The most appropriate management is an attempt to reduce this patient's opioid use. A sleep study showed this patient to have central sleep apnea (CSA). Comorbid illnesses that predispose to instability of the ventilatory control system are the most common risk factors for CSA. The most important and prevalent association is between CSA and heart failure, which classically manifests as the Cheyne-Stokes breathing pattern. However, the association between opioid analgesics and CSA is increasingly recognized. Reduction or withdrawal of opioids improves CSA. This patient does not have a history or findings suggestive of heart failure; therefore, opioid analgesics are the most likely cause. The most appropriate next step in management is to seek ways to reduce this patient's opioid intake, possibly through a pain rehabilitation program or in consultation with a pain management specialist.

Adaptive servoventilation (ASV) is a form of positive airway pressure (PAP) therapy sometimes used in patients with CSA. ASV provides a variable amount of pressure during inspiration superimposed on a low level of expiratory PAP, combined with a baseline respiration rate. There is some evidence that ASV may have a positive effect in patients with opioid-induced CSA, but controlled trials showing improvements in important outcomes are lacking. Although a trial of ASV may be warranted in some patients, it should be preceded by an attempt at reduction of opioids.

Continuous positive airway pressure (CPAP) is effective at maintaining upper airway patency in obstructive sleep apnea but is generally ineffective in treating CSA, a disorder of ventilatory control. In fact, CPAP can exacerbate CSA.

Modafinil is used to combat excessive sleepiness associated with the hypersomnia syndromes (such as narcolepsy) and residual sleepiness associated with obstructive sleep apnea despite adequate PAP therapy. There is no role for stimulant medication in the setting of CSA due to opioids.