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9 Articles in Volume 17, Issue #9
Can Physiological Profiles Affect Pain Treatment?
Editorial: Moving Forward from Trump's Opioid Declaration
How Might Pain Practitioners Best Offer Patients Relief Without Pharmacology?
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients
Lumbar Lordosis and Back Pain
Oxytocin, an Opioid Alternative, Ready for Regular Clinical Use to Manage Chronic Pain
Pain, Sleep & Suicide: The Core Role of Interventional Care
Spiritual Factors Impacting a Patient’s Ability to Cope with Uncertainty (Part 3)
The Inter-Connection between Smoking and Opioid Misuse

Pain, Sleep & Suicide: The Core Role of Interventional Care

When chronic pain begins to affect sleep patterns, induce depression, challenge functionality, or determine medication use, a comprehensive care plan may help to ward off suicidal thoughts.

Suicide in the United States has reached a 30-year high across all age groups, not only in completed action, but in ideation, according to the National Center for Health Statistics.1 Suicide is a persistent, yet preventable, cause of death that affects men and women of all races and socioeconomic status throughout the lifespan.2 Researchers have estimated that 9.2% of the US population will have contemplated suicide at least once in their lifetime,3 and it is estimated that 60% of individuals who have contemplated suicide will follow through within the first year of the onset of ideation.2 Therefore, identifying and managing patients who are at risk for suicidal behaviors represents an important consideration for all health practitioners who have fragile patients, particularly those with chronic, severe, or intractable pain.4 Although there are many risk factors for suicide, chronic pain and related factors such as sleep disturbance and depression may strongly contribute to suicidal ideation.

Editor’s Note: In an online poll last month, Practical Pain Management invited a response to the following question: Does your practice assess for sleep disorders in your pain patients? to which 58% of respondents indicated “yes” and 42% replied “no”.

Given the health implications of disrupted sleep, particularly in patients with chronic pain conditions, gaining a deeper clinical insight and tools may be of immense value to every pain practice.

Related Research

Researchers have recently focused on the relationship between poor sleep, mental illness, and the onset of pain, all of which are associated with suicidal behaviors.4 According to Racine, one in five adults who suffer from chronic pain had suicidal ideation, and 8% to 41% of those adults attempted suicide at least once.3 A potential explanation for a sleep and suicide inter-relationship may originate from the role of sleep disturbances as a precursor to depression.5 Patients with chronic pain patients conditions have reported problems with sleep and sleep disturbances as common concerns, as well as indicated good sleep as one of the most important outcomes from effective pain treatment.6-10

In a large-scale survey investigating pain and sleep, participants experiencing pain also reported sleep difficulties significantly more often than those who did not report chronic pain.11,12 Pain has also been known to increase an individual’s risk of developing insomnia.13-15 In addition to chronic pain, researchers have examined the comorbid relationship between opioid abuse, major depressive disorder, and sleep disturbance in suicide risk.16 Researchers have sought to identify specific risk factors of chronic pain that may lead to increased likelihood for attempting suicide. Tang and Crane identified both pain duration and depression as factors that increased an individual’s suicidal ideation.16 In particular, individuals who suffered from chronic pain for more than three months reported higher ideations of self-harm or suicide.

Later life is often characterized by increased frequency of sleep complaints and higher rates of suicide, as well.17 With timing, structure, and consolidation of sleep changing tremendously in older age, greater sleep fragmentation and difficulty maintaining sleep frequently have been reported.17 For example, Goodwin and Marusic found that short-sleep was more common in older age, with an increased likelihood of suicide ideation and suicide attempts.18 Reports of decreased time spent in deeper stages of sleep, such as slow-wave or REM sleep, have been cited more often with increasing age.17,18 Furthermore, improved risk assessments for suicide and suicide prevention efforts may be needed in primary care settings. Indeed, studies have supported the common occurrence of older adults visiting their primary care physician in the final weeks (45%) and month (73%) prior to a suicide death.19

Inside the Role of Sleep  

An electroencephalogram (EEG) measures electrical activity of the brain (via placing electrodes on the head) by mapping the firing of neurons involved in brain wave activity. These brain waves are indicative of the low-voltage electrical activity transmitted through the neurons. Four basic brain-wave patterns, which differ in frequency and amplitude, may be evaluated:

  • Beta [high frequency (> 13 Hz), low amplitude) occurs in states of relative alertness
  • Alpha (8-3 Hz, higher amplitude), occurs during states of relaxed wakefulness
  • Theta (4-8 Hz, even higher amplitude) occurs during a drowsy state
  • Delta (< 4 Hz, low amplitude) occurs during deeper sleep.

In addition, EEG may be used to measure the different stages of sleep, including rapid eye movement (REM) and non-REM phases of sleep. Non-REM sleep is further broken down into four separate stages:

  • Stage 1 is the earliest and lightest stage of sleep (consisting of theta waves when we begin to sleep), but one can be easily awakened by any significant stimulus in the environment
  • Stage 2 occurs when heart rate and respiration begin to even out, body temperature decreases, and brain waves alternate between short bursts (or spindles) and longer, more complex waves
  • Stages 3 and 4 reflect deep sleep, which is marked by delta waves and are most important in terms of restoring energy, strengthening the immune system, and regulating the release of growth hormones.
  • REM sleep is characterized by a period of unconsciousness that is notable for the eyes darting back and forth, as well as more fluttering of heart rate and changes in respiration. In addition, individuals usually report having vivid dreams at this stage, which is marked by beta waves. This sleep stage is an important time for the consolidation of memories, storing knowledge into long-term memories, as well as slowing consolidation from the previous stage. It has been found that there are usually five to seven REM periods during a normal night’s sleep. Of particular note, during periods of pain and depression, there is usually a disruption of normal sleep and REM patterns that negatively affect homeostasis or normal bodily functioning.

The Inter-relationship between Pain and Sleep

Sleep and pain have a cyclical relationship such that individuals who experience chronic pain are at an increased risk of developing sleep disturbances.20 A persistent lack of sleep may lead to hyperalgesia, in which the patient may perceive a heightened pain leading to poorer sleep.13,21,22 In one study, researchers reported that pain-free volunteers who underwent sleep disruption for four hours during REM sleep experienced more hyperalgesia than the volunteers who had four hours of non-REM sleep.23

Other findings suggested that individuals who experienced recovery sleep (eg, a nap) after slow wave sleep interruption, had a significant increase in pain threshold, although the effect was not found with interrupted REM sleep.24 In addition, Savard and Morin25 found that 30-50% patients suffering from chronic pain conditions (eg, osteoarthritis, rheumatoid arthritis, fibromyalgia, and musculoskeletal pain conditions) also reported insomnia and 53% of pain patients who had insomnia required medical attention for their sleep dysfunction.26

Chronic pain may be described as an epidemic, especially in older adults. In a nationwide survey of 7,601 seniors in the United States, 52.8% reported experiencing pain that interfered with activities of daily living in the previous month.27 In general, similar findings have been reported in Asia, Australia, and Europe, from first- to third-world countries.28-30 Several reports suggest that patients with chronic pain may be more likely to develop psychosocial comorbidities (eg, depression, anxiety, and suicidality) leading to dysfunction in various aspects of pain such as duration, intensity, and sleep-onset.13,16

Pain has been linked to symptoms found in major depressive disorder among older adults as well, including reduced sleep time and suicidal ideation.31 Older adults may experience  pain severe enough to disrupt sleep, often waking more frequently to use the bathroom.32 Older adults also may be more likely to take medications with adverse side effects, including agitation, restless legs, or sleeplessness, contributing to disrupted sleep. When sleep is interrupted in older adults, they may not gain the benefit of sleep’s process for promoting body repair, enhancing the immune function, or memory processing.32

Suicide Reduction

By approaching the inter-relationship between chronic pain, sleep disturbance, and suicide as a common occurrence, pain practitioners have an opportunity to tailor treatment to reduce suicide risk.33 This necessitates a recognition that major depressive disorder (MDD) is a common comorbidity with chronic pain,37 and may influence adherence to a treatment program. For example, 66% of individuals with MDD reported chronic pain versus only 43% of individuals without MDD.37 Also, in many instances, the comorbidity of depression and chronic pain may increase the risk of suicide, due to poor adherence to treatment plans.38 However, the lack of sufficient—both in quality and quantity—sleep is not the only risk factor for suicide.

Well-researched risk factors, such as employment status, sleep quality, and sense of hopelessness, in addition to pain-specific risk factors (ie, pain location, duration of pain, and catastrophizing) may be contributing factors for suicide to be considered as part of a pain treatment plan.34-38

Whole Body Function

Good sleep is crucial to achieve functional well-being, whereas a lack of sleep may lead to a decline in physical and mental health.13,21,22 Recent evidence has reinforced the association between the level of sleep achieved and the maintenance of health with aging. Limited or restless sleep may increase the risk of a variety of poor health outcomes, including high blood pressure, diabetes, obesity, stroke, depression, cognitive declines, and Alzheimer’s disease.32 Increasing evidence supports the cascade that occurs when reduced sleep quality catalyzes inflammation, which may lead to illnesses such as obesity, diabetes, heart disease, and some forms of cancer.32

Too much sleep may also have a comparable adverse effect that increases the risk of some illnesses.32 Excessive sleep behavior appears more likely to arise as a side effect of other medical problems (ie, chronic pain or sleep apnea), rather than as a causative factor.32 Inadequate sleep and poor sleep quality are also associated with difficulty concentrating, irritability, fatigue, lethargy, emotional instability, and memory lapses, while insomnia specifically increases the risk of road or work accidents.39

Chronic insomnia has been defined as an unrelenting disturbance in sleep with a marked daytime impairment and distress.40 Research has yielded a pattern in which insomnia may precede the onset of depressive symptoms; however, this may infer that insomnia symptoms present as an imperative factor in the development of depression and suicidal ideation, which may occur but not exclusively.41

Exploring further, Baglioni and colleagues described insomnia as both a symptom of depression, but also as a potential precursor.5 Patient concerns about the consequences of poor sleep may lead to disastrous thinking about insomnia that result in changes to their routine (eg, canceling daytime activities due to poor sleep), and beliefs about their inability to control sleep, leading to feelings of helplessness and hopelessness.42 These dysfunctional beliefs may perpetuate a state of insomnia through many pathways, such as autonomic arousal, emotional distress, and negatively toned cognitive activity.43 As such, cognitive behavioral therapy (CBT) has shown effective in altering these dysfunctional beliefs; however, the most powerful effects have been observed when CBT was integrated into pain treatment.40 There are numerous resources that provide guidance for treating sleep disorders.44

Secondary Influencers Nightmares

Similar to symptoms of insomnia, nightmares are commonly reported among individuals who suffer from depression and who are at risk for suicidiation.45 Nightmares usually arise during REM sleep, and disturbed REM sleep may facilitate the frequency of nightmares. Evidence suggests that poor REM sleep and recurrent nightmares may be correlated with suicidal behavior among people who are diagnosed with depression.46 However, nightmares also have been associated with suicidal thoughts and behaviors, independent of a confirmed diagnosis of major depression.47,48 Researchers have pointed to different sleep variables in relation to suicidality with nightmares presenting with the strongest association.48

Sjostrom and colleagues concluded that individuals who reported experiencing nightmares at the time of the index-event (suicide attempts which occurred prior to the baseline interview) had a three-fold risk to re-attempt suicide.49

With treatment, both pharmacological and cognitive behavioral treatment (CBT) have effectively decreased nightmares and negative dream content.50 Moore and Krakow have also demonstrated that imagery rehearsal therapy to be effective in reducing nightmare frequency, intensity, and associated distress, specifically in nightmares related to post-traumatic stress disorder.51

Sleep Deprivation

Sleep deprivation, as well as long habitual sleep duration, may impair access to advanced cognitive functioning.52 Studies have uncovered the possibility that when a person is awake but not biologically meant to be alert, brain activity associated with executive functioning (ie, cognitive processes that include problem solving, divergent thinking, and planning) appears to suffer.41,52

An individual in this situation may lack the proper resources to make reasoned choices.41 Interestingly, according to Perlis and colleagues, 20% of suicides occur during the sleeping hours.41 When the proportion of the population that is awake at each given hour throughout the day is accounted for, suicide remains most prevalent during the nighttime, as opposed to the morning or afternoon hours.41

Opioid Use

Another factor that introduces concern for a person with chronic pain who is at risk for suicide is opioid misuse/abuse due to the possibility of overdose. Since the risk of suicide increases with the prevalence and severity of chronic pain, opioids may represent a catalyst if improperly prescribed.39 Although hard to quantify, some cases of overdose may have been intentional, while other deaths more likely may be accidental and attributable to a failure to following opioid prescribing guidance. For example, Im and colleagues recruited veterans who were prescribed opioid medications for chronic pain with the goal of examining the effectiveness of guidelines for opioid therapy and risk of suicide attempts.53 Results of the study indicated that facility-level care, where guidelines were strictly enforced, decreased the risk of suicide in patients taking opioid medications.53 To achieve this level of care, private practices and clinic settings may need to implement a process to ensure patients were keeping their follow-up appointments, passing drug screenings, and avoiding coprescription with other pain medications. This model seems to support a viable process to lessen the risk of suicidal events with sufficient medical oversight.

Opioid use in current and former addicts has been reported to not only sedate the user, but actually to interrupt sleep.54-57 Specifically, opioid use has demonstrated an increased wakefulness, greater shifts in sleep-waking states, and a reduced total sleep time, sleep efficiency, delta-wave sleep, and REM sleep.55-57 The impact of opioid use in disrupting sleep has also been studied in postoperative patients.58 A study conducted by Dimsdale and colleagues found that morphine and methadone were both reduced deep sleep and increased Stage 2 sleep.59 Many opioid receptors are situated in the nuclei which are active in sleep regulation,60 and it has been suggested that opioid peptides influence the maintenance of sleep states.61

Also, it has been suggested that opioids’ influence on sleep may be a due to central sleep apnea since opioids are well documented as respiratory depressants.62 Research has shown sleep architecture differs for each of the four phases of opioid dependence and withdrawal: drug induction phase, drug maintenance phase, acute abstinence phase, and protracted abstinence phase.63 During the induction phase, the use of morphine-like opioids (eg, μ-opioids) significantly disrupts sleep with decreased REM sleep and slow wave sleep and increased wakefulness and arousal during sleep. Total sleep time and sleep efficiency generally decrease during the induction phase while Stage 2 sleep duration and REM latency increase.

During the maintenance phase of morphine-like opioid use, a reduction in slow wave sleep and REM sleep continue, as do increases in wakefulness, arousal, and REM sleep latency, but symptoms of vocalization during REM sleep, significant delta burst, and increased daytime sleepiness may appear more frequently. In the acute abstinence phase, induction of insomnia is often reported in chronic opioid withdrawal, along with frequent arousals and reduced REM sleep. During the protracted abstinence phase total sleep time, slow wave sleep, and REM sleep increases, but the increase in slow wave sleep and REM sleep generally occurs between 13 and 22 weeks of abstaining from opioids.64,65

Interpersonal Theory of Suicide

In conjunction with the aforementioned risk factors for suicide, researchers have examined the Interpersonal Theory of Suicide in chronic pain patients.61 This theory aims to integrate psychological and social components that may contribute to an individual’s risk of suicide. Specifically, it examines an individual’s feelings of  “thwarted belongingness and perceived burdensomeness.”61 Researchers described the feeling of thwarted belongingness as the individual’s unmet needs for basic social connection.61 Furthermore, perceived burdensomeness was defined as an individual belief of becoming a source of hardship for others.

To test this theory, Wilson and colleagues recruited 303 individuals who suffered from chronic physical pain.61 All participants completed a wide-range of questionnaires examining pain severity, disability, depression, interpersonal constructs, and perceived burden. Findings confirmed that an individual’s sense of thwarted belongingness and perceived burdensomeness was directly correlated with risk of suicide, demonstrating a link between chronic pain and increased risk of suicidal ideation.61

Interventional Approaches to Tackle Pain and Poor Sleep

Pain practitioners who recognize that sleep disruptions may hinder any efficacy for pain relief, may more readily address the problem by adjusting their approach to the patient’s pain, and by doing so, may simultaneously lessen the risk for suicidal ideation.66 Nonpharmacological treatments may offer effective adjunct therapy for lessening pain, while also managing sleep disturbances. The most effective approach may be one that relies on interdisciplinary pain management programs, encompassing CBT for primary insomnia (CBT-I).67,68

Interdisciplinary pain management programs, based upon the biopsychosocial model, typically address any and all factors that may be impacting a patient’s pain.67 For example, physical activity has consistently shown beneficial effects on pain, sleep, cognitive, and physical function. In effect, patients with chronic pain who have incorporated aerobic exercise, muscle strengthening, or movement therapy (eg, Tai Chi and yoga) have shown improved strength, mobility, and balance, as well as less depression and anxiety.68 Conversely, inadequate self-efficacy has been identified as a considerable barrier to increasing physical activity and reducing sedentary time.68 A key aspect of the biopsychosocial model is to tailor an exercise plan to the individual, which promotes motivation, self-efficacy, and adherence.68

Before introducing an interdisciplinary pain management program, sleep was mentioned in CBT programs, but it was not typically used as an outcome measure.68 Currie and colleagues examined the effectiveness of CBT-1 in patients with chronic pain.68 CBT-I consisted of seven weekly, two-hour group sessions encompassing psychoeducation about sleep and sleep hygiene, cognitive therapy, stimulus control, relaxation techniques, and sleep hygiene. Patients following a CBT-1 approach reported improvements in both pain and good sleep as compared with a nonintervention control group three months posttreatment.68 Morin and colleagues also suggested that chronic pain patients suffering from insomnia may benefit from treatment aimed exclusively at altering sleep-related behaviors.42

Conclusion

In summary, the influences of pain and sleep on increased risk for suicide are well-documented, specifically regarding opioid use and sleep disruption.53,59 When designing a pain management plan for patients with a prior diagnosis of suicidal ideation, practitioners may first consider evaluating the patient’s pain and sleep cycle as possible originating or influencing factors for risk of suicide. Also, conventional biomedical treatments for pain (eg, prescription opioids) may impose an indirect influence by disrupting sleep quality.

The growing body of evidence suggests that an interdisciplinary pain management plan that incorporates a biopsychosocial approach may best address all the factors that encompass patients’ reasons for sleep disturbance and the possible onset of suicidal ideation.  

Last updated on: January 29, 2019
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Lumbar Lordosis and Back Pain

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