When Sleep Stops: Subtherapeutic Buprenorphine-Naloxone and Severe Central Sleep Apnea

Background Central sleep apnea (CSA) is a recognized complication of opioid use, yet its occurrence in individuals using subtherapeutic or inconsistent doses of buprenorphine-naloxone remains underreported. This case highlights the development of severe CSA in a patient with opioid use disorder despite partial adherence to a low-dose regimen of buprenorphine-naloxone. Additionally, it demonstrates the efficacy of adaptive servo-ventilation (ASV) in managing both CSA and coexisting obstructive sleep apnea (OSA) when standard positive airway pressure therapies prove ineffective. Case Presentation A 43-year-old male with a history of opioid use disorder was inconsistently using a self-reduced subtherapeutic maintenance dose of buprenorphine-naloxone of 2 mg/0.5 mg daily. He presented with excessive daytime sleepiness and witnessed apneas. Polysomnography revealed severe CSA with an apnea-hypopnea index (AHI) of 45. Standard treatments, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP), failed to alleviate his CSA. However, ASV successfully reduced his AHI to 2.0, effectively treating both CSA and OSA. After using ASV for 2 months, our patient reported a notable improvement in sleep quality and daytime alertness. Conclusions Our case highlights the often-overlooked risk of CSA in patients who are using subtherapeutic or inconsistent doses of buprenorphine-naloxone. It also reaffirms that ASV is the preferred treatment option for opioid-induced CSA when discontinuing opioids is not feasible. Clinicians should remain vigilant and maintain a high level of suspicion for CSA in patients with opioid use disorder, regardless of their buprenorphine-naloxone dosage or adherence patterns.