By JOSEPH KRAININ, M.D.

His voice had the unusual ability to convey both aggressive muscularity and profound vulnerability. Scott Weiland and Stone Temple Pilots were icons of my adolescence. Personally, my memory of Mr. Weiland will always be inextricably linked with “Plush,” that initial hit single which, upon first listen, instantly captivated me and thousands of other kids like me. During my high school days, “Plush” was elevated to the highest sonic status possible, joining Metallica’s “Enter Sandman” and Pearl Jam’s” Black” as an essential component of our football team’s pre-game locker-room pump-up playlist.

So it was with shock and sadness that I read in the New York Times this morning that Weiland had “died in his sleep” on Thursday during a tour stop in Bloomington, MN. He was 48.

My years practicing sleep medicine make me wonder if sleep apnea may have been a factor in Weiland’s demise. To put this tragedy in context, we must explore the background of vacillation that doctors have had with pain management.

Roots of the Problem – The Medical Pendulum

When I started my training in the early 2000s, the ethos of the medical establishment was a sort of collective guilt about not being aggressive enough in the treatment of pain. Pain was re-branded as the “fifth vital sign” and physicians were encouraged to treat it early and often. It was during this time that the visual analog scale (below) and other similar scales came into heavy rotation.

Essentially, all patients needed to do was to point at a less than 100% smile to keep the morphine or Dilaudid flowing.

However, the pendulum has now swung back the other way. The results of this mindlessly aggressive pain treatment initiative are coming in and they are horrifying. Now we are seeing massive public health initiatives across the country to severely restrict the prescription of opiates.

An Epidemic Is Born

According to the CDC, over 100 Americans died every day from opiate -related causes in 2013. The graphs from the CDC below illustrate the startling mortality trends associated with these substances:

In 2012, 259 million opioid pain medication prescriptions were filled, equivalent to one bottle of pills for each American adult. Opiates have devastated entire communities. In an expose earlier this year, The Washington Post reported on one county in rural Pennsylvania that has been hit particularly hard by opiates. During a single 70-minute period there were eight overdoses.

A syringe labeled “adrenaline?”

Managing risk with these substances is complex. Unfortunately, while clean needle programs have gained traction to prevent the spread of HIV and other blood borne illnesses in IV drug users, there has been less progress in finding effective ways to prevent fatal overdoses. How is an overdose treated? Many of us probably recall the harrowing overdose scene in Pulp Fiction. But Quentin Tarantino wasn’t exactly shooting cinema verite during that memorable encounter between John Travolta and Uma Thurman. The antidote for an opiate overdose is a actually a drug called naloxone. However, if a patient had a cardiopulmonary arrest, epinephrine – aka adrenaline – might be used to try to restart the heart. But it is administered intravenously no need for the large bore needle and violent assault on the chest.

The primary strategy to prevent overdoses is for health centers to give laypersons naloxone kits to administer should their close contact OD. According to a 2014 CDC survey, from 1996-2014, 26,463 overdoses have been successfully reversed by this method. Unfortunately, 20 states don’t have any naloxone kits in the hands of laypersons and 9 more have less than 1 per 100,000 persons in the state. Clearly with the successes that this type of community program has shown, the disparity between states needs to be addressed.

I Don’t Like the Drugs but the Drugs Like Me

Weiland’s struggles with drugs, particularly with heroin, were well known. He had several run-ins with the law as a result of his substance abuse and is known to have attended rehab on at least one occasion. He reportedly suffered a near-fatal heroin overdose in 1999. During a 2010 interview with MTV News, he stated that he hadn’t used heroin since 2002. In April of this year, however, after a dismal concert performance, rumors began circling in the music community that Weiland had gone back to using heroin, which he denied.

How Opiates Kill and the Sleep Connection

Besides pain control, opiates have multiple effects on several organ systems. The major danger with them is that they can cause respiratory depression. Too much of these drugs will cause complete cessation of breathing, known as a pulmonary arrest, where the lungs stop working completely. This, in turn, if not immediately treated, will shortly devolve into a cardiopulmonary arrest where both the lungs and heart cease to function. Death follows quickly after that.

During sleep, our respiratory drive naturally diminishes and our bodies are less sensitive to physiological problems caused by abnormal breathing. These factors, combined with opiates’ effects on breathing, can create a toxic combination, resulting in a condition called central sleep apnea, or CSA, where the brain essentially forgets to tell the body to breathe, increasing the risk of stopping breathing permanently.

Scientific research indicates that CSA in opiate users is quite common, with one study showing a rate of approximately 25% with the disorder. This particular type of sleep apnea is very difficult to treat, often not improving with CPAP. What’s worse, many physicians are not aware of this disorder and it often goes undetected.

The Cure Can Be Worse Than the Disease

The prevailing approach to treating opioid addiction is transitioning patients to a “safer” alternative such as methadone or Suboxone. Methadone is an opiate with an extremely long half life and therefore has low abuse potential. Suboxone, a newer drug, is a mixed partial opiate-receptor agonist and antagonist. What that means in plain English is that it produces a watered-down opioid effect without allowing things to get out of hand. It is possible that Weiland was telling the truth, that he really was off heroin. In that case, he may have been taking one of these “maintenance” drugs to help prevent relapse.

Doctor often think of methadone and Suboxone as less dangerous than other opiate compounds but methadone has been implicated in one third of opiate-related deaths nationwide, despite accounting for less than 5% of prescriptions . Suboxone is felt to be safer but it is a relatively new drug and there are limited data on mortality rates with prolonged use. Anecdotally, the vast majority of sleep studies that I have ordered on Suboxone-using patients with sleep-related complaints have demonstrated central sleep apnea. A review of the medical literature reveals that there is only one paper on the topic which seems to support my experience as the reported incidence of CSA in this patient population was 63%. More research studies in this area are clearly needed.

Big Empty

We may never know exactly what took Scott Weiland’s life. But the chances that an otherwise healthy-appearing 48-year-old with a long history of substance abuse died from substance-related causes are quite high. The New York Times article mentioned that authorities found a small bag of cocaine in Weiland’s tour bus. It is possible that he died of cocaine-related causes – a massive heart attack or stroke, or maybe a fatal irregular heart rhythm. What is certain is that, as we’ve seen so many times in the past after beloved artists have passed in the night, there will be a short-term increase in the chatter about drug-related mortality. It is my hope to interject the potentially underappreciated role that central sleep apnea could be playing in these deaths into the conversation.

Joseph Krainin, MD, FAASM is the Founder of Singular Sleep, LLC, an innovative comprehensive online sleep clinic. A graduate of the renowned Michael S. Aldrich Sleep Disorders Center at University of Michigan, Dr. Krainin is a fellow of the American Academy of Sleep Medicine and board certified in both Sleep Medicine and Neurology. He has a special interest in sleep apnea and restless legs and is an expert in the field of sleep and human performance, having worked with many professional athletes throughout his career. He is a commentator for the American Sleep Association.