Features March 2013 Issue

Don’t Let Chronic Pain Keep You Awake

Seek help to get the rest you need and prevent sleep disturbances that can worsen your pain.

About two-thirds of people who experience chronic pain from arthritis or other causes report poor or unrefreshing sleep, according to the National Sleep Foundation.

Sleep and chronic pain form a vicious cycle. “If you don’t sleep as well and you have many sleep complaints, difficulty falling asleep or waking during the nighttime, more than likely it can worsen your pain,” says Tina Waters, MD, with Cleveland Clinic’s Sleep Disorders Center.

But pain may not be the only thing keeping you from suboptimal slumber. That’s why it’s important to discuss any sleep problems with your doctor and explore all possible causes so you enjoy sleep that helps alleviate, not proliferate, your pain.

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Fitful sleep
Your body needs adequate sleep to recuperate and reset itself. Generally, the longer you’re awake and the more active you are while you’re awake, the more your body needs sleep and the better you’ll be able to sleep, Dr. Waters explains. Unfortunately, arthritis and other sources of pain prevent many people from staying active and increasing that sleep drive. Also, some studies suggest that patients with chronic pain may have altered brain-wave patterns that can disrupt sleep.

“If you have bad sleep, you set up this sleep deprivation state, and you’re always trying to catch up with your sleep, but then you’re not feeling as well so you’re more fatigued,” Dr. Waters says. “You become less active, which can worsen your mobility and pain.”

And if your pain is affecting your quality of life and preventing you from doing what you want, you may develop depression, a common product of chronic pain and contributor to sleep problems. In a 2011 study, arthritis patients with depression and anxiety had the highest risk of sleep disturbances.

Compounding the problem is that several medications used to treat arthritis—including aspirin, ibuprofen and naproxen—may worsen sleep efficiency in some patients. Similarly, antidepressant drugs, several of which are now used in managing chronic pain, may contribute to insomnia, which in turn may feed depression.

Arthritis may not be the lone source of your sleep troubles. Increasing age and obesity are leading risk factors not only for arthritis, but also obstructive sleep apnea (OSA), in which brief cessations of breathing cause arousals during sleep. OSA may be suspected especially if you snore or are excessively sleepy during the day. Another potential culprit is restless legs syndrome, characterized by nagging crawling sensations in your legs.

“More than likely, there are other contributing factors to sleep disruption,” Dr. Waters says.

Treating the problem
If your sleep is suffering, talk to your physician about your pain management, and consider an evaluation by a sleep specialist. A comprehensive sleep assessment should include a detailed review of your sleep history and sleep hygiene (see info box).

Based on this review, your sleep specialist may recommend further testing, such as an overnight sleep study to look for OSA or other primary sleep disorders and help guide treatment. Depending on the cause of your problem and your overall health, your physician may recommend a trial of a sleep aid. Dr. Waters says, these medications should be used with caution, especially in older adults, because they can worsen balance and cause memory disturbances, particularly when used along with pain medications.

“You don’t necessarily want to be on sleep medicines long term,” she adds. “You have to get a broad picture of what’s going on with older patients, what medications they’re taking and what aspects of sleep need to be looked at. If you still feel the need for a sleeping pill, pick the one with the least side effects that may target whatever the main complaint is.”

You also may be referred to a sleep psychologist for cognitive behavioral therapy for insomnia. As part of this treatment, the specialist will assess your sleep, identify factors that may prohibit good sleep, and work to correct these problems. “We often refer patients to a sleep psychologist because some studies have shown that in conjunction, cognitive behavioral therapy for insomnia and a sleeping aid for six months have the best long-term outcomes,” Dr. Waters says. “And you can potentially wean people off sleeping pills.”

With the right treatment and better sleep habits, she says, you can get the rest you need, even if you have chronic pain.

“Not everyone’s going to get eight hours of sleep and wake up feeling like a million bucks. That’s probably not realistic for someone with underlying chronic medical conditions,” she says. “It’s good to have a multidisciplinary approach and look at the pain, any depression, and sleep. You have to target each of those aspects, and if they are all well managed, I don’t see why you can’t have decent sleep.”