The Chicken or the Egg?
By Raj N. Sureja, MD and Jenny L. F. Andrus, MD
As Interventional Pain Management Specialists, we frequently hear patients complain that they cannot fall asleep, or are awakened during the night by pain. Most practitioners know that lack of sleep can increase pain, and that restorative sleep can be the best medicine for relief. Our challenge is to break the cycle of sleep disruption, so our patients get the rest they need when pain is present.
• Pain is the number one medical condition to cause insomnia.
• A new study found that approximately two-thirds of all chronic back pain sufferers have sleep disorders.
• About 65 percent of those who report chronic pain experience non-restorative or disrupted sleep.
• The most prevalent complaint is difficulty falling asleep due to pain.
• Surveys revealed that waking too early due to pain (62 percent of respondents) and waking during the night (65 percent) are reported by chronic pain patients.
Many patients with chronic pain had sleeping problems before their pain started. The pain then turned a moderate sleep issue severe.
To help our patients sleep more deeply and efficiently, with fewer arousals and awakenings, we first determine which came first – the sleep disturbances or the pain. We address the older problem first, and handle each condition differently. If the predominate problem is pain, we address the painful process first; fixing the pain often corrects the impaired sleep. When sleep issues predate the pain, both issues must be addressed.
We start by counseling patients on proper sleep hygiene. We may suggest Cognitive Behavioral Therapy. If they adapt these behavior changes and still have difficulty, we may order a sleep study. A qualified sleep medicine physician can usually pinpoint the problem, whether sleep apnea, restless legs syndrome, periodic limb movement disorder or any other condition. Once a diagnosis is made, appropriate treatment can be recommended.
Sleep apnea is particularly important to diagnose. If severe, it can be dangerous, and is linked to many health problems, including chronic pain. We have seen patients with a chronic pain disorder become almost pain-free after their sleep apnea was addressed. Additionally, sedative medications are riskier when used in a patient with under-treated sleep apnea. These drugs include narcotic pain medications, as well as some commonly-used prescriptions for sleep. It’s important to evaluate for sleep apnea before using these medications.
We more commonly prescribe medications for sleep that have less risk to the patient and that may also address pain. These include some medications used for neuropathic pain.
For patients whose pain is causing the sleep disruption, we can treat the pain through a variety of techniques, including:
• Interventional pain treatments like steroid injections or nerve blocks;
• Pain medications, most typically non-narcotic;
• Physical therapy;
• Structured exercise to promote pain reduction and well-being;
• Cognitive behavioral therapy;
• Regenerative medicine techniques, including proliferant therapy, PRP, stem cell injections.
Managing pain involves much more than treating the pain generator. When sleep is impaired, pain worsens and patients don’t have the energy to deal with the important things in life, like their family and work. An effective mullti-disciplinary pain management program addresses all aspects of pain – including sleep – so the patient can return to wellness.
Raj N. Sureja, MD and Jenny L. F Andrus, MD are fellowship-trained, Board-certified Interventional Pain Management Specialists and practice at Orthopaedic & Spine Center in Newport News, VA.