Sleep: An Important Ingredient in the Healing Process

Individuals who suffer from chronic pain often present with significant medical and psychiatric comorbidities that can exacerbate the pain experience and contribute to disability and a further erosion of quality of life. In this current climate of reducing the reliance on opioids or opioid sparing it is essential that clinicians effectively and efficiently identify and manage these comorbidities. One way to improve patient’s quality of life is to help them improve their sleep. If you utilize some of the behavioral interventions with appropriate rational pharmacotherapy, I think you’re going to have a really big impact on people’s sleep and with chronic pain.

• 70% to 80% of patients with chronic pain have sleep disturbance
• Pain and sleep are bidirectional: if someone is not getting restorative REM sleep, it causes release of interleukin 6, a proinflammatory cytokine, causing inflammation in the body. If pain is generated by the inflammatory process, like in rheumatoid or osteoarthritis, pain will be worse with bad sleep
• When sleep deprived, pain tolerance is lowered: If a cold pressor test (putting an arm in a bucket of cold water) is done, let’s say a pain patient can keep it there 30 seconds; that’s the pain tolerance. If you REM-deprive sleep and bring them back for the test, they’ll last 15 seconds
• With sleep deprivation comes a higher level of irritability
• A baseline depression + sleep deprivation = a greater level of depression
• Medications are part of the solution. But most clinicians don’t know how to effectively treat these patients for sleep; some treatments used are nonbenzodiazepines like trazodone, mirtazapine; some tricyclics
• The ultimate goals:
  • Improved sleep
  • Decreased pain
  • Improved mood
  • Opioid sparing
• Behavior change is important:
  • Sleep hygiene
  • Nutritional changes
• Behavioral insomnia programs are effective, getting people to change behaviors. For example, how many people have televisions in their bedroom? That’s a no-no. I always tell patients there’re only two things to do in your bedroom, the two Ss: sex and sleep. Intimacy and sleep. Everything else has to be out. People look at their cell phones right before they go to bed, and that’s not good.