exposure to alcohol or methamphetamine who simply haven't tolerated stimulants at even micro-dosages because they send them into aggressive rages or make them irritable and intolerable. I have several handfuls of kids who have done quite well on clonidine as monotherapy for ADHD (e.g., young children, children with in utero substance exposure), but I tend to use it adjunctively. That said, I typically use Tenex over clonidine because it is less sedating, but in a kid with insomnia who hasn't benefitted from melatonin, I might go with clonidine first.

I also tend to use alpha agonists in very young children with ADHD when they're not going to tolerate a stimulant--say 3 and 4-year olds who are so hyperactive that they are exhibiting language delay and can't work with a speech therapist because they're bouncing off the walls like a ping pong ball. 0.25mg of Tenex can be your friend, and it can be quite effective. Give them even a milligram of methylphenidate, and you run the risk of seeing dilated pupils, hyperactivity and aggression. Clonidine and Tenex are also helpful for tics, whereas stimulants can be the exact opposite.

If you look at meta-analyses, clonidine actually has a decent effect size of 0.58 in the treatment of ADHD.

http://www.ncbi.nlm.nih.gov/pubmed/10596256

Prazosin is extremely effective for nightmares, and I found that working in a trauma-focused residential treatment center that I rarely came across an adolescent where I couldn't get them sleeping and get rid of their nightmares with it in short-order. I have seen Tenex and clonidine both be effective for hyperarrousal during the day for adolescents with PTSD, but I don't tend to use prazosin for this given its limited half-life.

Just one man's experience as a child psych. I like the alpha agonists and use them regularly.
Click to expand...

How do you know that the micro dosages of stimulants are causing this worsening of aggression in the kids, rather than it being hyperactivity that simply needs a higher dose of stimulant before you see an effect?
 
PistolPete said:
How do you know that the micro dosages of stimulants are causing this worsening of aggression in the kids, rather than it being hyperactivity that simply needs a higher dose of stimulant before you see an effect?
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Several ways. 1) A consistent report from parents that the kid gets aggressive 20-30 minutes after administration of the stimulant that lasts for 2-4 hours, at which points the kid returns to baseline. Most parents won't wait more than 2-4 days like this before they're calling you. I do make them repeat the experiment once or twice if they're calling after one administration, as you may have caught the kid on a bad day. 2) You may also see is a kid whose irritability (maybe not having rages) gets better once you take him off of a stimulant. The opposite should be occurring. 3) I typically prescribe at least two dosages of stimulants when I first prescribe. One dose slightly lower than what I think they need (or a starter dose) and one higher dosage. Sometimes the kid does best when you underdose but gets cranky on the higher dosage. You lower the dose, and they get better.

A number of kids who see me have first seen a PCP who has started them on what I might consider an overly aggressive dosing of a stimulant. They get super cranky, and I might try a lower dosage if I think the dosage seemed high, which sometimes does the trick or other times simply induces the same irritability. Or sometimes I make them irritable by overshooting. I can think of a few kids where methylphenidate IR 2.5mg was too much, but where 1mg seemed to work quite well, at least until they grew some. Yes, that's well below manufacturer suggested dosing, and you're likely going to need to be using a liquid formulation.
 
Doctor Bagel said:
Yeah, weren't the main prazosin studies VA studies? Anecdotally I've had mixed results with prazosin, and I think I've probably prescribed it to almost all my PTSD patients. It's hard to get the dosage to the right amount, and I'm probably not as aggressive with that as I should be.
Click to expand...
Yeah, but there are also other prazosin studies. There's a review article somewhere in the universe looking at both clonidine and prazosin for PTSD. The authors said that they like both in their anecdotal experience, but it was pretty clear that the evidence was much better for prazosin, so I've been using prazosin exclusively for that purpose (unless I have a specific reason to use clonidine, such as comorbid ADHD with impulse control problems) ever since I read that.

I've had pretty great results with prazosin, but you have to push the dose sometimes. I feel like psychiatrists are often reluctant to prescribe more than 1-2 mg, but there's evidence for doses as high as 15 mg for PTSD. I usually start with 2 mg unless the patient's blood pressure is low at baseline, and I've never gone above 5 mg. I usually use it primarily while I'm waiting for an SSRI to kick in, but sometimes I add it on for somebody who has persistent nightmares despite an SSRI. I don't think you can consider it to be a therapeutic failure until you've pushed the dose.
 
Information Underload said:
Several ways. 1) A consistent report from parents that the kid gets aggressive 20-30 minutes after administration of the stimulant that lasts for 2-4 hours, at which points the kid returns to baseline. Most parents won't wait more than 2-4 days like this before they're calling you. I do make them repeat the experiment once or twice if they're calling after one administration, as you may have caught the kid on a bad day. 2) You may also see is a kid whose irritability (maybe not having rages) gets better once you take him off of a stimulant. The opposite should be occurring. 3) I typically prescribe at least two dosages of stimulants when I first prescribe. One dose slightly lower than what I think they need (or a starter dose) and one higher dosage. Sometimes the kid does best when you underdose but gets cranky on the higher dosage. You lower the dose, and they get better.

A number of kids who see me have first seen a PCP who has started them on what I might consider an overly aggressive dosing of a stimulant. They get super cranky, and I might try a lower dosage if I think the dosage seemed high, which sometimes does the trick or other times simply induces the same irritability. Or sometimes I make them irritable by overshooting. I can think of a few kids where methylphenidate IR 2.5mg was too much, but where 1mg seemed to work quite well, at least until they grew some. Yes, that's well below manufacturer suggested dosing, and you're likely going to need to be using a liquid formulation.
Click to expand...

Thank you, that's pretty helpful!
 
shan564 said:
Yeah, but there are also other prazosin studies. There's a review article somewhere in the universe looking at both clonidine and prazosin for PTSD. The authors said that they like both in their anecdotal experience, but it was pretty clear that the evidence was much better for prazosin, so I've been using prazosin exclusively for that purpose (unless I have a specific reason to use clonidine, such as comorbid ADHD with impulse control problems) ever since I read that.

I've had pretty great results with prazosin, but you have to push the dose sometimes. I feel like psychiatrists are often reluctant to prescribe more than 1-2 mg, but there's evidence for doses as high as 15 mg for PTSD. I usually start with 2 mg unless the patient's blood pressure is low at baseline, and I've never gone above 5 mg. I usually use it primarily while I'm waiting for an SSRI to kick in, but sometimes I add it on for somebody who has persistent nightmares despite an SSRI. I don't think you can consider it to be a therapeutic failure until you've pushed the dose.
Click to expand...

I agree. In my experience, most people are not nearly aggressive enough with Prazosin. Didn't a large VA study (sorry I don't have the source) show that average affective doses of Prazosin for men with nightmares due to PTSD was around 9mg? I've seen dosage as high as 15mg. In my experience I titrate up until either the nightmares go away or the patient experience side effects (due to low BP) and can't tolerate higher doses.
 
PistolPete said:
I agree. In my experience, most people are not nearly aggressive enough with Prazosin. Didn't a large VA study (sorry I don't have the source) show that average affective doses of Prazosin for men with nightmares due to PTSD was around 9mg? I've seen dosage as high as 15mg. In my experience I titrate up until either the nightmares go away or the patient experience side effects (due to low BP) and can't tolerate higher doses.
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Agreed. Far too tame.

Clinically, the way I'm titrating it is getting a baseline of how many nights per week are they having nightmares working towards 2-3x/month. I don't want to push it beyond that because of the side effect profile and they ought to be working in therapy at the same time.
 
Shikima said:
Agreed. Far too tame.

Clinically, the way I'm titrating it is getting a baseline of how many nights per week are they having nightmares working towards 2-3x/month. I don't want to push it beyond that because of the side effect profile and they ought to be working in therapy at the same time.
Click to expand...
Yeah, that's what I do too, although maybe I should push doses higher if the mean effective dose was found to be 9 mg.
 
shan564 said:
Yeah, that's what I do too, although maybe I should push doses higher if the mean effective dose was found to be 9 mg.
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Titrate to effect.... Research is nice to let us know the mean dosage is this, but the individual may vary. I've had success at 2-3mg. The power is in the psychotherapy.
 
shan564 said:
Yeah, but there are also other prazosin studies. There's a review article somewhere in the universe looking at both clonidine and prazosin for PTSD. The authors said that they like both in their anecdotal experience, but it was pretty clear that the evidence was much better for prazosin, so I've been using prazosin exclusively for that purpose (unless I have a specific reason to use clonidine, such as comorbid ADHD with impulse control problems) ever since I read that.

I've had pretty great results with prazosin, but you have to push the dose sometimes. I feel like psychiatrists are often reluctant to prescribe more than 1-2 mg, but there's evidence for doses as high as 15 mg for PTSD. I usually start with 2 mg unless the patient's blood pressure is low at baseline, and I've never gone above 5 mg. I usually use it primarily while I'm waiting for an SSRI to kick in, but sometimes I add it on for somebody who has persistent nightmares despite an SSRI. I don't think you can consider it to be a therapeutic failure until you've pushed the dose.
Click to expand...

Not disagreeing with you. I'm just saying that culturally prazosin is more likely to be used in the VA because studies from the VA showed its efficacy. It's also more likely to be used in the west coast for the same reasons. I think it's interesting how the culture around us affects our prescribing practices, which is what I was trying to get at. I, too, use prazosin over clonidine, but when I work with people who didn't work at the VA or who from other parts of the country, it seems like they use it less and are more likely to use clonidine.

And yeah, it's not necessarily prazosin's fault, but if patients are unwilling to work with you in pushing the dose, the drug still doesn't work for them. Which actually is an annoying thing about lots of our medications coupled with unwilling patients -- they don't want to titrate or deal with the working through medication adjustment process, well unless it's a benzodiazepine. Then they're game.
 
I saw a patient today who had significant improvement in nightmares on prazosin 2mg qHS. Last week, I might have kept her on that dose and called it a therapeutic success. After this thread, I talked to her about risks/benefits of pushing the dose to 4mg, and we decided to go higher in an effort to abolish her nightmares (SBP was 135, so she can tolerate it). Just thought I'd point out that this discussion helped make me a slightly better doctor. Although I guess it's hard to say whether that's true until I see her again and see if it actually worked...
 
Shan, you don't have to go right to 4mg, you can go by 1mg increments if you wish.

Also if you are curious, look up the AASM practice guidelines for nightmares, you'll see that Prazosin is pretty much the golden boy.
 
shan564 said:
I saw a patient today who had significant improvement in nightmares on prazosin 2mg qHS. Last week, I might have kept her on that dose and called it a therapeutic success. After this thread, I talked to her about risks/benefits of pushing the dose to 4mg, and we decided to go higher in an effort to abolish her nightmares (SBP was 135, so she can tolerate it). Just thought I'd point out that this discussion helped make me a slightly better doctor. Although I guess it's hard to say whether that's true until I see her again and see if it actually worked...
Click to expand...
Just wanted to add that abolishing the nightmares, although it is what most patients would want initially, might not always be the best thing. I find that the nightmares can be helpful as a guide and progress indicator for patients with trauma. I have some patients who have them every night, now if we could cut those back to the occasional, then that would be a different story. I have a patient with constant nightmares who was prescribed 4mg prazosin HS with no effect so the nurse practitioner d\c ed it. Might have to have a chat with her about potentially increasing the dosage. Also wondering if you think that severity of trauma or intensity or frequency of nightmares is correlated with effective dose?
 
smalltownpsych said:
Just wanted to add that abolishing the nightmares, although it is what most patients would want initially, might not always be the best thing. I find that the nightmares can be helpful as a guide and progress indicator for patients with trauma. I have some patients who have them every night, now if we could cut those back to the occasional, then that would be a different story. I have a patient with constant nightmares who was prescribed 4mg prazosin HS with no effect so the nurse practitioner d\c ed it. Might have to have a chat with her about potentially increasing the dosage. Also wondering if you think that severity of trauma or intensity or frequency of nightmares is correlated with effective dose?
Click to expand...

Yes, and it depends on neurochemistry (which we don't have a test for) to look at how titration is going. For example, I just saw a 66 yr old with significant PTSD from a terrible car wreck where a family member died. She was doing relatively well at 8mg but with an increase in stressors at home, this kicked in worsening of insomnia symptoms from excessive thought rumination and had a cascading effect upon sleep with worsening of dreams and nightmares. I increased Prazosin to 10mg. Just remember, it won't take the dreaming away, it will change the character and quality so that it is less intense and with the improved sleep, can work better in psychotherapy.

Additionally, be sure to screen for other sleep disruptive disorders which could be the cause & effect for the nightmares, and treating the underlying cause along with accurate medication management will result in a much better therapeutic process. It really does end up being a team game in treating PTSD.
 
Shikima said:
Yes, and it depends on neurochemistry (which we don't have a test for) to look at how titration is going. For example, I just saw a 66 yr old with significant PTSD from a terrible car wreck where a family member died. She was doing relatively well at 8mg but with an increase in stressors at home, this kicked in worsening of insomnia symptoms from excessive thought rumination and had a cascading effect upon sleep with worsening of dreams and nightmares. I increased Prazosin to 10mg. Just remember, it won't take the dreaming away, it will change the character and quality so that it is less intense and with the improved sleep, can work better in psychotherapy.

Additionally, be sure to screen for other sleep disruptive disorders which could be the cause & effect for the nightmares, and treating the underlying cause along with accurate medication management will result in a much better therapeutic process. It really does end up being a team game in treating PTSD.
Click to expand...
We are also dealing with chronic pain and through psychotherapy, chiropractor, and pain management medications are making some progress there. It is all interrelated. The pain is exacerbated by the psychological distress and was caused by excessive working to avoid/cope with the PTSD symptoms. I don't know about sleep apnea, but this is the type of patient who tends to have it all so we might have to look at that down the road.
 
shan564 said:
I saw a patient today who had significant improvement in nightmares on prazosin 2mg qHS. Last week, I might have kept her on that dose and called it a therapeutic success. After this thread, I talked to her about risks/benefits of pushing the dose to 4mg, and we decided to go higher in an effort to abolish her nightmares (SBP was 135, so she can tolerate it). Just thought I'd point out that this discussion helped make me a slightly better doctor. Although I guess it's hard to say whether that's true until I see her again and see if it actually worked...
Click to expand...

We should start getting CME credits for reading SDN. 🙂
 
smalltownpsych said:
We are also dealing with chronic pain and through psychotherapy, chiropractor, and pain management medications are making some progress there. It is all interrelated. The pain is exacerbated by the psychological distress and was caused by excessive working to avoid/cope with the PTSD symptoms. I don't know about sleep apnea, but this is the type of patient who tends to have it all so we might have to look at that down the road.
Click to expand...

OSA is linked to worsening of chronic pain syndromes. And plenty of research to show the correlation of worsening of mood symptoms with worsening of depression and anxiety symptoms - in some cases, it's not a direct cause and effect, rather the experience one has with pain and how they cope with the symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/?term=osa+and+chronic+pain -- this was quickly searched between patients. You get the idea.

Additionally, pain medications can create a different kind of sleep apnea called Central Sleep Apnea. The effect is still the same as it is a sleep breathing disorder which interrupts sleep, thus contributing to worsening of mood, anxiety and pain symptoms potentially. Again, it's not a 100% correlation but looking at it from a holistic management POV, it does get pretty complicated and a lot of education needs to be provided. Most of the time people are receptive to the information, those with significant personality disorders are the ones who'll buck back hard and would likely benefit from DBT initially to reduce the extreme catastrophic thinking.
 
Shikima said:
OSA is linked to worsening of chronic pain syndromes. And plenty of research to show the correlation of worsening of mood symptoms with worsening of depression and anxiety symptoms - in some cases, it's not a direct cause and effect, rather the experience one has with pain and how they cope with the symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/?term=osa+and+chronic+pain -- this was quickly searched between patients. You get the idea.

Additionally, pain medications can create a different kind of sleep apnea called Central Sleep Apnea. The effect is still the same as it is a sleep breathing disorder which interrupts sleep, thus contributing to worsening of mood, anxiety and pain symptoms potentially. Again, it's not a 100% correlation but looking at it from a holistic management POV, it does get pretty complicated and a lot of education needs to be provided. Most of the time people are receptive to the information, those with significant personality disorders are the ones who'll buck back hard and would likely benefit from DBT initially to reduce the extreme catastrophic thinking.
Click to expand...
Thanks for the info, I hadn't heard of CSA and also didn't really know about the sleep apnea/pain connection although I am aware of the depression/pain/opiate interaction and educate my patients about it. I wonder if our pain management person knows about it. I might talk about it with my patient today depending on the session, if not I'll have the pain management person address it with patient and make the referral. Fortunately this patient doesn't have a lot of axis 2 symptomatology which is almost surprising since she has everything else.
 
Opiate induced CSA may/may not present with EDS (Excessive daytime sleepiness). Just something to be aware of and would do well having some kind of screening done.
 
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