Sleep Disturbance

What is a sleep disturbance?

Patients with chronic pain frequently experience sleep disturbances. Sleep disturbance is a catchall phrase for any type of problem in sleeping. The most common forms of sleep disturbances in patients with chronic pain are the following:

  • Insomnia
  • Hypersomnia
  • Sleep apnea
  • Restless leg syndrome

Sleep disturbance can make coping with chronic pain more difficult and can actually make pain worse.

Everyone doesn’t cope well when getting poor sleep. After awhile, people tend to find it harder to deal with the normal hassles of life. They get frustrated more easily or they find themselves losing their patience when normally they might have stayed calm. As the duration of the sleep disturbance continues, people tend to get irritated easily or perhaps even tearful more easily.

Chronic pain patients are no different. With on-going sleep disturbances, they also tend to become frustrated or irritated more easily with the normal problems of life. In addition, though, chronic pain patients are dealing with pain. While perhaps not a normal problem in life, chronic pain is a problem. Chronic pain patients have to cope with it. With persistent sleep disturbances, their abilities to deal with it get challenged in just the same way as their abilities to cope with other problems of life. That is to say, it becomes harder and harder to deal with chronic pain when not sleeping well.

On top of it all, sleep disturbances can make chronic pain worse. An on-going lack of refreshing sleep can stress the nervous system. The nervous system consequently becomes more reactive. This reactivity of the nervous system amplifies the pain signals and makes pain worse.

In either case, it is important to resolve the sleep disturbance. It is one way to manage chronic pain well.

Insomnia

Insomnia is a problem of persistent difficulty getting enough sleep. People typically have difficulty either falling asleep when they first lay down or they awake in the early morning and are unable to return to sleep. Sometimes, people experience both difficulties -- falling asleep and staying asleep.

Common causes of insomnia for chronic pain patients are the following:

  • Pain
  • Worry and anxiety
  • Daytime sleeping
  • Night sweats (particularly when taking methadone)

Insomnia can readily develop into a chronic condition because of associations that patients unintentionallymake between going to bed and remaining awake. It’s distressing to be unable to sleep and it makes its mark. People recall it the next night. Apprehension builds over whether it will happen again. The apprehension leads to increased worry and a sense of arousal. This worry and arousal aren’t, of course, conducive to sleeping and so the anticipatory insomnia comes to reinforce insomnia. After a few weeks to months of this vicious cycle, insomnia is hard to break without help.

With regard to a long-term resolution of insomnia, the most effective treatment for insomnia is cognitive behavioral therapy.1, 2, 3 Cognitive behavioral therapy is a short-term psychotherapy, usually provided by a psychologist, that breaks the cycle and creates new associations with going to sleep.

In actual practice, most patients get medications to help them sleep rather than cognitive behavior therapy. Common medications for sleep are the following:

  • hypnotics, like zolpidem and eszopliclone
  • benzodiazepines, like diazepam, clonazepam, or lorazepam
  • tricyclic antidepressants, like trazadone or amitriptyline

While commonly prescribed, these medications are at best mildly effective.

When compared to placebo, people taking hypnotics fall asleep on average 12.8 minutes sooner. People taking benzodiazepine medications fall asleep 10 minutes sooner on average than those taking a placebo. People taking tricyclic antidepressants fall asleep 7 minutes faster than those taking a placebo.4 

The use of these medications involves some risk. Benzodiazepine medications are associated with rebound insomnia (i.e., an exacerbation of insomnia after stopping the use of the medication) and dependency.5 Hypnotic medications are associated with a slight, increased risk for sleep-related activities, like sleep walking or eating.6 

The one advantage of taking a tricyclic antidepressant, particularly amitriptyline, is that, in addition to being a sleep aid, it is one of the most effective pain medications available.7, 8 

Chronic pain rehabilitation programs are also a treatment option. Usually, patients participate in such programs with the goal of learning how to self-manage chronic pain, return to work, and reduce their reliance on the healthcare system. However, an important component of achieving these goals is to resolve or reduce any secondary stressors that occur as a result of living with chronic pain, like on-going insomnia. Most chronic pain rehabilitation programs are cognitive behavioral based and so incorporate cognitive behavioral approaches to insomnia when needed.

Hypersomnia

Hypersomnia is sleeping too much. When it is in conjunction with chronic pain, most cases of hypersomnia are caused by one of the following:

  • Depression
  • Over-medication

Depression can be fatiguing and so people with chronic pain and depression can sometimes sleep too much. Sleeping too much can also be a form of escape, escaping the distressing realities of living with chronic pain. Over-medication, particularly with opioids, can lead to excessive sedation and consequently sleeping too much.

Chronic pain rehabilitation programs are likely the best treatment option for individuals with chronic pain and hypersomnia. Their focus is to assist patients in acquiring the abilities to self-manage chronic pain. In doing so, patients overcome their depression, when it is secondary to chronic pain, and reduce their need for opioid medications, allowing them to taper these sedating medications.

Sleep apnea

Sleep apnea is a sleep disorder in which people temporarily stop breathing while asleep. The most common form of sleep apnea is obstructive sleep apnea. It is associated with snoring, being overweight, and having cardiovascular disease and type II diabetes. Using sleep studies, sleep specialists diagnose all forms of sleep apnea.

Treatments for sleep apnea are the following:

  • Lifestyle changes, such as losing weight, quitting smoking, and avoiding alcohol
  • Mouth pieces
  • Continuous positive airway pressure devices, or C-PAP’s

It is important to treat sleep apnea as it can significantly improve quality of life. It is also a possibly serious condition, particularly when combined with obesity, type II diabetes, and/or cardiovascular disease. Lastly, patients with chronic pain who are taking long-term opioid medications should especially be concerned about sleep apnea.9 Patients who suspect that they may have sleep apnea should consult their healthcare provider.

Restless leg syndrome

Restless leg syndrome is a condition in which people have restless sensations and an urge to move the legs.It usually occurs at night, while trying to sleep. It is associated with central sensitization.10, 11 Central sensitization is a condition of an over-reactive nervous system and is associated with most chronic pain syndromes.

To treat restless leg syndrome, patients often take medications that are used for Parkinson’s disease.

Chronic pain rehabilitation programs are likely the most effective treatment for chronic pain syndromes that are marked by central sensitization.12 However, there are no clinical studies determining the effectiveness of such programs for restless leg syndrome per se.

References

1. 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.

2. 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.

3. Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavior therapies. Sleep Medicine Reviews, 13, 205-214.

4. 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.

5. Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

6. Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

7. 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.

8. 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.

9. Walker, J. M., Farney, R. J., Rhondeau, S. M., Boyle, K. M., Valentine, K., Cloward, T. V., & Shilling, K. C. (2007). Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine, 3, 455-461.

10. Wallace, D. J. & Clauw, D. J. (Eds.). (2005). Fibromyalgia and other central pain syndromes. Philadelphia: Lippincott Williams and Wilkins.

11. Yunnus, M. B. (2007). Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis and Rheumatism, 36, 339-356.

12. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

 

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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