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8 Articles in this Series
AAPM's Advice for Evidence-Based Opioid Prescribing Guidelines
CBT for Chronic Pain and Insomnia Needs More Research
Farewell Opioid Therapy, Hello Mental and Behavioral Health
Ketamine’s Growing Use in Chronic Non-Cancer Pain Management
MR Neurography in CRPS Assessment
Navigating New Opioid Prescribing Requirements: Practical Legal Advice for PCPs & Pain Specialists
TACs: Identifying and Treating the Non-Migrainous Headache
Video: Dr. Aronoff on Shifts in Pain Care

CBT for Chronic Pain and Insomnia Needs More Research

With presentation by Fiona Barwick, PhD

Put simply, sleep benefits accumulate over time, said Fiona Barwick, PhD, a clinical assistant professor at the Stanford Center for Sleep Sciences and Medicine, during the American Academy of Pain Medicine’s annual meeting in Vancouver, in April 2018. In a review of current research on the impact of cognitive behavioral therapy (CBT) on patients who suffer from both chronic pain and insomnia, Dr. Barwick shared why more long-term research may be needed to determine the full relationship between these two conditions.

The Sleep/No Sleep Pain Cycle

Most are familiar with the vicious cycle of insomnia, depression, and increased pain. Finding the right mix of CBT—including patient education, self-regulation, behavioral activation, and cognitive reframing—may help to break this circle. Patient education is often the first step. Unless a physician gets buy-in from the patient, said Dr. Barwick, it may not matter what he or she recommends. Helping patients to understand the dynamic between sleep and pain could be life-changing for them. Specifically, they need to know that “sleep affects pain more than pain affects sleep,” she said.

It’s also important for patients to distinguish between curative CBT for insomnia, which may involve a time-in-bed restriction, relaxation training, and bed re-association, for example, and sleep hygiene, which is preventive and may include steps such as avoiding stimulants, keeping the room dark, and sticking to a schedule.  

The Eye-Opening Research

While cognitive behavioral therapy for pain has been well validated and effective in improving patient outcomes (see Williams AC, et al’s 2012 Cochrane Database review and Qaseem A, et al.’s 2016 Ann Int Med review), it has been harder to demonstrate benefit in pain severity, especially when insomnia is involved.

Four studies examining a variety of pain conditions, combined with insomnia, found that sleep consistently improved with CBT therapy among chronic pain patients. Follow-up ranged from 3 months to 12 months. Pain outcomes did not improve, however, in terms of pain severity scale or pain interference measure. These results were disappointing given the close association between pain and sleep, said Dr. Barwick. Why was there no shift in pain if sleep improved, she asked? Potentially because these studies targeted sleep rather than pain.

Another set of researchers attempted to target pain in patients with a variety of chronic conditions where insomnia was also involved. The CBT studies showed improved sleep outcomes (less wake time, etc) but, again, on average, no improved pain outcomes. Dr. Barwick explained that some reasons for these results may have been small sample size among different types of pain, and patient selection (low ratings to begin with).

She pointed to one more in-depth CBT pain-targeted sample that integrated third-wave therapies and ended up seeing some pain-scale rating improvements. The broader scope and patient education conducted among the study group may have impacted the results, she noted.

Toward a Resolution

So what does all this mean? Clearly, chronic pain, biopsychosocial elements, comorbidities, and individuals make for complex relationships, explained Dr. Barwick. Why does CBT for sleep and pain improve sleep but not pain? Is there a unique chronic pain-insomnia phenotype? Do altered cognitive and affective regulation, activity level, or autonomic dysregulation severity play a role, she asked the audience.

“Perhaps we need to sequence self-relaxation strategies earlier in the treatment protocol,” Dr. Barwick offered as one potential tweak to a CBT approach. “The change in pain outcome that we’re hoping for in connection to sleep may just take longer to shift.” For instance, one study with an18-month follow-up did show some improvements with statistical (but not clinical) significance, she noted.

In conclusion, Dr. Barwick said hybrid therapies seem feasible and effective for sleep but not for pain. An integrated protocol may be the best option for now, especially if it involves refined components and tested protocols in larger populations with longer-term follow-up. This will take some work, she said.



Barwick F. Non-Drug Treatments for Pain and Sleep. Presented at the American Academy of Pain Medicine, April 26-29, 2018. Vancouver, British Columbia.


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