Sleep and Persistent Pain

Sleep problems can look like this:

• Difficulty falling asleep

• Difficulty maintaining sleep

• Getting enough sleep (less than 7 hours)

Consequences can include these:

• Fatigue

• Lack of concentration

• Mood changes

Long-term sleep issues can lead to chronic fatigue, possible development of pain & exacerbate existing pain issues (1)

However, pain can also lead to sleep issues/disturbances (1).

The relationship between pain and sleep disturbances seems to be bi-directional as both can negatively influence the other (1-4). Poor sleep can in fact worsen pain intensity (1-2,4,9) through several different mechanisms (e.g., central sensitisation and low grade inflammation)(1,4). Poor sleep can also decrease the efficacy of pain medication (1). Insomnia is also related with Depression and Anxiety which is a common comorbidity in chronic pain (10-11)

An estimate of 50-80% of people with persistent pain report sleep disturbances, with roughly 53% meeting an insomnia diagnosis (2). This is compared to 3% in the ‘pain’ free population (2).

Human beings need both sleep and pain to survive (3).

Sleep is essential in maintaining a homeostasis of the body and benefits include (5):

• Aides in tissue healing

• Reduce systemic inflammation

• Increase immunity

• Improve cognition

• Many others.

Pain is essential (and inevitable) to survive as it helps protect us from disease and injury and assist in maintaining homeostasis (6-7). An example is a very rare condition called Congenital insensitivity to pain and anhydrosis (CIPA). People with this condition often die from a very young age and often don’t life past 25 (8).

So what can you do about it?

1. Assess for possible causes of sleep disturbance. It is recommended to assess for sleep apnoea and other sleep disorders (4).

2. Adopt sleep hygiene strategies. Surprisingly these are not extremely effective in improving sleep and/or pain and/or pain related disability. However, they are relatively easy to adopt and have no adverse effects.

3. If these do not lead to any meaningful improvements a treatment named CBT-i (cognitive behavioral therapy - insomnia) could be explored. This treatment has been shown to be effective for insomnia including for people with persistent pain (2,4). It has also shown to improve fatigue and Depression (4). These results were maintained in the long term (at 1 year follow up). CBT-i is a treatment that actually encompasses a number of strategies including: sleep education, sleep restriction therapy, stimulus control education, sleep hygiene, cognitive therapy, stress management, relaxation, self-monitoring sleep (4).

What about medication?

There are numerous medications options available to assist with insomnia and sleep disturbances. However, none come without possible adverse effects and overall it is questionable if these effects outweigh the benefits (4). To break it down further:

• Opioids are advices against to treat insomnia. With possible side effects including; sleep-disordered breathing, opioid-induced hyperalgesia, tolerance, and dependence in populations at risk (2).

• Benzodiazepine may be prescribed for insomnia and have shown good effects in the short-term but not in the long-term (at 1 year+) (2). They are not a good options for everyone (e.g., if suffering from mood disorders) (2).

• Nonbenzodiazepam such as zopiclone and eszopiclone are another option that have been studied and have shown to have possible positive effects on pain (1).

• Antidepressants are another options, although not every type is effective. Some positive improvements in sleep are seen from amitriptyline, nortriptyline, trimipramine, and doxepin (2). These however, do not come without possible side effects and should not be mixed with a variety of other medications (2).

• Melatonin is commonly prescribed for insomnia and can also have an impact on pain (in the short term)(1).

• Antipsychotics (specifically quetiapine and olanzapine), anticonvulsant (pregabalin and gabapentin) are also option that could be explored by your Dr (2). Now a common theme, these again come with possible side effects and need to close monitoring from your prescriber.

References

1. Andersson, E., Kander, T., Werner, M. U., Cho, J. H., Kosek, E., & Bjurström, M. F. (2023). Analgesic efficacy of sleep-promoting pharmacotherapy in patients with chronic pain: a systematic review and meta-analysis. Pain reports, 8(1), e1061. https://doi.org/10.1097/PR9.0000000000001061

2. Cheatle, M. D., Foster, S., Pinkett, A., Lesneski, M., Qu, D., & Dhingra, L. (2016). Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Sleep Medicine Clinics, 11(4), 531–541. https://doi.org/10.1016/j.jsmc.2016.08.004

3. Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path forward. The journal of pain, 14(12), 1539–1552. https://doi.org/10.1016/j.jpain.2013.08.007

4. Nijs, J., Mairesse, O., Neu, D., Leysen, L., Danneels, L., Cagnie, B., Meeus, M., Moens, M., Ickmans, K., & Goubert, D. (2018). Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Physical therapy, 98(5), 325–335. https://doi.org/10.1093/ptj/pzy020

5. Hughey, L., Flynn, T. W., Dunaway, J., Moore, J., Sabbahi, A., Fritsch, A., Koszalinski, A., & Reynolds, B. (2023). Mindfulness, exercise, diet, and sleep - A necessary and urgently needed skill set of the musculoskeletal practitioner. Musculoskeletal care, 21(1), 198–201. https://doi.org/10.1002/msc.1686

6. Bonavita, V., & De Simone, R. (2011). Pain as an evolutionary necessity. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 32 Suppl 1, S61–S66. https://doi.org/10.1007/s10072-011-0539-y

7. Nagasako, E. M., Oaklander, A. L., & Dworkin, R. H. (2003). Congenital insensitivity to pain: an update. Pain, 101(3), 213–219. https://doi.org/10.1016/S0304-3959(02)00482-7

8. Daneshjou, K., Jafarieh, H., & Raaeskarami, S. R. (2012). Congenital Insensitivity to Pain and Anhydrosis (CIPA) Syndrome; A Report of 4 Cases. Iranian journal of pediatrics, 22(3), 412–416.

9. Onen, S. H., Alloui, A., Gross, A., Eschallier, A., & Dubray, C. (2001). The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. Journal of sleep research, 10(1), 35–42. https://doi.org/10.1046/j.1365-2869.2001.00240.x

10. Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of psychiatric research, 37(1), 9–15. https://doi.org/10.1016/s0022-3956(02)00052-3

11. Neckelmann, D., Mykletun, A., & Dahl, A. A. (2007). Chronic insomnia as a risk factor for developing anxiety and depression. Sleep, 30(7), 873–880. https://doi.org/10.1093/sleep/30.7.873

This blog was written by Samuel Bulten