Pain specialist Steven King, MD, highlights a new review that looks at the complex, bidirectional relationship between sleep disturbance and chronic pain.
Many people with chronic pain have problems with sleep. Although sleep problems in people with chronic pain are often simply attributed to the pain, we have known for years that the relationship can be much more complex.
For example, more than 45 years ago it was reported that interfering with normal sleep cycles in healthy people can cause them to suffer widespread pain similar to fibromyalgia.1
Studies have also found a correlation between nighttime sleep and next day pain.2
It is now generally accepted that there is a bidirectional relationship between chronic pain and sleep disorders and that both need to be addressed when they are present if they are to be successfully managed.
A new review of the association between sleep disturbances and chronic pain3 sought to examine our current state of knowledge regarding 3 issues:
1. Chronic pain severity and duration in patients with both pain and sleep disturbances
2. Common comorbidities in patients with chronic pain and sleep disturbances
3. Treatment options when both chronic pain and sleep disturbances are present
PATIENTS WITH CHRONIC PAIN AND SLEEP DISORDERS. Compared to patients with chronic pain but without sleep disturbances, patients with both problems appear to be more likely to have pain of greater severity and duration that is more disabling and to suffer more often from comorbid depression, anxiety and suicidal ideation.
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TREATMENT OPTIONS. Very few studies on the topic, particularly medication management. The greatest number of studies on a single drug are on pregabalin, and there were 5. Of medications used primarily to treat impaired sleep, only melatonin was found to improve both sleep and pain, and this was based on a single study.
ADDITIONAL MEDICATIONS. Sodium oxybate– used to treat symptoms of narcolepsy and was found in 3 studies to improve both pain and sleep quality. Amitriptyline – a tricyclic antidepressant with potent analgesic effects improved pain and sleep in the 1 study looking at its effect on both. Sleep benefits of amitriptyline are considered a result primarily of the drug’s antihistaminic effects.
RESEARCH NOTABLY ABSENT. Noticeably missing: studies showing that either the benzodiazepines approved as sleep medications or the nonbenzodiazepine sleep medications (ie, zolpidem, eszopiclone, zaleplon) are beneficial for both sleep and pain. These medications continue to be frequently prescribed for patients with both pain and sleep problems and also coprescribed with opioids.
NONPHARMACOLOGIC TREATMENT. Cognitive behavioral therapy (CBT): most widely studied nonpharmacologic treatment for comorbid pain and sleep disorders. Considered first-line treatment for both problems when they occur separately. In patients with both conditions, studies have looked at the effect of CBT focused solely on the pain or the sleep component, and a hybrid version that addresses both. All 3 forms of CBT were found to be equally effective although again there are a limited number of studies.
§The current review highlights the importance of addressing both chronic pain and sleep disturbances when they occur together.
§It also demonstrates how limited our knowledge still is regarding treatment options and especially whether pharmacologic treatments are beneficial and, if so, which ones.
§Although there are many guidelines on how best to treat chronic pain and how to treat sleep disorders, there are apparently no published guidelines on how best to treat patients with both problems.
§It is apparent that at the present time, CBT should be considered the best treatment when both problems are present.