Ah, elusive sleep. Insomnia. Many of us have been there. For people with chronic pain — from back pain to fibromyalgia to the pain of cancer — sleep issues are especially common. And pain is one of the most common causes of insomnia. Up to two-thirds of patients with chronic pain conditions suffer from sleep disorders.
“Pain worsens sleep patterns and sleep disturbances worsen pain–it’s a vicious cycle,” says Robert Bolash, MD, from the Department of Pain Management at Cleveland Clinic. These problems can range from difficulty falling asleep to difficulty staying asleep; in turn causing heightened pain and worsening sleep.
Each year, Michelle Drerup, PsyD, of Cleveland Clinic’s Sleep Disorders Center, treats hundreds of patients who come to her with insomnia and a variety of painful medical conditions. “Treating insomnia can help a patient’s chronic pain subside,” she says. But before treating a patient for insomnia, she explains that it’s important to rule out other issues that could be causing the problems, including other sleep disorders, psychiatric disorders (like depression or post-traumatic stress disorder) or specific medications.
“At times, we see patients with pain diagnoses who really have a medical condition such as sleep apnea and when their sleep apnea is treated, their pain diminishes as well,” Dr. Bolash explains. “Those are the simple cases.”
More often, treating pain and insomnia requires a multidisciplinary team approach with help from different medical specialists. “We know that certain pain medications can improve sleep, and we prescribe these for patients who have both a sleep disorder and a specific pain disorder,” says Dr. Bolash. On the other hand, opioid pain medications can disrupt sleep and prevent patients from entering deep sleep after as little as one dose. Opioid pain medications can also cause sleep-related breathing disturbances.
He adds that once easily reversible causes such as excess caffeine or opiate use is stopped, behavioral therapy is often the next treatment of choice to help patients who have pain and trouble sleeping.
First: Understanding the insomnia
To understand how chronic pain might make it difficult to fall asleep, it is helpful to think about your bedtime routine. Most people will eliminate distractions in order to relax and fall asleep, including things such as turning off lights, making it quiet and getting comfortable.
“This quiet environment can cause problems for people with chronic pain,” says Dr. Drerup, “because then the only thing left for the person to focus on is the experience of his or her pain.” Unfortunately, without other distractions, pain seems to become “louder” and in many cases, the perception of pain — not necessarily the actual pain — increases when attempting to fall asleep.
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Second: Understanding the therapy
Cognitive behavioral therapy for insomnia (CBT-I) includes a number of strategies designed to improve sleep quality and help people change thoughts and behaviors that interfere with sleep. This type of therapy is often preferred over medications because it has no side effects and is a more effective long-term solution.
One of the main goals of CBT-I interventions is to help patients control or eliminate negative thoughts and worries that keep them awake. Through CBT work there is an increased awareness of thoughts related to sleep and once controlled, they tend to decrease and it is easier for the patient to fall asleep.
Another strategy is relaxation training, which is used to reduce or eliminate muscle tension and distract one from racing thoughts. Techniques include progressive muscle relaxation, guided imagery and meditation, among others. Regardless of the type of relaxation strategy used, the treatment involves professional guidance and the teaching of these skills over a number of sessions.
Dr. Drerup conducts both individual and group sessions on CBT for insomnia. Usually, patients will take part in three to eight sessions to learn these techniques and discover what works for them.
In addition to cognitive restructuring, behavorial strategies and relaxation techniques, Dr. Drerup goes over the standard guidelines for good “sleep hygiene” as follows:
- Use the bed and bedroom for sleep and sex only. Avoid sleep-incompatible behaviors in the bed, including reading, watching TV or worrying.
- Go to bed only when sleepy
- If unable to sleep within 15-20 minutes of getting in bed, get up and go into another room. Return to bed only when sleepy again. (Repeat if necessary.)
- Maintain a regular wake time regardless of the amount of sleep that night
- Avoid naps during the day
- Watch caffeine and alcohol intake
- Exercise, but don’t do it within a couple hours of bedtime
The good news is that CBT for insomnia has been proven effective with 70 to 80 percent of patients who seek this treatment.