PPM Editorial Board Outlines Management Strategies for Chronic Pain Patients With Insomnia
Educate, Then Let Patient Choose
C. Norman Shealy, MD, PhD
Fair Grove, MO
As with all medical problems, I list the best options I see and then let the patient choose. Here are some of the measures typically discussed:
- No caffeine after 3 p.m., and no alcohol within 3 hours of sleep. This may seem obvious, but it is important to review with patients because caffeine and alcohol abuse are so common: Excess caffeine is seen in more than 50% of patients with chronic pain, and alcohol abuse is present in 15% to 20%.
- Dietary supplements. I often recommend timed-release melatonin plus 0.5 g of taurine and 20 mg of lithium orotate (a salt of orotic acid and lithium). Regarding melatonin, only timed-release melatonin seems of use. I have patients begin with 1 mg just before bed. They may increase that dosage slowly up to 6 mg. Just today I had a patient who had gone up to 10 mg and was delighted with her response. Still, about 10% of patients do not experience a satisfactory response with melatonin, and non–timed-release formulations fail in a majority of patients.
- Cranial electrotherapy stimulation (CES), one hour each morning. CES devices deliver microcurrent levels of electrical stimulation directly to the brain and are used to treat anxiety, insomnia, and depression. To date, I have treated approximately 30,000 patients with the Liss CES device (now licensed to Fisher Wallace Laboratories). Used alone, the stimulator significantly reduces depression in 50% of patients. If I add the Shealy RelaxMate, a photostimulator, 85% of my patients with depression respond well. As noted, the CES device also is excellent for insomnia—but it needs to be used in the morning for that problem. Indeed, I prefer that patients not use the Liss device in the afternoon.
- Acupuncture/acupressure stimulation. There have been many studies done on this nonpharmacologic approach to treating insomnia. I recently completed an unpublished study of an approach that seems to have promise: LifeWave Silent Nights acupuncture patches. These patches use a variety of modalities, including acupressure, to stimulate acupuncture points and enhance sleep. In the study, I saw an 88% improvement in length of sleep, with improved quality of sleep and decreased daytime sleepiness. I am currently completing a double-blind study with the patches, and those initial promising results appear to be holding up: So far, about half of the study subjects who have used these patches for a month have reported improved sleep.
Diet, Exercise, and Good Sleep Hygiene Are Crucial
Elmer G. Pinzon, MD, MPH
My approach is to first have a solid understanding of the physiologic basis of sleep disturbances in patients with chronic pain. Abnormalities in sleep are thought to disorder the processing of painful stimuli by the central nervous system (CNS). The CNS is capable of modifying the way it processes a variety of impulses (neuronal plasticity). These abnormalities can lower pain thresholds. Substance P levels in the CNS (not in serum) are higher in fibromyalgia patients, for example, than in control subjects.1,2 In patients with fibromyalgia, a condition that often has sleep disturbances as a comorbidity, these elevated levels of substance P may be associated with nonrestorative sleep, in which a disorder of serotonin metabolism results in musculoskeletal pain.
In terms of therapeutic interventions, I have had some positive experience with chlorpromazine, a drug that increases delta sleep and decreases patients’ pain and tender points in fibromyalgia. But there are nonpharmacologic options as well. The use of nonoverexertional aerobic exercise, flexibility exercises, good dietary habits, avoidance of misuse of habituating medications, and regulation of sleep schedules are fostered in my clinic, with emphasis on interventional pain-modulating procedures and nonhabituating medications to control pain conditions.
- Vaerøy H, Helle R, Førre O, Kåss E, Terenius L. Elevated CSF levels of substance P and high incidence of Raynaud phenomenon in patients with fibromyalgia: new features for diagnosis.Pain. 1988;32(1):21-26.
- Vaerøy H, Helle R, Førre O, Kåss E, Terenius L. Cerebrospinal fluid levels of beta-endorphin in patients with fibromyalgia (fibrositis syndrome). J Rheumatol. 1988;15(12):1804-1806.
First, Diagnose the Problem
Peter A. Moskovitz, MD
Control of chronic pain is difficult, if not impossible, without restorative sleep. First, determine if it is falling asleep, staying asleep, or getting back to sleep that is troublesome. Second, is “restless” sleep with daytime tiredness a problem? If so, that might imply sleep apnea. Third, consult an internist, psychopharmacologist, or “sleep clinic” for advice on control of sleep patterns and insomnia.
Behavioral Approach a Core Strategy
Kern A. Olson, PhD
First, you have to get the pain under control. From a behavioral perspective, I use relaxation augmented by biofeedback to teach patients to lower their arousal levels; this will lower their pain level and promote sleep. I have reviewed a number of sleep studies of patients with pain and found a predictable pattern of stage 1 and 2 sleep with no stage 3 and 4 or slow-wave sleep. The goal is to improve stages 3 and 4; that will have a positive effect on mood and pain and will result in less daytime fatigue. In terms of pharmacologic interventions, I would add a note of caution about prescription sleep aids; these medications can have a negative influence on REM sleep, which is important for both sleep and mood. A natural alternative that I recommend is extended-release melatonin, which helps regulate the sleep clock. If patients continue to awaken, I encourage them to try more relaxation techniques, including self-hypnosis, to lower their arousal levels. I also recommend an additional small dose of melatonin 1 mg sublingual.
“Audio Drugs” and Other
Alternative Methods for
David E. Bresler, PhD, LAc
Because we’re usually trying to reduce the amount of medications that our patients with chronic pain are taking, we begin with a trial of alternative approaches to determine if they can reduce sleep latency (the length of time between closing their eyes and entering stage 1 of sleep); increase sleep duration; minimally affect sleep architecture (little or no REM suppression); avoid nightmares, night terrors, and multiple awakenings; and minimize hangover effects the next morning. Only if these alternatives are ineffective do we use hypnotics, anxiolytics (especially the benzodiazepines), antiseizure medications, antidepressants, and β-blockers. We never recommend opiates for insomnia.
Here are the three classes of alternative or complementary therapies that we have found most helpful to date:
Nutritional and Herbal Supplements