Chronic Pain Management and the Role of Sleep Disturbances

Posted on Monday, April the 13th at 11:09pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

Over the years one problem common to most patients undergoing chronic pain management are sleep problems. For some it is minor inconvenience, but for others it can become debilitating. According to the National Sleep Foundation two-thirds of people living with chronic pain experience sleep problems, whereas only about 15 percent of the normal population has difficulty falling asleep. Compounding the problem is the fact that some chronic pain medications also disrupt sleeping patterns!

In one study, it was found that approximately two-thirds of patients undergoing chronic pain management for back pain suffered from sleep disorders. Research has demonstrated that disrupted sleep will, in turn, exacerbate the chronic back pain problem. Thus, a vicious cycle develops in which the back pain disrupts one’s sleep, and difficulty sleeping worsens the pain, which in turn makes sleeping more difficult, etc.

Difficulty Falling Asleep

Chronic pain can impact sleep in a number of ways. To understand how a pain problem can make it difficult to fall asleep, it is helpful to think about the process associated with going to sleep for the night. In getting ready for bed, it is common to try and eliminate all distractions or other influences in an effort to “relax” and begin to fall asleep. This may include quieting the room, turning off the lights, eliminating any other noises, trying to get comfortable, and beginning to try to fall asleep.

However, this “quieting” of one’s environment can cause problems for people undergoing treatment for chronic back pain since the only thing left for the brain to focus on is the experience of the pain. Patients will often report that one of their primary pain management tools during the day is being able to distract themselves from the back pain by staying busy with other tasks (e.g., reading, watching television, engaging in hobbies or crafts, working, interacting with others, etc.), Yet, when trying to fall asleep there are no other distractions available to focus on except for the pain. In many cases, one’s perception of the pain actually increases when attempting to fall asleep. The longer falling asleep is delayed, the more stressful the situation becomes.

Difficulty Sleeping Through The Night

In addition to difficulty falling asleep, many patients undergoing chronic pain management also report awakening frequently during the night. Research has demonstrated that individuals with chronic lower back pain may experience several intense “micro-arousals” (a change in sleep state to a lighter stage of sleep) per hour of sleep, which lead to awakenings. Thus, chronic pain can be a significant intrusion into a night’s sleep and disruptive to the normal stages of sleep.

This problem is often the cause of “non-restorative sleep.” Individuals with chronic pain often experience less deep sleep, more arousals and awakenings during the night, as well as less efficient sleep. Thus, the quality of the sleep is often light and not refreshing. This non-restorative sleep pattern can then cause diminished energy, depressed mood, fatigue, and worse pain during the day.

One of my former patients, George, had only been sleeping 2-3 hours per day for several months when he first came to see me. He had been undergoing chronic pain treatment for about four years at that time. George’s sleep deprivation was causing major problems with his thinking and emotional management as well as negatively impacting his pain management. For him it was a depressing cycle—he hurt so he couldn’t sleep; when he couldn’t sleep he hurt more; when he hurt more he couldn’t sleep.

The consequences of sleep deprivation include physical effects, mental impairment, and mental health complications. Inadequate rest impairs our ability to think, to handle stress, to cope with pain, to maintain a healthy immune system, and to moderate our emotions. Total sleep deprivation is fatal: lab rats denied the chance to rest die within two to three weeks.

Other people who take medications for pain and sleep may end up going to the other end of the sleep disorder spectrum. Take Sara—she was so heavily medicated her family became concerned. She had been going to a chronic pain management clinic for about three years, during her tolerance increased along with her medication. She would sleep 18-20 hours per day and yet still be groggy. In this instance she was definitely over-medicated. The New York Times reports that about 42 million prescriptions for sleep medication were issued in 2005. Aside from being over prescribed, sleep medications these days can have strange side effects such as sleep-driving or sleep-eating!

For George and Sara the solution was to help them transition to a biopsychosocial chronic pain management plan that included more effective medication management. This allowed them to experience significant quality of life improvements, an important part of which was to practice good sleep hygiene, and as a result, get a better nights rest.

Developing Good Sleep Hygiene

So what do you do when you live with chronic pain and need to sleep? Do you give in and use potentially dangerous sleep medications or just suffer? Most experts recommend practicing good sleep hygiene, along with understanding the cause of disturbed sleep patterns. Sleep hygiene looks to the habits, environmental factors, and practices that may influence the length and quality of your sleep. These include bedtime, nighttime rituals, and disruptions to one's sleep. These are typically represented by simple guidelines meant to effectively promote a good night's rest.

If sleep problems persist after implementing sleep hygiene practices, it may be time to seek medical help. But what are some examples of good sleep hygiene? Below is some information I found during my research for this article. If you want to learn more, please go to the www.about.com website and type in “Sleep Hygiene.”

• Relax before bedtime
• Make sure your bedroom is quiet, dark, cool, and comfortable
• Make sleep a priority: don’t sacrifice sleep to do daytime activities
• Get up and go to bed at the same time every day, even on weekends
• Avoid caffeine and other stimulants
• Don’t smoke - in bed or at all
• Exercise every day, but avoid doing it 4 hours before bedtime
• Bedrooms are for sleeping and sex, not for watching television or doing work
• Don’t toss and turn
• Don’t take naps

I’ve been helping people with this problem for a long time and have used most of interventions listed above with them. One of the tools I also recommend for patients is the use of headphones with relaxation techniques, soothing sounds or music to help them to sleep. I also teach people relaxation response techniques that take about 7-10 minutes and one of the positive and surprising (to them!) side effects is a reduction in their sensation of pain.

So if you or someone you care about is undergoing chronic pain management treatment and is experiencing any of the sleep problems listed above, please know there is hope. The most important tool is for people living with chronic pain and any coexisting problem is to become active participants instead of passive recipients of their chronic pain management treatment plan.