Insomnia
 

Insomnia

What is insomnia?

Insomnia is a sleep problem that is marked by having difficulty falling asleep at the beginning of the night or returning to sleep upon awakening in the middle of the night.

 

Insomnia is common in persons with chronic pain. Upwards of half of all people with chronic low back pain, for instance, report insomnia. Tang, N. K., Wright, K. J., & Salkovskis, P. M. (2007). Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. Journal Sleep Research, 16(1), 85-95. doi: 10.1111/j.1365-2869.2007.0057.x Purushothaman, B., Singh, A., Lingutla, K., Bhatia, C., Pollock, R., & Krishna, M. (2013). Prevalence of insomnia in patients with chronic low back pain. Journal of Orthopedic Surgery, 21(1), 68-70.

 

Researchers and healthcare providers differentiate insomnia into two forms – primary insomnia and secondary insomnia.

  • Primary insomnia is a period of having difficulty sleeping and this difficulty is not due to a specific psychiatric disorder, medical condition, or environmental reason (such as persistent loud noise or light); primary insomnia is typically conceptualized as a pattern of arousal that has come to be habitually associated (i.e., classically conditioned) with bedtime

  • Secondary insomnia is a period of having difficulty sleeping due to a health condition, such as chronic pain, that interferes with sleep

People with chronic pain can develop either primary or secondary insomnia. Nonetheless, it’s likely that most people with chronic pain who also experience insomnia would attribute their insomnia to chronic pain. As such, they would be characterized as having secondary insomnia.

 

InsomniaPatients with chronic pain can also develop a combination of both primary and secondary insomnia. Chronic pain might start a bout of insomnia (i.e., secondary insomnia), but over time patients habitually develop increased arousal and distress in anticipation of another poor night’s sleep that leads to having further difficulty sleeping (i.e., primary insomnia). The persistent pairing of increased arousal and distress with attempting to sleep at bedtime leads to an association that unintentionally maintains insomnia night after night. So, what initially causes insomnia is not always the only thing that maintains it.

 

Is there a cure?

Research studies consistently show that cognitive behavioral therapy is the most effective treatment for insomnia. Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and pharmacotherapy for primary insomnia: A randomized controlled trial and direct comparison. Archives of Internal Medicine, 164(17), 1888-1896. doi: 10.1001/archinte.164.17.1888. Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O. E., Kvale, G., Nielsen, G. H., & Nordus, I. H. (2006). Cognitive behavioral therapy vs zolplicone for treatment of primary insomnia in older adults: A randomized controlled trial. Journal of the American Medical Association, 295(24), 2851-2858. doi: 10.1001/jama.295.24.2851. Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of primary insomnia: A randomized controlled trial. Journal of the American Medical Association, 285(14), 1856-1864. doi: 10.1001/jama.285.14.1856. Morin, C. D., Colecchi, C., Stone, J., Sood, R., & Brink, D. (2001). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, 2811(11), 991-999. doi: 10.1001/jama.281.11.991. Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Medicine Reviews, 13, 205-214. Morin, C. M., Vallieres, A., Guay, B., Bastien, C., & Baillargeon, L. (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. Journal of the American Medical Association, 301(19), 2005-2015. doi: 10.1001/jama.2009.682. Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients with insomnia. Journal of Clinical Sleep Medicine, 6(2), 169-175. Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40. Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buyesse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11. In particular, cognitive behavior therapy is best at making long-term changes in sleep patterns that produce sustained relief from insomnia. All other treatments, especially medications, can at best provide only short-term relief, which is not sustained over time, particularly after the treatment is ended.

 

Despite its greater effectiveness, it’s probably fair to say that cognitive behavior therapy is not the most common therapy for insomnia.

 

Therapies and Procedures

Broadly, there are three common types of treatments for insomnia:

  • Hypnotic medications (often called “sleeping pills”)

  • Tricyclic antidepressant medications

  • Cognitive behavior therapy

 

Hypnotic medications

Hypnotic medications are what many people call “sleeping pills.” These medications come from two classes of medications that are technically called non-benzodiazepine hypnotics (e.g., zolpidem) and benzodiazepines hypnotics (e.g., temazepam). Despite how commonly they are prescribed, the use of hypnotic medications is controversial in the healthcare field. Lader, M. H. (1999). Limitations on the use of benzodiazepines in anxiety and insomnia: Are they justified? European Neuropsychopharmacology, 9(S6), S399-S405.  A number of problems are associated with their use.

 

While providing short-term relief, insomnia typically returns after stopping their use. In the case of benzodiazepine hypnotics, the insomnia typically returns worse than it was prior to initially starting the medication. Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

 

Moreover, the use of hypnotics has been associated with hallucinations, amnesia, sleep-walking and other behaviors performed while sleeping. Ignaki, T., Miyaoka, T., Tsuji, S., Inami, Y., Nishida, A., & Horiguchi, J. (2010). Adverse reactions to zolpidem: Case reports and a review of the literature. Primary Care Companion to the Journal of Clinical Psychiatry, 12(6). doi: 10.4088/PC.09r00849bro Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

 

In addition, it’s generally known that both classes of medications aren’t real effective. When compared to placebo, people taking non-benzodiazepine type hypnotics fall asleep on average 12.8 minutes sooner and people taking benzodiazepine type hypnotics fall asleep 10 minutes sooner. Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T. P., & Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs. Journal of General Internal Medicine, 22, 1335-1350. In a later meta-analysis, the use of hypnotics produced a 22 minute average increase in sleep when compared to a placebo. Huedo-Medina, T. B., Kirsch, I., Middlemass, J., Klonizakis, M., Siriwardena, A. N., (2012). Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: Meta-analysis of data submitted to the Food and Drug Administration. BMJ, 345, e8343. Doi: 10.1136/bmj.e8343

 

Their use reinforces subtle, yet important, beliefs about one's abilities to overcome insomnia. Namely, they foster associations that insomnia is a medical problem and that you need to rely on medicines to resolve this medical problem. In other words, they serve as a nightly reminder that you can’t overcome it yourself. You remain, in a word, helpless and must rely on something external to you (i.e., the pill) to do it for you. Now, of course, no one has these thoughts on an overt basis when going to bed at night after taking these medications. But, these subtle beliefs inevitably come to mind when the prospect of reducing the use of these medications is raised. After their long-term use, people can become quite concerned about reducing their use. The prospect is almost inevitably distressing and leaves people feeling helpless to the return of insomnia. It is a subtle form of psychological dependence – the belief that you need the “sleeping pill” in order to sleep at night. Lastly, the benzodiazepine type hypnotics and, to a lesser extent, the non-benzodiazepine hypnotics, have the potential for abuse and one can become classically addicted to them. Licata, S. C., & Rowlett, J. K. (2008). Abuse and dependence liability of benzodiazepine-type drugs: GABA receptor modulation and beyond. Pharmacology, Biochemistry, and Behavior, 90(1), 74-89. doi: 10.1016/j.pbb.2008.01.001 Victorri-Vigneau, C., Feuillet, F., Wainstein, L., Grall-Bronnec, M., Pivette, J., Chaslerie, A., Sebille, V., & Jolliet, P. (2013). Pharmacoepidemiological characterization of zolpidem and zoplicone usage. European Journal of Clinical Pharmacology, 69(11), 1965-1972. Benzodiazepine type hypnotics also tend to enhance the euphoria effects of opioids, making dependency on both opioid and benzodiazepines common among patients with chronic pain. Jones, J. D., Mogali, S., & Comer, S. D. (2012). Polydrug abuse: A review of opioid and benzodiazepine combination use. Drug and Alcohol Dependence, 125(1-2), 8-18. doi: 10.1016/j.drugalcdep.2012.07.004.

 

For all these reasons, the use of hypnotics and benzodiazepines for insomnia is controversial.

 

Chronic pain rehabilitation providers typically prefer to use a combination of two other types of therapies. These therapies are the use of tricyclic antidepressants and cognitive behavioral therapy.

 

Tricyclic antidepressants for insomnia and pain

Tricyclic antidepressants are old style antidepressants that are typically no longer used for depression. Rather, they are commonly used for chronic pain and insomnia. With regard to insomnia, they are sedating and so are used at night to aid in falling and staying asleep. They do not seem to produce a sense of dependency as sometimes seen in the hypnotic medications. Research on their effectiveness for insomnia, however, is modest. Clark, M. S., Smith, P. O., & Jamieson, B. (2011). Antidepressants for the treatment of insomnia in patients with depression. American Family Physicians, 84(9), 1-2. Morin, C. M. & Benca, R. (2012). Chronic insomnia. Lancet, 379(9821), 1129-1141. doi: 10.1016/S0140-6736(11)60750-2 However, they are also some of the most effective pain medications available. Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307. Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87.

 

Cognitive behavior therapy for insomnia

Cognitive behavioral therapy for insomnia has the greatest sustained benefits over time, especially after treatment has ended. As such, it’s a form of treatment that changes the habitual patterns of arousal for good.

 

Cognitive behavior therapy is a short-term psychotherapy, usually provided by a health psychologist. It requires a multi-pronged effort over time on the part of the patient. It involves the following:

  • Sleep hygiene changes

  • Regular use of relaxation exercises

  • Regular mild, low impact aerobic exercise

  • Cognitive interventions in which you learn how to overcome worry, or anxious thinking

  • Cognitive interventions in which you change your conceptualization of sleep to a more accurate and healthy understanding

  • Stimulus control (i.e., changing what you do in the bedroom in order to break patterns or associations that have developed over time between being in the bedroom and being awake)

  • Sleep restriction (i.e., intentionally limiting when you lay down to sleep or remain asleep in order to develop a normal sleep-wake cycle within the 24-hour day)

  • Tapering hypnotic or benzodiazepine medication use

 

While its hard work, cognitive behavioral therapy is the most effective treatment for insomnia.

 

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. He also blogs at the Institute for Chronic Pain Blog.

 

References

Last Updated on Monday, 26 October 2015 00:05

Published on Saturday, 19 October 2013 18:16

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