Management of Insomnia in Patients with Chronic Pain Conditions

Abstract

The management of insomnia in patients experiencing chronic pain requires careful evaluation, good diagnostic skills, familiarity with cognitive-behavioural interventions and a sound knowledge of pharmacological treatments. Sleep disorders are characterised by a circular interrelationship with chronic pain such that pain leads to sleep disorders and sleep disorders increase the perception of pain. Sleep disorders in individuals with chronic pain remain under-reported, under-diagnosed and under-treated, which may lead--together with the individual's emotional, cognitive and behavioural maladaptive responses--to the frequent development of chronic sleep disorders. The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. This article discusses the evaluation of patients with chronic pain and insomnia and the available pharmacological and nonpharmacological interventions to manage the sleep disorder. Non-pharmacological interventions should not be considered as single interventions, but in association with one another. Some non-pharmacological interventions especially the cognitive and behavioural approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation). Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.

A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer

“…In other words, the level of pain at baseline resulted in worsening problems in getting to sleep even when the level of pain did not intensify over time. This is consistent with previous research has shown that problems with disturbed sleep can become chronic once they have begun, even if the original trigger is no longer present (Stiefel & Stagno, 2004). Adequate treatment for pain may prevent both current and future sleep problems for women with metastatic breast cancer.…”

“…Previous research has shown that pain and disturbed sleep can have a circular pattern in relation to each other, with pain triggering disturbed sleep and disturbed sleep increasing perceptions of pain (Latham & Davis, 1994;Stiefel & Stagno, 2004). Women with metastatic breast cancer and high levels of pain may be at risk for problems getting to sleep and staying asleep and those with these types of disturbed sleep may be at risk for even greater pain.…”

The relative importance of specific risk factors for insomnia in women treated for early‐stage breast cancer

“…low physical activity [15,23,24], alcohol intake [25,26], smoking [27][28][29][30][31]), poor physical health [32,33] and physical symptoms (e.g. pain [23,[34][35][36][37], vasomotor symptoms [38][39][40][41][42][43]), and poor psychosocial functioning (e.g. poor social functioning [44,45], life stress [15,[46][47][48][49], depression/depressive symptoms [19,23,50], and personality traits such as anger/hostility [51]).…”

Schlafstörungen im Alter

“…Insbesondere Erkrankungen, die mit einer Schmerzsymptomatik verbunden sind, wie z.B Arthritiden, Neuropathien, aber auch Schmerzen bei Patienten mit Neoplasmen gehen mit Schlafstörungen einher [25][26][27]. Es ist dabei die wechselseitige Verstärkung der Schlafstörung und der Schmerzsymptomatik zu beachten, die ein Aufbrechen eines sich selbst intensivierenden Circulus vitiosus notwendig macht [26,28].…”

“…Es ist dabei die wechselseitige Verstärkung der Schlafstörung und der Schmerzsymptomatik zu beachten, die ein Aufbrechen eines sich selbst intensivierenden Circulus vitiosus notwendig macht [26,28].…”