Key

If you answered yes to all five questions, keep reading. This brochure was written with you in mind. If you answered no to the first two questions, you should consult your doctor or a pain specialist. If your sleep difficulty is chronic, you should also consult your doctor or a sleep specialist. (See information at end of brochure on finding an accredited sleep center.) If you don't get enough sleep, or your sleep is troubled, you, and those around you, may suffer. You could be more susceptible to accidents or at risk for falling asleep at the wheel.

The good news is that you can take action to manage your sleep and pain together and/or with other treatment options.What you can do depends on the type of pain, when it occurs, and how willing you are to try something new.

BACK PAIN

Back pain is the most prevalent medical disorder in industrialized societies, affecting at least 80% of American adults at some time during their lives. One in every 50 American workers suffers a back injury and low back pain disables 5.4 million Americans each year. It is estimated that over $80 billion is spent on back pain each year. The personal cost is all too familiar to back pain sufferers. While most people with back pain (70%) recover in less than two weeks, some last longer. However, back pain can return and worsen. The more severe the pain, the more likely it is to interfere with sleep. A recent study found that about two-thirds of patients with chronic back pain suffered sleep trouble. This same study suggests that disrupted sleep seems to make the pain feel worse. Some pain medication, such as analgesics, may alter sleep patterns and make sleeping more difficult.

HEADACHE, ARTHRITIS & OTHER MEDICAL CONDITIONS

Headache is the second most common pain. Of those who experience the onset of headaches during sleep, 55% report having sleep disorders. In particular, there is a sleep connection with tension or migraine headaches (throbbing pain with blood vessels tightening and opening.) For example, migraine headaches can occur following sleep deprivation or too much sleep. Headaches have also been associated with such sleep disorders as sleep apnea, (frequent pauses in breathing accompanied by loud snoring during sleep), especially upon awakening and sleep movement disorders. In some cases, (e.g. snoring and sleep apnea) treatment of the sleep disorder reduced the headaches. Another type of headache that is even worse, cluster headaches, strike one after another in cycles. Blood vessel activity appears to play a role too. Cluster headaches may be related to sleep and sleep disorders as well.

Of people with rheumatic or arthritic disorders, as many as 75% often suffer from sleep problems. For example, people with osteoarthritis, especially of the hips and knees, tend to sleep lighter or have restless sleep. People with rheumatoid arthritis often have disturbed sleep with morning stiffness along with a decrease in energy, weakness and function. Flares, or an increase in inflammation and tenderness, can lead to sleep arousals. Individuals with fibromyalgia, a condition of aches and pains throughout the body and many tender points, usually report light and unrefreshing sleep, daytime fatigue, and difficulty with thinking and mood. Frequently, such people share many similar features with people that have chronic fatigue syndrome. They may suffer from chronic headaches, irritable bowel syndrome, and sometimes jaw pain or temporomandibular disorder. Often they have an arousal disturbance in their brain wave pattern during sleep, which may accompany restless legs (an unpleasant, tingling feeling in the legs) and sometimes sleep apnea (pauses in breathing during sleep accompanied by snoring). Because the poor quality of sleep can be associated with persistent muscle pain, tenderness and low energy of rheumatic illnesses, people with osteoarthritis, rheumatoid arthritis and fibromyalgia might require evaluation for primary sleep disorders.

In general, there is a high prevalence of sleep problems in various medical conditions with pain often altering the sleep process, and at the same time, the sleep problem interacts with the disease process. For example, patients with heart disease tend to have less deep sleep, more fragmented and less efficient sleep. This poor sleep can affect their well-being. Gastrointestinal problems, such as heartburn, ulcers and irritable bowel syndrome with their associated discomfort, often lead to difficulty obtaining a good night's sleep. In a recent Gallup poll, 75% of respondents reported that nighttime heartburn made it difficult to fall asleep and wakes them during the night. All of these problems may be associated with psychological distress, which also contributes to poor, inadequate sleep.

MANAGING PAIN & SLEEP PROBLEMS

Pain is often considered one of the most poorly treated health problems in America. Sleep problems and disorders are often not recognized or treated properly either. However, medication that appropriately addresses both the pain and sleep problem, exercise and psychological approaches may help. The psychological methods include:

These approaches take time and practice with a specialist. However, these methods have no known side effects, drug interactions, or concerns about long-term use. In fact, there may be more long-term benefits.

IDENTIFYING THE SOURCE OF THE PAIN

The first step in managing pain is to describe it and identify its source with your physician. Pain caused by inflammation, for example such as in arthritis, will call for a different treatment than pain related to migraine. And sudden (or acute) pain should always be discussed with a physician, as should severe and chronic pain. The pain medication selected should not negatively alter your sleep or lead to sleep problems such as insomnia. And sometimes, good, restorative sleep combined with relaxation, medications and other therapies can be the best medicine of all! Therefore, treatment may also address the sleep problem.

An anti-inflammatory drug would be indicated for inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDS) are generally the first line of treatment for conditions such as arthritis. NSAIDS include aspirin, ibuprofen, naproxen sodium and ketoprofen; all can be used for pain. However, long-term use of NSAIDS can hurt the stomach. Research and development of safer NSAIDs is now taking place. In the future, new OTC and prescription drugs may be available that don't affect the stomach. Some studies show that these medications interact with sleep, but there is no consensus regarding their effects on poor sleepers.

Acetaminophen is not an NSAID, but it is also indicated for mild to moderate pain. It has not been associated with stomach problems, as have the NSAIDS. And it seems to work in different ways in the body. It may prove helpful for a variety of types of pain. However, like the NSAIDS and many other over-the-counter drugs, acetaminophen is labeled for no more than seven to ten days of use. Again, no conclusions have been agreed upon concerning its effects on sleep.

IS THE PAIN RELATED TO STRESS OR DEPRESSION?

Some prescription drugs aimed at depression, i.e., antidepressants, may be effective for controlling pain in a low dose that is not usually used for treatment of depression. Tricyclic medications (e.g. amitriptyline), that are prescribed as antidepressants in low doses, may be effective for some people. While helpful for depression, some antidepressants (e.g., fluoxetine), can cause or worsen insomnia. You should ask your physician or pharmacist for information about potential sleep problems that can be caused by any medications that you are taking.

WHEN PAIN IS ACCOMPANIED BY SLEEPLESSNESS

When pain and sleeplessness strike at the same time, two drugs or a combination product may be recommended. Unfortunately, there is little published research on OTC drugs aimed at sleep problems. The common ingredients in OTC combination products are acetaminophen or an NSAID for pain and an antihistamine for sleeplessness.

Antihistamines are commonly used for allergies and colds, but they also have a calming or sedating effect. Such drugs may also cause dry mouth and throat and more severe side effects. They are meant to be used no more than seven to ten days without a prescription, and should be used with caution in elderly patients, especially males. There are no known effects of antihistamines on chronic pain.

Prescription drugs that promote sleep, called hypnotics, may be prescribed to help those with difficulty falling asleep, staying asleep or who wake earlier than they'd like (insomnia). They can be very effective in promoting and maintaining sleep. With current hypnotics available, there are fewer side effects and less concern about abuse or addiction.

Hypnotics are commonly prescribed for up to four weeks and can be particularly effective for acute (short-term) medical problems. There is little information about long-term use of hypnotics. Although they may have little effect on pain, the improved sleep can help daytime fatigue.

Many sleep specialists may also prescribe sleeping medication along with the changes in behavior discussed earlier to help a patient break a painful cycle of insomnia and emotional distress. For pain, narcotic drugs or medications that include narcotics, such as codeine, may be indicated. However, be sure to talk to your doctor about the possibility of dependence and unpleasant side effects.