Assessing Sleep Disturbances in Pain Patients

LAS VEGAS—Work-ups of pain patients with insomnia should include assessments of the analgesics the patients are taking as well as their comorbidities, especially psychological issues, according to Michael T. Smith, PhD, Director of the Center for Behavior and Health and Director of the Behavioral Sleep Medicine Program at Johns Hopkins University in Baltimore, Maryland.

Various pain medications can cause sleep disorders. Opioids, for example, can disrupt sleep and decrease REM sleep. They also can contribute to sleep-disordered breathing. Patients with sleep problems often have mental health issues such as depression and suicidal ideation and may be on antidepressants such as serotonin selective reuptake inhibitors (SSRIs) that often cause sleep disturbances. Tricyclic antidepressants also can decrease REM sleep.

Most studies show that around 75% of pain patients have some form of sleep disturbance, he said. Insomnia is probably the most common sleep disorder most pain specialists will encounter. Patients with insomnia have trouble initiating and maintaining sleep. Their sleep is nonrestorative, they are unable to sleep when they want to, and the sleep problem impacts daily functioning in some way. “Sleep is a drive, just like hunger. If you don't get enough of it, it builds up,” he said.

He noted that insomnia is more serious than is widely believed. “When you have a chronic problem with insomnia, it's really a potentially life-threatening disorder,” he said.

As insomnia wears on, individuals often start adapting to it in ways that are actually maladaptive. As insomnia becomes chronic, perpetuating factors take over, such as drinking alcohol to induce sleep, taking naps, and keeping regular schedules.

Cognitive behavioral therapy (CBT) is a recommended first-line treatment for primary insomnia, and it is as efficacious as pharmacotherapy, he said. It is a relatively brief treatment and it can be done in an individual or group format. The benefits of CBT over pharmacotherapy are that its effects are prolonged, it targets the driving factors of insomnia, and there are fewer side effects, he said.