Relearning to Sleep: How to Cope with Pain Series

Many people with chronic pain have trouble getting regular, restful sleep. To improve sleep, it helps to understand how the 24-hour circadian rhythm works and to grasp other biological rhythms that affect sleep-wake cycles. In other words, what we do during the day impacts our ability to sleep well at night and visa versa.

Everything alive has a biological rhythm, an internal clock. We are aware of some rhythms and less aware of others: the earth’s rotation, the tides, flowers blooming, insects hatching, and our own biological rhythms such as digestion, hormones, body temperature, neurotransmitters and many other patterns that fluctuate on a schedule.

What do biological rhythms have to do with sleep?

Poor sleep affects our health and our health and habits affect our sleep. Disrupted sleep or insufficient slow wave (deep) sleep affects mood, the ability to think clearly, appetite regulation, immune system functioning, growth hormone release, and glucose regulation, among others. Poor sleep can cause poor wound healing, high blood pressure, mental errors, weight gain, depression, anxiety, and, of course, fatigue.

Each organ, in fact each cell, behaves according to a rhythm and depends on cues from its environment to start or stop its cycle. We may think of our genetic code as a set code we cannot control, but various environmental cues may trigger a gene or set of genes to express themselves – to start or stop their function. So called “clock genes” are triggered at night to initiate and maintain sleep while other parts of the brain are notified to inhibit wakefulness.

You feel your best when a biological cycle starts and stops at the optimal, or Sleep Patternintended, time. When we talk about wanting to sleep better, what we really want is to be more awake during the day and logically assume the best way to feel more awake is to get better sleep. But the circadian rhythm is not isolated. Rather, it’s interdependent with many other cycles. A part of the brain, called the suprachiasmatic nucleus of the hypothalamus, is the sleep engine that can operate somewhat independently to cause sleep. However, many other factors keep us asleep and set the stage for the quality of sleep we have.

Many naturally occurring hormones such as glucocorticoids and catecholamines fluctuate related to circadian rhythms. Cortisol is a glucocorticoid, sometimes referred to as a stress hormone, and has a daily rhythm that increases in the early morning to help us feel awake and then decreases throughout the daytime hours into nighttime to allow sleep. This diurnal pattern of cortisol can flatten out leaving you feeling tired all day and still unable to sleep well at night.

Melatonin is another naturally occurring hormone that assists with sleep. It is regulated by light and would ideally be low during the day and high at night for optimum sleep. Putting light, activity, and food into the proper times of each day to establish a routine helps hormones like cortisol and melatonin do their jobs.

What is deep sleep and how do I get more of it?

We all go through various stages of sleep approximately every 90 minutes or so. This includes shallow sleep, deep sleep, and rapid eye movement (REM) sleep, which is best known for when we dream. It is not uncommon to wake briefly in between 90-minute cycles. The most common issue arising for people with chronic pain is not often a lack of REM sleep or shallow sleep, but insufficient deep sleep. Deep sleep is dominated by delta waves, which are slow brain waves. It is the most restful type of sleep that helps you feel refreshed. Eight hours of shallow sleep will likely cause you to feel worse than fewer hours, which includes deep sleep.

There are many things that can rob us of deep sleep. Common culprits are:

  • Daytime habits involving light, activity, & food (LAF)
  • Oversleeping the day before or “catching up”
  • Doing other things in bed
  • Anxiety
  • Medications
  • Alcohol
  • Caffeine
  • Temperature
  • Noise

What can I do during the day to help me sleep at night?

Separate Day from Night: LAF

  • Light is the most obvious indicator for the body that day is separate from night. Be awake with the sun and asleep with the moon. Of course, this pattern has been altered artificially with the invention of electricity and with the flip of a switch. In other words, we can have bright lights all night. Natural light in the morning will signal melatonin to stop being released, while darkness at night will help signal for melatonin to be released.
  • Activity during the day will help increase deep sleep, as long as the activity is not too close to bedtime. Movement indicates it is daytime. Movement also signals to the body and brain that we are using energy and will be tired later.

If you don’t move enough during the day, deep sleep will be reduced. It can be a frustrating dilemma for many people with physical limitations or chronic pain. Moving may hurt, but restless sleep does no favors either. For the sake of improving sleep, movement can come in many forms. Some people find swimming or water movement is best for them. Others do chair exercises, chair dancing, or simple bike pedals they use from an easy chair. Regular aerobic exercise is a good way to increase delta wave sleep.

  • Food is key because you when you eat, you release other hormones like ghrelin, leptin, and glucose. Breakfast is still the most important meal of the day, as we “break the fast” of the nighttime hibernation, if you will. If you frequently skip or delay breakfast, try starting with small amounts of easy to digest food within an hour after waking.

As far as eating at night, you may have heard of tryptophan, a naturally occurring amino acid, found in certain foods. While turkey meat has a little tryptophan, dairy products have more and grandma may have been onto something with the glass of warm milk before bed. However, before you pour the milk or scoop a bowl of ice cream, remember that we are trying to signal to the brain-body that it is nighttime. If it has digesting to do, it signals to the body to be awake and would like to burn these calories. Since the energy consumed is not being utilized, it goes into storage — as fat.

Plant-based diets are gaining more and more support for improving energy, reducing risk of many diseases, and their anti-inflammatory properties are good for pain and healing as well. Fats take a lot of work to digest while carbohydrates and sugar signal quick energy is needed. It makes good sense to avoid eating several hours before bedtime. If you are used to late night feedings, it may take a few nights for your body and brain to adjust to skipping the last calorie boost, but you will sleep better for it.

What can I do at night to improve sleep?

  • Keep a regular wake time. You may not be able to control when exactly you fall asleep, but you have more control over when you wake up and also how long you stay in bed awake. You can use these two things to your advantage. Set your wake-up time to be the same time every single day, even if it means waking up earlier than you need to on certain days. This anchors one part of the 24-hour cycle so circadian rhythms know what to expect tomorrow around the same time. The other anchors are built in already: light, activity, and food.
  • Give up the fight to force yourself to fall sleep. Avoid going to bed until you are sleepy so you minimize the time you spend trying to fall asleep. (This includes giving up the idea that you need 8 hours of sleep). Yes, try less rather than harder to sleep and simply wait until you are sleepy. However, do not allow yourself to doze on the couch. Dozing starts a sleep cycle and then you wake, crawl into bed, possibly now wide-awake.

Use the 20-minute rule. If you snuggle into bed and lie awake for more than 20 minutes, get up, go back to the chair or couch, use a low reading light to read, do needle work, or something else relaxing until you are drowsy again. This will likely be at least an hour later. Then go to bed and you will begin a new 90-minute sleep cycle. If you wake later in the night and are awake for more than 20 minutes, get up and wait until you are sleepy again before you get back into bed.

  • Avoid oversleeping. Sorry, no more sleeping in. People often ask, “Can I catch up on sleep?” Short-term, yes, but it is only helpful for a day or so. Oversleeping is a common mistake that reduces deep sleep. It happens when we sleep in, go to bed early, and take long naps. This “catching up” on sleep may feel good temporarily, but the brain tracks the amount of sleep you have gotten for that 24-hour period and then will likely not allow you to get a good night sleep the next night. This often leads to restless shallow sleep, staying up late, more sleeping in, and before you know it, your brain wants to sleep during the day and cannot at night. The more you try to “catch up” the worse sleep quality and insomnia may become.
  • Create a sacred space for sleep. The antidote to insomnia is relearning to sleep. It is important to keep sleep only for bed and bed only for sleep. This pairing of bed and sleep is an example of classical conditioning similar to toilet training. We put toddlers on the toilet and wait for them to learn what physiological sensation goes with it. They eventually learn that these two things go together. We want the brain and body to learn that sleep and bed go together. Bed and sleep, sleep and bed. When we do other things in bed like watch TV, work, think or just be awake, we are teaching the brain that the bed is a place to be awake. If we then move to the couch to fall asleep, we are teaching the brain that the couch and sleep go together. We want to untangle this pattern and re-teach the brain that sleep and our bed are the two things that go together best. If you are awake for more than 20 minutes or so, get up and be awake somewhere other than your bed. Once your brain is ready to start a new 90-minute sleep cycle, you will feel sleepy and can crawl back into bed.

What is the #1 thing that keeps people from sleeping?

In a word: worry. Stinking thinking. Monkey Mind. Anxiety, fear, and ruminative thinking are the most common things that keep us awake at night. Humans are the only species known to replay regrets and worry about the future. Sometimes even the anxiety about not sleeping can keep you awake and it becomes a vicious cycle.

There are many techniques to help with these problems, including diaphragmatic breathing, mindfulness practice, biofeedback skills, relaxation, and meditation. These techniques are best practiced during the daytime without falling asleep, and then applied at nighttime with the intention of total relaxation in bed, followed by sleep. The daytime practice trains the brain to stay present and focused. Let go of worry and allow sleep at night and leave problem-solving for the daytime. Designate a worry place for scheduled worry time during the day in a place other than the bedroom.

Other Factors that Influence Sleep

Sleep and Pain Medications: Many medications may affect sleep. Two of the most troublesome are benzodiazepines (sleep and anxiety pills) and opioids (pain medication), which are often prescribed to help with sleep and pain. However, because the body naturally defends against long-term use of them, a natural tolerance builds when they are used frequently and they become less effective. Both benzodiazepines and opioids affect the breathing centers in the brain stem by slowing respiration. The brain may protect against this by reducing the amount of deep sleep, eventually not allowing any deep sleep at all. Some people have tried taking more medication or combining medications with alcohol. This practice is risky and can lead to slowed breathing and death.

Alcohol: Alcohol may seem to help with sleep, but it reduces good quality deep sleep. Having a drink with dinner may be better than a drink near bedtime; however, alcohol may be best avoided until you are sleeping well. Alcohol does not mix safely with most medications, especially benzodiazepines and opioids.

Caffeine: Caffeine is a stimulant that prevents sleep for most people. Moderate amounts of coffee unadulterated by too much sugar and cream in the morning may be fine for you and even have some health benefits. Since caffeine can stay in your system for up to 10 hours, if you drink more than a couple of cups in the morning or drink it afternoon, it may affect your sleep. Overall, keep the use of caffeine in moderation. Consume it only in the morning. Try to keep it “clean,” which means minimize processed ingredients.

Temperature: Being too warm can prevent sleep. The body cools at night as metabolism slows and you will be more comfortable at a lower temperature. A warm bath before bed may still be helpful as long as there is enough time for the cooling system of the body to kick in. A fan might provide white noise and keep you cool as well.

Noise: Intermittent noise and light of the TV, although possibly mind-numbing and comforting, actually tells your brain to avoid deep-sleep. If other noises keep you awake, it may be worth investing in a pair of custom made earplugs. There are many types of earplugs on the market, as well as white noise and sound machines. However, if you want to be able to hear things because you are a parent or caregiver, you will have to choose between allowing deep-sleep or staying more alert in shallow sleep. You cannot have both at the same time. Caregivers, military, and firefighters often train themselves to sleep shallowly so they can quickly be awake and alert in a moment’s notice. This practice is not a sustainable way to sleep and eventually will have health consequences.

Am I supposed to get 8 hours of sleep?

Eight hours of sleep is an average, but oversleeping and spending time in bed trying to sleep decreases deep sleep and disrupts the 24-hour circadian rhythm. For poor sleepers, less may be more. If a chronic pain condition prevents you from sleeping for too many consecutive hours, you may choose to sleep in chunks (e.g, from 10pm-1am and again 3am-6am). For now, let go of the 8-hour idea and focus on getting better quality sleep until you are sleeping better. Once you relearn how to sleep through the night for shorter amounts of time, such as in 3-hour chunks, try going to bed a little bit earlier (15 minutes) each night until you find what works for you. If you decide that chunking sleep into 2 separate parts works better, just be sure to keep the same schedule each night for the chunks and continue to avoid oversleeping.

In summary, do your best during the daytime to engage in daytime activities (LAF) even when you are tired. Do not try to force sleep. Accept when you are awake and find something pleasant to do somewhere else until you are sleepy. Practice letting go and surrender to the sleep gods so you can keep calm and sleep on.

Date of last modification: August 1, 2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

Chronic Pain and Insomnia

Insomnia is common among people with chronic pain. It’s also problematic. It typically makes your pain worse and saps your abilities to cope. Understanding and overcoming insomnia is therefore important to successfully self-manage chronic pain.

Overcoming insomnia is possible for most people with chronic pain. Like most good things in life, though, it takes some work. There are no quick fixes when it comes to overcoming insomnia. There are actually a number of steps in the process. First, it’s helpful to understand the cyclical nature of chronic pain and insomnia. Second, it’s helpful to understand something about the three basic treatment options that are available for insomnia. Third, pursue one or some combination of these options.

Understanding the cyclical nature of chronic pain and insomnia

It’s common to think of chronic pain as the sole cause of insomnia – as if it’s a one-way street from chronic pain to insomnia. In some ways, of course, it makes sense as pain does in fact make it hard to sleep at night. Pain is a function of our nervous systems and when in pain our nervous systems are reactive. Our normal physical, emotional, and cognitive responses to pain are indicative of this reactive nervous system as well: we remain tense, alarmed, and focused on the pain. None of these automatic reactions to pain are conducive to falling or remaining asleep!

From these observations about pain and its effect on sleep, it seems logical that the best thing to do is to get rid of the pain. This approach, however, is insufficient in most cases of chronic pain.

First, this approach assumes that we can get rid of chronic pain. The reality, though, is that we can’t get rid of it. This fact is one of the things we mean when we use the adjective “chronic.” The most powerful procedures and medications can only reduce chronic pain, and don’t tend to get rid of it. So, there is no way around the fact that most people with chronic pain go to bed with pain. Even if it’s reduced, pain can continue to disrupt sleep.

Second, even if there was a way to fully cure chronic pain, it still might not be sufficient to overcome insomnia once you have it. Certainly, pain can start a bout of insomnia. However, insomnia is almost invariably maintained by more factors than just pain. One common factor is anticipatory anxiety about experiencing another night of insomnia. As you experience an insufficient amount of sleep night after night, it’s almost inevitable that you’ll start to worry about not sleeping as it comes time to go to bed. The arousal associated with this worry –as a form of anxiety or nervousness – can itself prevent you from falling asleep. In other words, insomnia can come to maintain itself!

Third, anxiety of all types can cause or maintain insomnia. People with chronic pain can become anxious for any number of reasons: loss of work; how to pay the bills; people not understanding what you are going through; loss of social or recreational activities; loss of your role in the family; and so on. People with chronic pain can also have anxiety disorders unrelated to their chronic pain. All of these issues can initiate and/or maintain insomnia.

Indeed, in most people with chronic pain, insomnia has multiple contributing causes. Certainly, pain can be one of those causes, but typically it is not the only cause. Moreover, these multiple contributing causes can come to exacerbate each other, making a vicious cycle of chronic pain and insomnia.

For example, say that chronic pain initially causes insomnia in someone. Over time, the insomnia becomes further complicated by nightly bed-time anticipatory anxiety about not getting enough sleep. At some point, worry sets in about loss of work, medical bills, strained marriage, and so forth. All of these factors come to maintain the insomnia over and above the role that pain has in maintaining insomnia. This chronic lack of sleep further stresses the person’s nervous system, making the reactive nervous system even more reactive. As such, the stress of it all makes the original chronic pain worse via its effects on the nervous system. As a result, we have a vicious cycle of chronic pain causing insomnia, which, in turn, makes the chronic pain worse.

This state of affairs reduces the individual’s ability to cope with pain and any of the other life’s stressors. Chronic pain and chronic insomnia can take its toll on anyone. This decreasing ability to cope fosters a greater sense of stress, which, in turn, elicits further pain and insomnia.

Chronic pain and insomnia are therefore complex phenomena that occur in a cyclical nature.

Therapies to address these problems must reflect this complexity. It just isn’t realistic to think that there can be simple, easy or quick fix to insomnia related to chronic pain.

Therapies for insomnia related to chronic pain

Many people rely on so-called “sleeping pills” to cope with insomnia. These pills are from two classes of medications that are technically called hypnotics (e.g., zolpidem) and benzodiazepines (e.g., diazepam). While common, their use is controversial in the healthcare field.

A number of problems are associated with their use. While providing short-term relief, they do not actually cure insomnia. Upon stopping their use, insomnia typically returns and, in the case of using benzodiazepines, the insomnia typically returns worse than when you initially started the use of the medication (Longo & Johnson, 2000). Moreover, the use of hypnotics has been associated with sleep-walking and other behaviors performed while sleeping (Morganthaler & Silber, 2002). In addition, it’s generally known that both classes of medications aren’t very effective. When compared to placebo, people taking hypnotics fall asleep on average 12.8 minutes sooner and people taking benzodiazepine medications fall asleep 10 minutes sooner (Buscemi, et al., 2007). Lastly, their use reinforces subtle, yet important, beliefs about yourself and your abilities to overcome insomnia. Namely, they foster associations that insomnia is a medical problem and that you need to rely on medicines to resolve this medical problem. In other words, they serve as a nightly reminder that you can’t overcome it yourself. You remain, in a word, helpless and must rely on something external to you (i.e., the pill) to do it for you. Now, of course, no one has these thoughts on an overt basis when going to bed at night after taking these medications. But, these subtle beliefs inevitably come to mind when the prospect of reducing the use of these medications is raised. After their long-term use, people can become quite concerned about reducing their use. The prospect is almost inevitably distressing and leaves people feeling helpless to the return of insomnia. What we are really talking about, here, is a subtle form of psychological dependence – the belief that you need the “sleeping pill” in order to sleep at night.

For all these reasons, the use of hypnotics and benzodiazepines for insomnia is controversial.

Chronic pain rehabilitation providers typically prefer to use a combination of two other types of therapies. These therapies are the use of tricyclic antidepressants and cognitive behavioral therapy.

Tricyclic antidepressants are old style antidepressants that are typically no longer used for depression. They are, however, used for chronic pain and insomnia. One of them, amitriptyline, is one of the most effective pain medications available (Hauser, Wolfe, Tolle, Uceyler, & Sommer, 2012; Wong, Chung, & Wong, 2007). They are also somewhat sedating and so are used at night to aid in falling and staying asleep. They do not produce a sense of dependency as often seen in hypnotics and benzodiazepines.

Cognitive behavioral therapy for insomnia is a short-term psychotherapy, usually provided by the psychologist on the chronic pain rehabilitation team. Cognitive behavioral therapy by itself can resolve insomnia once and for all. It breaks the vicious cycles of insomnia and creates new patterns of sleeping. However, it takes a whole lot more work than taking a pill.

Cognitive behavioral therapy requires a multi-pronged effort over time on the part of the patient. It involves the following:

  • Sleep hygiene changes
  • Regular use of relaxation exercises
  • Regular mild, low impact aerobic exercise
  • Cognitive interventions in which you learn how to overcome worry, or anxious thinking
  • Cognitive interventions in which you change your conceptualization of sleep to a more accurate and healthy understanding
  • Stimulus control (i.e., breaking patterns or associations that have developed over time between being in the bedroom and being awake)
  • Sleep restriction (i.e., intentionally limiting when you lay down to sleep or remain asleep in order to develop a normal sleep-wake cycle within the 24-hour day)
  • Tapering hypnotic or benzodiazepine medication use

Cognitive behavioral therapy is generally considered the most effective treatment for insomnia (Mitchell, Gehrman, Perlis, & Umscheid, 2012; Riemann & Perlis, 2009; Smith, et al., 2002; Taylor, Schmidt-Nowara, Jessop, & Ahearn, 2010).

While cognitive behavioral therapy is hard work, it neatly fits into the established protocols of a chronic pain rehabilitation program. As we have discussed in previous posts, chronic pain rehabilitation programs are cognitive behavioral based programs that already involve engaging in regular mild aerobic exercise, regular relaxation exercises, lifestyle changes some of which overlap with fostering sleep hygiene, and cognitive interventions for managing pain which have some overlap with those for managing insomnia.

The right approach for you

Whenever you decide upon a therapy that’s best for you, it is important that you discus it with your healthcare providers and allow them to be part of the decision making process. They are working for you and should have your best interests in mind. They also have an expertise in the field as well as knowledge of you as an individual, which puts them in the best position to advise you on what’s best.

It’s also important to get advice from healthcare providers who practice in the manner that’s right for you. As discussed in a previous blog post, all pain clinics are not alike. There are chronic pain rehabilitation clinics. There are long-term opioid management clinics. There are interventional pain clinics. There are spine surgery clinics. They can all go by the name of a “pain clinic.” Some of these clinics may be more prone to recommend hypnotic or benzodiazepine medications for your insomnia. Some of these clinics, specifically clinics with chronic pain rehabilitation programs, are apt to be more prone to recommend tricyclic antidepressants and cognitive behavioral therapy for your insomnia.

 

References

Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T. P., & Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs. Journal of General Internal Medicine, 22, 1335-1350.

Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40.

Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavior therapies. Sleep Medicine Reviews, 13, 205-214.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buyesse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.

Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients. Journal of Clinical Sleep Medicine, 6(2), 169-175.

Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-16-2013