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Pain and Sleep: A Real Nightmare

Chronic pain can interfere with work, exercise, activities, and general daily life.  At the end of the day, after suffering through pain to complete necessary daily tasks, a good night’s sleep sounds like the perfect cure.  However, for the majority of chronic pain sufferers, laying down for a solid eight hours is unfortunately not that simple. An estimated 90% of chronic pain patients treated at a pain management clinic describe seep issues, and 53% of these patients are diagnosed with moderate to severe insomnia.  

The correlation between pain and sleep trouble can become a vicious cycle.  Being in pain can prevent sleep, and lack of sleep can increase perception of pain, making it even harder to sleep, and so on.  Pain can either make it difficult to fall asleep, or cause frequent nightly wake ups. Chronic pain can be debilitating enough, that a patient cannot work or exercise, and is therefore not capable of using energy stores during the day to be tired enough to sleep.  Additionally, day time activities can keep the mind off of pain, but once the TV is off, the bedroom is dark and quiet, more focus can go on the pain, and making falling asleep more difficult. It is also common for pain to wake a patient up several times a night, due to a change in positions, or having to maintain the same position for too long.  Additionally, if the pain is treated with opioid medication, this too can potentially lead to insomnia, since these medications are known to interfere with the REM sleep, and can lead to respiratory issues while sleeping.  

Unfortunately typical tricks to help with sleep troubles may not be as helpful when the insomnia is secondary to pain.  Increasing mobility during the day can be a difficult, if not impossible feat. Some of the medications used to treat insomnia are dangerous to take with opioids, medications like Ambien and Xanax, and therefore patients are frequently left to choose between pain medication or sleep medication.  

There are, however, therapies that can help with sleep, which include both non-medication and medication based solutions.  First, it is recommended to make sure to practice good sleep hygiene. This includes a consistent bedtime, avoid caffeine in the afternoons, no strenuous activity four hours prior to sleep, and avoid naps.  If this does not improve sleep issues, psychotherapy can be beneficial. This can include deep breathing exercises, meditation, cognitive behavioral therapy, and other therapeutic techniques. If these don’t work, there are medications that can help which are safer to take with opioid medications, such as melatonin, benadryl, or prescription medications.  Additionally, acupuncture is a useful tool that can help with both the pain and the insomnia.  

Chronic pain can lead to difficult days, but unfortunately it frequently also leads to difficult nights.   Insomnia can be equally debilitating. If pain and insomnia are something you are suffering from, you can discuss options with your PCP or your pain management specialist, and they would be happy to help find the right resources to improve your daily, as well as nightly life.  

Resources

Bolash, R., & Drerup, M. (2019, November 18). How to Beat Insomnia When You Have Chronic Pain. Retrieved January 16, 2020, from https://health.clevelandclinic.org/managing-insomnia-for-those-with-chronic-pain/

Deardorff, W. (2016, December 12). Psychological Approaches for Insomnia. Retrieved January 16, 2020, from https://www.spine-health.com/wellness/sleep/psychological-approaches-insomnia

Mann, D. (2010, February 17). Pain and Sleep: When Chronic Pain Disrupts Sleep and Causes Insomnia. Retrieved January 16, 2020, from https://www.webmd.com/sleep-disorders/features/pain-sleep

Tang, N. K. Y. (2008, September). Insomnia Co-Occurring with Chronic Pain: Clinical Features, Interaction, Assessments and Possible Interventions. Retrieved January 16, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589931/

Depression and Pain

It is estimated that up to 85% of chronic pain patients suffer from severe depression.  Sometimes pain is a symptom of pre-existing depression, and sometimes the depression comes as a result of the effects of chronic pain.  With potentially one fifth of the US population suffering from chronic pain, understanding the association between depression and pain, and the subsequent treatment of the two, is becoming more and more important.  

The areas of the brain in charge of mood management include the prefrontal cortex, the amygdala, and the hippocampus.  Evaluation of the brain post-injury shows that body pain is controlled by most of the same regions of the brain. The chemicals in the brain associated with depression, such as serotonin and norepinephrine, play a major role in pain perception.  When the regulation of these chemicals fail, which can be the case with depression, pain perception is intensified. Additionally, autopsies performed on patients who had chronic depression showed a consistently smaller prefrontal cortex. This could potentially mean that depression can cause a physical change in the brain, therefore leading to a chronic, and possibly permanent change in the brain structure.  

Another correlation between chronic depression and pain is due to the similar impacts both can have on someone’s quality of life.  Depression can cause a lack of interest in hobbies, activities, socialization, and can therefore lead to isolation. Without the ability or desire to partake in everyday activities, more focus is paid to pain, which increases the perception of pain.  Pain can cause immobility, loss of ability to work or function, also leading to isolation, and therefore depression. Therefore, regardless of which came first, the onset of chronic pain or depression can either cause or increase the severity of the other.  

Being aware of the correlation between these two debilitating diagnoses can help lead to more effective treatment.  Physical therapy can help increase a patient’s strength and mobility, which is widely known to help with pain, however movement itself produces endorphins, the chemicals which help with happiness and reward, and therefore can decrease depression symptoms as well.  Psychotherapy is widely known to help with depression, however this can also help to alter a patient’s perception and focus on pain, and can either decrease the pain symptoms, or help a patient better cope with chronic pain symptoms. Many antidepressant medications are also used with chronic pain management, regardless of whether or not a patient has been diagnosed with depression as well.  

Overall, chronic pain can be extremely debilitating on its own, but unfortunately it commonly occurs with depression.  Treating one without acknowledging the other can lead to insufficient treatment of both, so understanding their correlation in onset, as well as treatment, can help patients improve their quality of life, both mentally and physically.  

References

Depression and pain. (2009, June). Retrieved January 14, 2020, from https://www.health.harvard.edu/mind-and-mood/depression-and-pain.

Sansone, R. A., & Sansone, L. A. (2008, December). Pain, pain, go away: antidepressants and pain management. Retrieved January 14, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729622/.

Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Retrieved January 14, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494581/.