Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea (OSA) is a very common disorder affecting about 10% of the population with an increasing incidence in those above 60. It is particularly common in the obese and in those with large necks. It is characterized by a temporary stoppage in breathing or decrease in breathing that occurs multiple times during the night caused by obstruction in the airway. The fragmented, non-restful sleep that results can cause daytime problems such as headaches, abnormal fatigue, and depression. OSA is also associated with an increase incidence of hypertension and atrial fibrillation. People with OSA are at particular risk for unintentional injuries, especially motor vehicle accidents, because of their daytime sleepiness. The diagnostic test for OSA is polysomnography, a test which measures breathing during sleep. This is an overnight test that is best done in a sleep laboratory but can also be done at home. Apnea, a complete absence of airflow, and hypopnea, in which effective breathing is decreased enough to drop the blood oxygen saturation, are measured. All apneic and hypopneic episodes lasting at least 10 seconds are added up and divided by the total sleep time. If there are 15 episodes of apnea or hypopnea per hour, or if there are at least 5 episodes in the presence of symptoms, the diagnosis is made.
Once the diagnosis is confirmed, the treatment of choice is continuous positive airway pressure (CPAP) in which air pressure is administered through a mask worn during sleep. The pressure maintains open airways and the optimal pressure must be individually determined. This allows a more restful sleep, improves daytime fatigue, and seems to be helpful in the blood pressure control and some cardiac symptoms that accompany OSA. Unfortunately, almost half of people prescribed CPAP do not tolerate its use by 6 months. New styles of masks often allow more comfortable fits. Surgery to the mouth and throat for OSA is of doubtful value although bariatric surgery for weight loss is very effective in correcting OSA.

Medical Marijuana

 

Medical marijuana, or cannabis, has been legalized in 28 states, including Connecticut, and recreational marijuana is available in 7 states and the District of Columbia. Recreational and medicinal cannabis use has increased 45% in the general population since 2007. In states that allow medical marijuana, the most widely recognized qualifying diagnoses include cancer, HIV, multiple sclerosis, glaucoma, seizure and pain. With its wide spread availability, what is actually known about its biological effects?Unfortunately, evidence regarding its health and therapeutic benefits are surprisingly scant. This year, the National Academies of Science, Engineering, and Medicine released its third comprehensive review of the literature concerning the health effects of cannabis. The committee found that among adults with chronic pain, those treated with cannabinoids (active chemicals derived from marijuana) had a modest improvement in pain compared to placebo. Similarly, in MS, there was a modest improvement in spasticity compared to placebo. In neither case were the cannabinoids compared to other established effective treatments, like Ibuprofen or Tylenol for pain. The control group in these studies only received placebos. Oral cannabinoids also have a modest benefit in chemotherapy induced nausea and vomiting. Overall the committee found a lack of evidence to support marijuana’s use for most of its stated approved indications.

The use of cannabis also presented worrisome side effects. The committee found an association with cannabis use and respiratory complaints including chronic obstructive lung disease and acute bronchitis. Recent evidence also linked marijuana to coronary artery disease. Cannabis use has also been associated with low birth weight in infants, poor achievement in school and/or work, difficulties in social situations, and motor vehicle accidents.  Problems with its use are generally linked to marijuana’s euphoric effect and to its being inhaled. The committee recommended high quality studies using non euphoric, orally administered preparations to define more clearly possible therapeutic indications.