Patients with chronic pain problems often have difficulty with sleep. If a patient does not have adequate control of their pain, it can often affect all areas of their lives, including sleep.
A night with inadequate sleep may result in increased pain the next day, which may disrupt sleep even further. It’s easy to see that if a patient gets into this cycle, it can lead to repeated visits to their health-care provider with complaints of inadequate pain control.
Most providers do an excellent job managing pain. However, patients are often not asked about how it’s affecting their sleep. This is an important question to ask, as 50% to 90% of patients with chronic pain have poor sleep quality.1 Pain can cause difficulty initiating and maintaining sleep, sleep fragmentation and unrestorative sleep.
Sleep issues are compounded if the patient also has comorbid sleep disorders, such as obstructive sleep apnea, restless leg syndrome/periodic limb movements of sleep or insomnia. Most patients will also have depression and/or anxiety related to their ongoing pain issues. Be sure to address these problems as well.
Opioids and analgesics are the usual drugs used to treat pain, but these medications are also known to cause sleep disruption. A study involving 42 healthy subjects assigned to sustained-release morphine sulfate 15 mg or methadone 5 mg showed significantly reduced deep, slow-wave sleep and increased non-REM stage 2 sleep.2 This may explain why patients who take chronic pain medications complain of increased fatigue.
Needless to say, management of sleep in patients with pain remains difficult. There are no standardized guidelines. Discussing good sleep hygiene is an important first step. Patients with pain often nap during the day. Ask them to refrain from doing so, as this can take away from their night time sleep. Also suggest they try keeping a sleep diary that includes the times they are taking their pain medications.
Advise patients to avoid stimulants such as coffee or soft drinks before bed, and teaching them relaxation techniques can be helpful, too. Other worthwhile alternative treatments include biofeedback and cognitive behavioral therapy, which will address both pain and sleep issues.
If sleep aids are necessary, start with a less sedating medication such as trazodone. Be careful when using zolpidem or eszopiclone as using these can cause over sedation and respiratory depression.
It can be difficult deciding which is most important, treating the pain or the sleep complaints. Ultimately, you must treat both and recognize that one will affect the other.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.
Lavigne G, McMillan D, Zucconi M. “Pain and Sleep.” Principles and Practice of Sleep Medicine 4th Edition. Philadelphia, PA: Elsevier Saunders, 2005. pp 1246- 1255.
Dimsdale JE, Norman D, DeJardin D et al. “The effects of opioids on sleep architecture.” J Clin Sleep Med 2007: 15:33-36.