Sleep Aids for People with Chronic Pain

Whether it is the inability to fall asleep, to stay asleep for the recommended seven to eight hours, or waking too early (for example, 4 a.m. versus 6 a.m.), chronic pain can cause sleep problems in a number of ways. Lack of sleep can worsen pain, and of course more intense pain then continues to interfere with sleep, so the two symptoms can become a vicious cycle. This makes sleep aids an important component of many treatment plans for people suffering from chronic pain.

It has been estimated that nearly two-thirds of those with chronic pain suffer from a sleep disorder. For those people, there are a variety of sleep aids available to address sleep problems and make it more likely that they will have more restful nights. Typical sleep aids include:

• Adopting habits that facilitate sleep, and condition the body to fall to sleep

• Using psychological techniques that can develop the mental state needed to fall to sleep and stay asleep

• Constructing the right sleep environment to minimize pain, including the right pillow(s) and mattress

• Using appropriate over-the-counter or prescription medication

Changing behavior is one of the best sleep aids

Eliminating behaviors known to interfere with sleep and adopting actions that can signal the body that it is time to prepare for sleep are both critical aspects of combating sleep problems.

Patients should avoid the following:

• Having caffeinated drinks like coffee, tea or soda within six hours of bedtime, which are stimulants

• Exercising within four to six hours of bedtime, because it can energize the body and require time to recuperate

• Eating too much, or eating spicy foods, close to bedtime because the body will not be as restful while digesting food

• Using alcohol or nicotine, both of which can disrupt sleep

In contrast, activities that alleviate pain and prepare the body for sleep can lead to higher-quality rest. These include:

• Vigorously exercising early in the day, which will help lead to deep sleep at night

• Taking a warm bath in the evening, which can relax muscles

• Stretching for three to five minutes before going to bed, which can loosen joints and make assuming a comfortable position in bed more likely

• Drinking a warm, non-caffeinated beverage about an hour before bedtime, such as warm milk, or herbal tea

In addition, going to bed and waking up at generally the same time every day will help reinforce a ‘sleep cycle’ that the body will recognize and to which it will respond appropriately.

Using psychological approaches to minimize pain at bedtime

"Mind over matter” can help patients override or re-balance pain signals with more pleasant, sleep-inducing thoughts. A few techniques that have proven successful are:

• Hypnosis, which can help a patient associate certain actions with sleep (such as turning off lights or closing doors and drapes)

• Visualization of something peaceful or relaxing, like clouds in a night sky, can be a good transition from the work day to more restful nighttime

• Meditation or other relaxation practices that incorporate deep breathing and aim to free or compartmentalize feelings of stress and in the body

• If worrying is a major deterrent to sleep, try “forced worrying”. Several hours before bedtime create a brief period of time (15 minutes or so) to write down worries. Then leave the room where you wrote down the worries, and if worrying recurs, remind yourself that you will have time to think about these worries tomorrow.

Creating an environment conducive to sleep

Sleep and inviting bedroom can also be effective sleep aids, and can make a difference in the quality of sleep experienced. The following can make for a restful environment:

• Body or neck pillows to provide support; pillows under the knee, or between the knees if a patient sleeps on his side, can relieve stress on painful areas

• A high quality mattress that is both comfortable and provides adequate support

• Appropriate levels of light and sound. Light can be minimized using black-out curtains, and noise diminished by a solid wood door between rooms. Alternatively, gentle music can provide a soothing background to drift off.

Using medication to manage pain and reduce sleep problems

If behavior changes and environment have not proven to be sufficient sleep aids, patients should discuss with their physician whether over-the-counter or prescription drugs should be used to treat their pain, improve their sleep or both.

• Pain medication. These include analgesics (e.g. Tylenol), and non-steroidal anti-inflammatory agents (NSAIDs), such as aspirin, ibuprofen (e.g., Advil), naproxen (e.g., Aleve), and the new COX-2 inhibitors. Stronger prescription pain relievers include muscle relaxants (generally used to treat muscle spasms) and antidepressants and anticonvulsants, which are sometimes used to treat nerve pain. Narcotic pain relievers are available but are generally used after surgery to treat intense pain.

• Sleep medications. These can include over-the-counter drugs that have a sedating effect, like antihistamines, or combination pain reliever and sleep aids, such as Tylenol PM. Hypnotics are stronger prescription medications that promote sleep, and fall into two classes: the benzodiazepines (e.g., Halcion or Restoril), and the non-benzodiazepines, benzodiazepine receptor agonists (e.g. Ambien or Lunesta). A new type of sleep medication, marketed as Rozerem, was introduced to consumers in 2006 and works by targeting the melatonin receptors in the brain that control the sleep-wake cycle.

• Antidepressants (Antidepressant medications). Sometimes sleep disturbance in pain patients can be a result of untreated clinical depression. Other symptoms of clinical depression include appetite disturbance, decreased energy and motivation, lowered sex drive, crying spells, anxiety, lack of enjoyment, or problems with concentration and memory. If you are experiencing these symptoms discuss the possibility of an antidepressants with your physician. Sleep disturbance should improve as the depression improves, beginning one to three weeks after starting antidepressants.

For more information on sleep medications, see Sleep medications by prescription and Insomnia medications non-prescription.

While all these medications have been approved by the FDA, it should be noted that all have side effects which patients should consider, including the highly addictive nature of some pain medications and sleep aids. Also, combinations of pain and sleep medications may interact poorly, so caution should be exercised when using both types of drugs.

Managing pain and sleeping well

Back pain regularly causes sleep problems, which can then delay healing or even make a back problem worse. Before deciding to use medications to treat their pain or sleep disorders, or in addition to medications, patients can adapt both their personal behaviors and physical environment to ensure each helps, not hurts, the chances of getting a good night’s sleep.

• Andrew R. Block, PhD

January 25, 2007

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