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14 Articles in Volume 15, Issue #6
Antihistamine for G-CSF–Induced Bone Pain
Book Review: Advanced Headache Therapy
Brain Drain: Lymphatic Drainage System Discovered in the Brain
Case History of Chronic Migraine: Update 2015 Part 2
Disturbed Sleep: Causes and Treatments
Is Topical Ketamine Ready For Prime Time?
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements
New App Helps Interpret Urine Drug Test Results
Osteoarthritis Update: 2015
Pain Catastrophizing: What Clinicians Need to Know
PPM Editorial Board: Tips for Treating Osteoarthritis
Practical Overview of Osteoarthritis
Status Report on Role of Stimulants in Chronic Pain Management
Treatment of Osteoarthritis

Disturbed Sleep: Causes and Treatments

Learn more about sleep-related neurological disorders, medications that adversely affect sleep, and how to treat poor sleep with good sleep hygiene, cognitive behavioral therapy, and CPAP devices.

In the Diagnostic and Statistical Manual of Mental Disorders 5, sleep-wake disorders encompass 10 conditions manifested by disturbed sleep, distress, and impairment in daytime functioning.1 Sleep disorders include insomnia, narcolepsy, restless leg syndrome, and breathing-related disorders (obstructive sleep apnea).

Excessive daytime sleepiness, or sudden somnolence, is a symptom that can occur with several sleep disorders. Excessive daytime sleepiness may include mild sleepiness, unrecognized episodes of “micro-sleep” or uncontrolled sleep attacks that result in falling asleep while in conversation, reading or watching television, or even while driving. Excessive daytime sleepiness may be caused by not getting enough hours of sleep or enough hours of quality sleep. On average, adults between 26 and 64 years of age need 7 to 9 continuous hours of sleep per day.2

 

Disturbed sleep can have many adverse health consequences, including fatigue, decreased cognitive focus, and altered mood, and can be a potential warning sign for medical issues—researchers believe that a lack of sleep may trigger inflammatory pathways that exacerbate arthritis pain.3 About two-thirds of patients who suffer from chronic pain also report poor or non-refreshing sleep due to a mutually reinforcing relationship between these 2 conditions.4,5

The problem of pain and sleep becomes even more complicated because many medications commonly prescribed to relieve pain, such as oxycodone (OxyContin, others), morphine (MS Contin, others), and codeine, can fragment sleep, or break up the sleep cycle.6 If a patient experiences poor sleep due to pain one night, he or she is likely to experience more pain the next night and so on, creating a vicious cycle. Chronic pain frequently is associated with a sleep-wake disorder, and these coexisting problems can be difficult to treat.

Sleep-wake disorders are diagnosed through a comprehensive assessment that includes a detailed patient history, physical exam, questionnaires, sleep diaries, and sleep studies. During a typical sleep study, patients are connected to testing equipment that measures various biological functions, including brain activity, muscle activity, respiratory effort, eye movements, heart rhythm, oxygen saturation, and sleep latency, duration, and efficiency.7 The temperature of the room is maintained at a comfortable level, and the lights are turned off. After the study is completed, the patient follows up with a specialist to review the outcomes and develop a treatment plan.

Narcolepsy

Narcolepsy is a neurologic disorder involving the loss of the brain’s ability to regulate sleep cycles normally. Patients with narcolepsy experience frequent excessive daytime sleepiness and disturbed nocturnal sleep, which often is confused with insomnia. Patients with narcolepsy generally experience the rapid eye movement (REM) stage of sleep within 5 minutes of falling asleep, but they tend to experience difficulties staying asleep. Patients with narcolepsy also have cataplexy, a sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions, such as laughing, crying, terror, etc. Some patients with narcolepsy also may suffer from sleep paralysis, or the temporary inability to move or speak while falling asleep or waking, accompanied by hallucinations. After developing narcolepsy, many patients suddenly gain weight, which can be prevented by active treatment.8

Restless Leg Syndrome

Another common sleep-wake neurological disorder is restless legs syndrome (RLS). RLS often is described as a creeping, crawling, tingling, aching, burning, pulling, or cramping sensation in the calves, thighs, feet, or arms. The sensations commonly are relieved by moving the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours. RLS can disrupt sleep, leading to daytime drowsiness. RLS affects 10% of the U.S. population.9 Prescription and over-the-counter (OTC) medications are available to reduce the restlessness. For example, OTC pain relievers (acetaminophen), nonsteroidal anti-inflammatory drugs (ibuprofen and naproxen), a trial of gabapentin, opioids, muscle relaxants, or sleep aids, as well as medications intended for certain other diseases (Parkinson’s disease and epilepsy) may be helpful.10 Also, self-care, coping skills, and avoidance of caffeine can help reduce symptoms.

Insomnia

The most common type of sleep-wake disorder is insomnia, which may cause difficulty falling asleep, staying asleep, or awakening. Many people have experienced a period of transient insomnia for less than 1 week due to stress or environmental changes, but if this persists it becomes acute insomnia (<1 month duration) or evolves into what specialists call chronic insomnia (>1 month duration).

There are several potential causes of chronic insomnia, including chronic pain or other physical illness, shift work, poor sleep habits, consuming too much alcohol or caffeine, certain medications, and certain psychiatric conditions.11 In primary insomnia, in which no clear environmental, psychiatric, or medical cause can be identified, individual differences in brain function may result in an overactive alerting signal that continues long after a patient would like to fall asleep. If underlying health issues or environmental factors cannot be identified or changed, then there are a variety of treatment options (besides medications) that are available to help patients with disturbed sleeping. These include biofeedback,12 meditation,13 and cognitive-behavioral therapy (CBT).

What is CBT for Insomnia?

CBT for insomnia is a psychological intervention (typically lasting 8-12 weeks) in which a provider will perform a series of sleep assessments, ask patients to complete a sleep diary, and work with the patient in session to help change the way he/she sleeps.14 During the 2005 National Institute of Health state-of-the science meeting on insomnia, panelists concluded that CBT is a safe and effective means of managing chronic insomnia.15 This program can help patients who suffer from insomnia even if their sleep problems have a biological etiology. The program does not use sleep medications but instead teaches patients how to improve their sleep by changing their behaviors.

The CBT intervention includes relaxation training (progressive muscle relaxation, diaphragmatic breathing, and guided imagery), cognitive restructuring (identifying and correcting inappropriate thoughts and beliefs that contribute to insomnia), stimulus control (associating bed only with sleep and sex), sleep restriction (decreasing excess time in bed awake), and sleep hygiene (instituting practices, habits, and environmental factors important for sound sleep).

Relapse prevention is another important element of CBT. Patients need to learn how to maintain what they’ve learned and prepare for a future flare-up. If a flare-up occurs, it is important that patients do not sleep more during the day to compensate for sleep loss. In addition, they should restart stimulus control procedures and re-engage in sleep restriction if symptoms persist.

Good Sleep Hygiene

There are 5 general areas that influence sleep hygiene: the circadian rhythm (24-hour cycle); age; psychological stressors; and substance use (nicotine, caffeine, and alcohol), and bedroom environment (see below).16

Circadian rhythms influence when, how much, and how well people sleep. These rhythms can be altered by various factors, including naps, bedtime, exercise, and exposure to light. Some recommendations for improving sleep hygiene include maintaining a regular bedtime and awakening time (including on weekends), getting out of bed at the same time every day, exercising regularly (finishing a few hours before bedtime), avoiding naps, and going to bed only when sleepy. Aging also plays a role in sleep and sleep hygiene. There are many more nocturnal awakenings after people reach the age of 40.

Psychological stressors can interfere with sleep. It is beneficial for patients to develop a pre-sleep ritual to break the connection between stress and bedtime. Relaxing rituals can include a warm bath or shower, aromatherapy, reading, listening to soothing music, drinking a warm glass of milk, and/or eating small portions of tryptophan-containing foods (seeds and nuts, cheese, and soy).17 Of note, patients should finish eating about 2 to 3 hours prior to their regular bedtime.

Patients also may want to designate another time of the day to write down problems and possible solutions instead of thinking of such things at bedtime. In addition, strenuous exercise during the day may promote better sleep, as long as it’s at least 3 hours before bedtime.

Providers should warn their patients about the role various substances (caffeine, alcohol, illicit drugs, medicines, and tobacco) can play in disturbed sleep. Many patients rely on caffeine daily to function. Caffeine is a stimulant that causes patients who ingest it to be more energized, awake, and capable of sustaining intellectual activity. Caffeine can be consumed in coffee, tea, soda, energy drinks, and chocolate, and takes 15 to 45 minutes to reach its maximum effect.18 Caffeine can stay in the body for up to 14 hours and can lead to disturbed sleep; thus, patients should avoid consuming caffeinated beverages within 6 hours of their regular bedtime.

Tobacco is another substance used by many patients, despite their knowledge of its harmful side effects. In 2013, an estimated 66.9 million Americans aged 12 or older were current users (during the past month) of a tobacco product. This represents 25.5% of the population, according to the National Survey on Drug Use and Health.19 Although smoking rates are down, the use of smokeless tobacco has increased from 4.8% in 2002 to 5.8% in 2013. Tobacco contains nicotine, a highly addictive drug that causes stimulation and almost immediately increases energy and alertness, which can affect sleep. An indirect public health problem posed by tobacco is accidental fires, usually linked with consumption of alcohol. Thus, if a patient cannot give up smoking, it is recommended that he/she discontinue smoking 2 hours before his/her regular bedtime.

Alcohol and drugs are yet another set of substances that many Americans consume daily, despite knowing the negative side effects of its use. Patients may drink alcohol as a means to facilitate relaxation, elevate mood, lower inhibitions in social situations, and relieve chronic pain. Alcohol initially can help patients become sedated, making it easier for them to fall asleep. The downside to alcohol is that it causes arousal 2 to 3 hours after it is metabolized and cleared.20 Providers should encourage their patients to discontinue use of alcohol within 2 hours of their bedtime.

Many prescription medications (antihypertensives, hormones, steroids, diet pills, and antidepressants) and OTC medicines (pseuodoephedrine [Sudafed, others]) can cause sleep problems.21 Illicit drugs (marijuana, cocaine, and MDMA [3,4-methylenedioxymethamphetamine], or “ecstasy”) also can negatively affect sleep. Smoking marijuana tends to reduce REM sleep, MDMA has arousing properties, and cocaine both increases wakefulness and suppresses REM sleep.22

Sleep Environment

Additional important considerations are environment factors, such as temperature and noise. If patients present with complaints of disturbed sleep, providers may want to ask about their sleep environment. The sleeping environment should be relatively cool, dark, quiet, and comfortable. Patients should be encouraged to sleep on a comfortable mattress and pillow. Patients should be informed about mattress flipping and the need to update their mattress after 4 years, which is considered optimal.23 The bedroom is to be used only for sleep and sex, and having a computer, tablet, cell phone, or TV on in the bedroom should be discouraged.

Obstructive Sleep Apnea

Obstructive sleep apnea is an extreme form of snoring in which a patient’s airway becomes partially or completely blocked several times during the night, leading to repetitive arousals without any recollection and disrupted sleep. Approximately 2% of women and 4% of men in the US suffer from the condition.24 There are several potential risk factors for breathing-related disorders, including obesity (excessive weight obstructs airway), inherited traits (small jaw size or large overbite), and use of alcohol before sleep. If left untreated, obstructive sleep apnea can lead to high blood pressure, heart disease, changes in mood, memory problems, and death.

If underlying health issues or environmental factors cannot be identified or changed, then there are a variety of treatment options (besides medications) that are available to help patients with breathing-related disorders, including weight loss, sleep positioning (do not sleep on the back), dental devices, and surgical procedures.25 The most common and efficacious way of treating this disorder is by using a continuous positive airway pressure (CPAP) device.

What does a CPAP device do?

A CPAP device works by blowing a steady stream of air into the nose through a mask, thus preventing pauses in breathing during sleep (apneas). CPAP is most commonly delivered through a nasal mask, but oral and naso-oral masks often are used when nasal congestion or obstruction is an issue.

The effectiveness of CPAP depends on user-compliance. If the patient does not wear the device, it will not work. Patients tend to become non-compliant when the CPAP mask is the wrong size or style, causing skin irritation or pressure sores. Therefore, the CPAP device needs to fit properly. In addition, some patients have trouble acclimating to the mask; they have difficulty tolerating forced air from the CPAP; the air causes them to have a dry mouth or a stuffy nose; they feel claustrophobic; they have difficulty falling asleep; they unintentionally remove the mask during the night; and/or they are annoyed by the noise of the device.26 Providers can give follow-up support and education to their patients to maximize compliance and ensure the success of CPAP treatment.

Another concern related to the use of CPAP is its cleaning and maintenance (see handout below). Patients, at times, are unaware of the need for daily cleaning of the tubing, mask, and headgear in warm soapy water (mild dish detergent). Patients also should wipe down the device with a damp cloth and wash the filter at the back of the machine with tap water weekly. The mask, tubing, filters, etc., also will need to be replaced after wear and tear.

 

Acknowledgements

The authors with to thank all the veterans and providers who contributed to the Pain Education School, from which this tutorial was created. The authors especially want to thank Carole Lexing, CRT, and Susan Payvar, PhD, BCIA-C, for their contributions to teaching about sleep disorders and their treatment.

The authors also want to thank the Jesse Brown VA Medical Center’s Anesthesiology/Pain Clinic department for their vision and ongoing support of the Pain Education School.

 

 

 

 

 

Last updated on: August 11, 2015
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Insomnia in Chronic Pain Patients
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