Sleep Apnea Secondary to Back Pain

If your back condition is service connected and a sleep study has diagnosed sleep apnea, you can claim the sleep apnea as secondary to the back. Veterans search for this as "sleep apnea secondary to back pain," but VA service connects the back condition, and the pain is its main symptom. Back pain does not narrow the airway, so the claim needs a middle step that a doctor can show in your records. The two that come up most are opioid pain medicine and weight gain from limited activity. One has stronger research behind it than the other, and this page is honest about both.

Can back pain cause sleep apnea?

Not directly. No study I found shows back pain itself causing sleep apnea. If your main problem is that pain keeps you awake, that is a different condition from sleep apnea; read about insomnia. The research supports two indirect paths.

Opioid pain medicine

The evidence here is real, and it is strongest for central sleep apnea, which a 2021 review traces to opioids disturbing how the brain sets the rhythm of breathing, rather than for obstructive apnea.

• The American Academy of Sleep Medicine's 2019 position statement (Rosen and colleagues, Journal of Clinical Sleep Medicine) says opioids are associated with several types of sleep-disordered breathing, including sleep-related hypoventilation, central sleep apnea and obstructive sleep apnea.
• A study of 60 people on chronic opioids matched with 60 people not taking them (Walker and colleagues, Journal of Clinical Sleep Medicine, 2007) found more breathing events per hour in the opioid group (43.5 against 30.2), driven by central apneas (12.8 against 2.1 an hour). Within the opioid group, higher doses went with more breathing events, after controlling for body mass index, age and sex.
• A 2021 review (Wang and colleagues, Anesthesia & Analgesia) put opioid-induced central sleep apnea at around 24% of chronic opioid users, typically after more than two months of use, usually in proportion to the dose. Treatment mainly uses CPAP, adaptive servo-ventilation or added oxygen.
• There is a limit. A 2020 meta-analysis of nine studies with 3,791 patients (Mubashir and colleagues, Journal of Clinical Sleep Medicine) found that overall sleep-disordered breathing was not significantly more common in chronic pain patients on opioids than in patients without them. Central sleep apnea was common in the opioid users, at 33% in sleep clinics and 20% in pain clinics.
• The timeline matters. Among 1,149,874 veterans of the recent wars in a national cohort enrolled from 2001 to 2014 (Chen and colleagues, Pain, 2020), those with obstructive sleep apnea were about twice as likely to be prescribed opioids. That study was a snapshot, so it cannot show which came first, and a VA examiner may read it as apnea leading to pain treatment.

Weight gain from limited activity

This is the more common theory and the thinner one in the research.

• A 2011 meta-analysis of 18 studies (Lin and colleagues, Pain) found that people with chronic low back pain and high disability are likely to have low physical activity. The authors noted that recent studies had challenged the assumption that back pain lowers activity.
• In a British cohort followed to age 33 (Lake and colleagues, Journal of Clinical Epidemiology, 2000), people with chronic back pain gained more weight between 23 and 33, but the difference was significant only for women (7.39 against 6.29 kilograms). The study found no significant relationships for men.
• The direction VA examiners cite runs the other way. A 2010 meta-analysis (Shiri and colleagues, American Journal of Epidemiology) concluded that overweight and obesity increase the risk of low back pain.
• Once weight goes up, the link to apnea is strong. Among 690 adults followed for four years (Peppard and colleagues, JAMA, 2000), a 10% weight gain predicted about a 32% increase in breathing events per hour of sleep and a sixfold increase in the odds of moderate-to-severe sleep-disordered breathing.

In my read, the opioid path has the better research, especially for central or mixed apnea on a sleep study. The weight path can win, but only when your own records show the back limiting your activity and your weight climbing after it.

How VA decides sleep apnea secondary to back pain

Secondary service connection is in 38 CFR § 3.310. VA grants it in two ways.

• Caused by. Your service-connected back condition caused the sleep apnea, at least as likely as not.
• Aggravated by. Your sleep apnea is aggravated by your service-connected back condition, meaning it would be less severe but for the back condition (M21-1 V.ii.2.D). VA rates only the part above the baseline, so the opinion should describe the baseline.

The file needs a sleep study diagnosis, a service-connected back condition, and a medical opinion that explains the middle step.

When weight gain is the link

VA does not treat obesity as a disability on its own, but VA's General Counsel (VAOPGCPREC 1-2017) allows it to be a middle step. The opinion has to answer three questions: did the back condition, or its treatment, cause the weight gain, was the weight gain a substantial factor in causing the sleep apnea, and would the sleep apnea not have happened without it. The Court of Appeals for Veterans Claims built on that framework in Walsh v. Wilkie (2020). Your weights at entry, separation and each later visit, work and exercise limits in your treatment notes, and statements from people who saw the change carry this theory.

When opioid medicine is the link

The opinion should name the drug, the dose and the dates, and compare them with your sleep study. A study that shows central or mixed apnea, or apnea that worsened after the dose went up, fits the research best.

Two Board grants

• In Board citation A24030459 (June 10, 2024), VA treatment records showed the veteran taking opioids, including Percocet and methadone, for service-connected neck and back pain, and a 2015 VA consent form for long-term opioids listed sleep apnea as a risk. With no VA medical opinion in the file, the Board found the evidence evenly balanced and granted obstructive sleep apnea secondary to the neck and back conditions.
• In Board citation A24016350 (April 3, 2024), a nurse practitioner's opinion traced weight gain of nearly 80 pounds after discharge to the service-connected back condition, citing treatment notes that the veteran could not exercise because of back pain. The Board gave little weight to two VA opinions, one that overlooked years of documented back pain and one that called the weight a pre-existing genetic problem without an adequate explanation, and granted the claim through the weight path.

Board decisions are not precedential, but they show what the Board accepts.

VA rating for sleep apnea secondary to back pain

Sleep apnea secondary to a back condition is rated the same way as any sleep apnea. Diagnostic Code 6847 in 38 CFR § 4.97, "Sleep Apnea Syndromes (Obstructive, Central, Mixed)," reads as follows.

Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy: 100

Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine: 50

Persistent day-time hypersomnolence: 30

Asymptomatic but with documented sleep disorder breathing: 0

The title covers central and mixed apnea, so apnea tied to opioids is rated under the same code. That is the current schedule. VA proposed new criteria in 2022 (87 FR 8474), but the proposal is not final; the sleep apnea VA rating page covers it.

VA rates the sleep apnea separately from the back, and the ratings combine under 38 CFR § 4.25, larger rating first. A 50 percent sleep apnea rating and a 20 percent back rating combine to 60 percent, because the 20 takes its share of the remaining 50. With a 40 percent back rating, the total is 70 percent.

The C&P exam for sleep apnea secondary to back pain

VA usually orders an exam or a medical opinion. The examiner is asked whether your sleep apnea is at least as likely as not caused by your back condition and, separately, whether the back condition aggravated it. An opinion that answers only the first question is inadequate under El-Amin v. Shinseki (2013).

The examiner looks at these things.

• Your sleep study: obstructive, central or mixed, how severe, and the date
• Your pain medicine history, with drugs, doses and dates
• Your weight history before and after the back injury
• Other risk factors, such as age, neck size, alcohol and smoking

Unfavorable opinions often say back pain does not affect the airway and stop there, or blame obesity without asking why the weight came on. Neither answers the opioid question or aggravation. C&P exam prep can help you prepare, and the Board section below shows how the Board ruled on these appeals.

Why sleep apnea secondary to back pain claims get denied

These are the usual gaps.

• The claim says "my back pain caused my sleep apnea" with no middle step.
• The opioid theory is raised, but the records do not show the drug, the dose or the timing against the sleep study.
• The weight theory is raised, but no weights or activity limits are documented.
• No opinion addresses aggravation or describes the baseline.
• The only opinion is a negative VA opinion, and nothing in the file answers it.

Nexus letter for sleep apnea secondary to back pain

A strong nexus letter for this claim does six things.

1. States that the doctor reviewed your records, including the full sleep study report, your back treatment and your pain medicine history.
2. Names the middle step: opioid medicine, weight gain, or both.
3. Gives an opinion on causation tied to that step, with dates.
4. Gives a separate opinion on aggravation: your sleep apnea is aggravated by your service-connected back condition, meaning it would be less severe but for the back condition, and describes the baseline, such as an earlier sleep study.
5. If weight is the path, answers the three weight gain questions with your weights and activity limits.
6. Cites the research honestly, including the meta-analysis that found no overall difference in opioid users, and deals with your other risk factors.

Where these opinions break down is predictable: no rationale, a conclusion with no reasoning behind it, or a weight theory with no weights. Raven Nexus can organize your records into a draft for your doctor, and buddy letters can document how your activity changed after the injury.

If chronic pain has also led to depression, sleep apnea secondary to depression covers that path. Other conditions claimed on top of a service-connected back are on the back secondary conditions page.

Questions veterans ask about sleep apnea secondary to back pain

Can back pain cause sleep apnea?

Not directly. The claim works through a middle step, usually opioid pain medicine or weight gain from limited activity, and a medical opinion has to show that step in your records.

Can I get VA disability for sleep apnea secondary to back pain?

Yes, if your back condition is service connected, a sleep study confirms sleep apnea, and a medical opinion links them under 38 CFR § 3.310. The sleep apnea is then rated under Diagnostic Code 6847 and combined with your back rating.

Do opioids cause sleep apnea?

Long-term opioid use is tied to central sleep apnea, with higher doses linked to more breathing events. The research on obstructive apnea is weaker, so the type of apnea on your sleep study matters.

Is central sleep apnea from opioids rated differently?

No. Diagnostic Code 6847 covers obstructive, central and mixed sleep apnea under the same rating levels.

What if I gained weight after my back injury?

That can support the claim if a doctor shows the back condition caused the weight gain, the weight gain was a substantial factor in the sleep apnea, and the sleep apnea would not have happened without it. Your weight records and activity limits carry that argument.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one.
• 38 CFR § 4.97, Diagnostic Code 6847, sleep apnea syndromes; 38 CFR § 4.71a, General Rating Formula for Diseases and Injuries of the Spine; 38 CFR § 4.25, combined ratings table.
• Schedule for Rating Disabilities-Ear, Nose, Throat, and Audiology Disabilities; Special Provisions Regarding Evaluation of Respiratory Conditions; Schedule for Rating Disabilities-Respiratory System, proposed rule, 87 FR 8474 (February 15, 2022), not final.
• VA General Counsel Precedent Opinion 1-2017 (VAOPGCPREC 1-2017), obesity as an intermediate step; Walsh v. Wilkie, 32 Vet. App. 300 (2020).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Board of Veterans' Appeals citations A24030459 (June 10, 2024, granted) and A24016350 (April 3, 2024, granted). Board decisions are not precedential.
• Rosen IM, Aurora RN, Kirsch DB, et al. Chronic Opioid Therapy and Sleep: An American Academy of Sleep Medicine Position Statement. Journal of Clinical Sleep Medicine. 2019;15(11):1671-1673. PMID 31739858.
• Walker JM, Farney RJ, Rhondeau SM, et al. Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine. 2007;3(5):455-461. PMID 17803007.
• Wang D, Yee BJ, Grunstein RR, Chung F. Chronic Opioid Use and Central Sleep Apnea, Where Are We Now and Where To Go? A State of the Art Review. Anesthesia & Analgesia. 2021;132(5):1244-1253. PMID 33857966.
• Mubashir T, Nagappa M, Esfahanian N, et al. Prevalence of sleep-disordered breathing in opioid users with chronic pain: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine. 2020;16(6):961-969. PMID 32105208.
• Chen K, Yaggi HK, Fiellin DA, et al. Associations between obstructive sleep apnea and prescribed opioids among veterans. Pain. 2020;161(9):2035-2040. PMID 32358418.
• Lin CC, McAuley JH, Macedo L, et al. Relationship between physical activity and disability in low back pain: a systematic review and meta-analysis. Pain. 2011;152(3):607-613. PMID 21251757.
• Lake JK, Power C, Cole TJ. Back pain and obesity in the 1958 British birth cohort. cause or effect? Journal of Clinical Epidemiology. 2000;53(3):245-250. PMID 10760633.
• Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. American Journal of Epidemiology. 2010;171(2):135-154. PMID 20007994.
• Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015-3021. PMID 11122588.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds, and of every decision since 1992 for the longer view.