Difficulty sleeping is a common problem with patients in pain. Good quality sleep throughout the night often reduces the intensity and perception of pain. There are many causes and not a single solution for poor sleep. Pain in the neck and low back regions can cause discomfort within a short amount of time while lying down. Chronic pain can also cause anxiety and depression and that can contribute to sleep issues. To make matters even more complicated, the medications used to control pain may have side effects that impair sleep. Patients with chronic pain may also have other medical conditions that cause difficulty with sleep.
Treating sleep problems in patients with pain is often quite complex. The first step in treating sleep-related pain is to make sure the patient has good positioning of the body with regards to the spine in a neutral position. For neck pain this would be using a pillow that supports the head without having the neck bent if lying on the side, or a thin pillow with a slight neck roll if lying on the back. Low back patients need pillows to support their position if lying on the side between the knees and sometimes supporting the stomach or against the back. Having multiple pillows to maintain a good position is normal. If lying on the back, having a pillow under the knees improves the low back position reducing stress on those muscles. A bed that accommodates and maintains natural curvatures of the body, such as a memory foam mattress or an adjustable air bed also may be helpful to reduce stress and pain on either the neck or low back.
Pain, Anxiety, and Sleep
Pain itself can cause sleep difficulties related to anxiety and depression. The centers in the brain that interpret pain signals and those associated with anxiety and depression are in the same regions. Often as one develops chronic pain, anxiety also occurs and contributes to sleep problems. Not treating this problem adequately can worsen the pain since these areas of the brain tend to interact. Often anxiety has been treated with benzodiazepines like:
These medicines induce the first phases of sleep but not the deeper sleep that is needed. Anxiety in pain patients is often a symptom of depression, and is not well treated with the above medications. Using antidepressants actually treats the chemical imbalances that occur and with the right medications the symptoms improve as well as the sleep.
In pain patients, recent studies show that sleep problems are often mixed with significant concern about not being able to sleep. Patients tend to concentrate on not being able to sleep and this then becomes the reality. More drugs with side affects is typically not the best solution. More effective treatment is the use of cognitive behavioral therapy (CBT). This is a psychological method of retraining the brain to think in a constructive fashion and this reduces the anxiety about sleep and anxiety. Studies have found the use of CBT to be equally or more effective in managing sleep problems in pain patients than the use of medications.
Traditional pain medications like opioids also have negative effects on sleep. These drugs tend to reduce deep sleep and increase the shallow phase 2 sleep. Deep sleep phases are the periods that are necessary to feel rested. The more potent opioids also have a tendency to increase both obstructive sleep apnea and central sleep apnea. Both decrease oxygen levels in the body and lead to frequent awakening. Sleep apnea will markedly decrease deep sleep and the quality of sleep.
New Sleep Medications
Ease of falling asleep, being able to stay asleep, and having deep restorative sleep measure good quality sleep. With good sleep, one should feel well rested and have less pain. As noted above, one of the best management techniques for sleep is using cognitive behavioral therapy. Medications are starting to get better. The newer sleep medications over the last ten years like Ambien and Lunesta help induce sleep, they do not keep one asleep and may cause hangover and odd behaviors like sleep walking. Melatonin type medications also induce sleep, can be used safely long-term, but do not maintain prolonged deeper sleep. The newest medication is Belsomra and this appears to be inducing and maintaining sleep. One old time medication, doxepin at very low doses also seems to have similar properties.
If one has pain and sleep difficulties, it is important to discuss the problem with your pain physician. A trial of simple solutions, either CBT or melatonin type medications is reasonable. If the sleep problems are ongoing, being evaluated by sleep specialists and having a sleep study done is beneficial. Sleep apnea is common in pain patients and treating these problems is essential in managing sleep. Ongoing sleep problems may require a combination of solutions since multiple factors are probably present. Like managing pain, sleep is complex and often difficult to find a solution to improve the situation.
Thomas Cohn, MD
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