Updated June 2004

WHEN PAIN AND SLEEP PROBLEMS ARISE

When you can't sleep and your head aches or your back hurts, you are also likely to lose a lot of sleep. In fact, 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more. That was the finding of a 2000 National Sleep Foundation (NSF) Sleep in America poll. Yet many people don't recognize how large the problem is. Nor do zthey consider the possible consequences, which may include difficulty maintaining alertness, lack of energy, impaired mood, and trouble handling stress. Lack of sleep, so often due to pain or discomfort, can also put you at risk for injury, poor health and accidents.

HOW PAIN AFFECTS SLEEP

Pain is a leading cause of insomnia. Difficulty falling asleep, staying asleep and waking earlier than desired are all symptoms of insomnia. When pain makes it hard to sleep, falling asleep is often a major problem. However, 65 percent of those with pain and sleep problems in a 1996 NSF Gallup survey, indicated that they were awakened during the night by pain. And 62 percent woke up too early because of pain. In addition, many people who experience pain wake up feeling unrefreshed. Insomnia may be a short-term problem experienced for only a night or two now and then, or it may be chronic, lasting for a month or more.

PAIN AND SLEEP COINCIDE AND AFFECT EVERY ASPECT OF OUR LIVES

The combination of pain and sleep is a two-way process:

People with pain, particularly if it is chronic, often experience less deep sleep, more arousals and disruptions with waking as well as less efficient sleep. It is estimated that over half of chronic pain sufferers have trouble falling and staying asleep.

While pain interferes with sleep, disturbances to deep sleep result in light unrefreshing sleep. The poor quality of sleep and waking pain create a vicious cycle affecting mood, energy, behavior and safety. Hence, sleep and pain sufferers will find it difficult to function at their best.

Following are the results of the NSF 1996 survey:

UNDERSTANDING YOUR PAIN

What's keeping you awake? In the 1996 NSF survey, back pain was the most common response, followed by headaches and muscular aches and pains. Regardless of the type of pain you experience, chances are that it accompanies your sleep problem from time to time. Here are some questions to help you try to understand your pain and find relief.

Ask Yourself...

1. Do you experience your pain only once in a while (occasional), rather than most of the time (chronic)?
2. Is your pain minor (i.e., headache, backache, muscular aches and pains, menstrual cramps) rather than severe (pain that is worse than experienced before or comes on suddenly and doesn't ease or lessen)?
3. When you have pain, do you also have difficulty falling asleep, staying asleep or waking earlier than you'd like?
4. Is pain affecting the way you feel, think, and/or behave at home, at work, or when you are with family and friends?
5. Do you want to take action to control your pain and/or improve your sleep?

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.

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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.

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:

• learning to relax your muscles and free your mind of stress (relaxation training)
• learning to control specific body functions involved in headaches or other sources of pain, such as temperature or muscle tension (biofeedback)
• therapies that focus on changing your way of thinking about the pain experienced (cognitive therapy) or changing the behavior or attitudes related to the pain (behavioral therapy)

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.

WHAT YOU CAN DO TO GET GOOD SLEEP

Practicing healthy sleep habits can help improve the quantity and quality of your sleep.

• Establish a relaxing bedtime routine such as listening to soft music or taking a warm bath. Avoid alerting activities before bedtime.
• Avoid heavy meals or feeling hungry before bed. A light, healthy snack is best.
• Create a conducive environment that is cool, quiet and dark.
• Go to sleep at the same time every night and awaken at the same time each morning.
• Avoid caffeinated drinks (coffees, teas, cola drinks, etc.) and foods (chocolate) in the afternoon and in the evening.
• Avoid the regular use of alcoholic drinks to help you sleep.
• Avoid or give up smoking. Nicotine, like caffeine, makes you more alert, but can lead to fragmented sleep.
• Exercise regularly, but not within three hours of bedtime. A gentle, preferably supervised, aerobic fitness program (e.g. walking, aquafit, stationary bicycle) carried out on a regular basis is very helpful for improving the quality of sleep and controlling muscles aching.
• Use the bed only for sleep and sex.
• Get out of bed if you can't fall asleep within 15 minutes.
• Avoid regular naps. If you need to take a nap, do so by mid-afternoon and for 15-30 minutes only.
• When these approaches don't help, or when the sleep and pain problems don't go away, it may be time to try medications.

MEDICATIONS

When pain is minor and occasional, doctors and patients alike frequently consider using over-the-counter (OTC) products. These products are relatively low cost, easy to get, and often effective. When the pain is accompanied by sleep difficulty, more than one product or a combination sleep and pain product, may be considered. When these methods don't help, talk with your doctor about visiting a pain specialist/ clinic and/or sleep specialist/center. Pain clinics use psychological, physical or drug treatment procedures to manage pain. Sleep centers are useful for diagnosing and treating sleep disorders.

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.

OTHER DRUGS CAN AFFECT SLEEP

Some drugs, such as tranquilizers, can interact with your pain and sleep medications. This interaction can affect how effective either medication treats a specific problem. Additional problems can develop when drugs interact with each other in your body. That's why individuals suffering from sleep problems should be sure to discuss with their physicians the medications they are taking. For example, some antihypertensives (medication to control high blood pressure) can trigger sleep problems.

Nicotine can also impair sleep. While there are definite medical hazards associated with smoking, nicotine consumption disrupts sleep and can lead to less restorative sleep.

Alcohol, like nicotine, causes sleeping problems. Drinking alcohol while taking aspirin or nonsteroidal anti-inflammatory agents has been connected with stomach problems.: Heavy use of alcohol and excessive use of acetamin- ophens appear to increase the risk of damage to the liver.

WHEN TO SEE A DOCTOR

When changing your sleep behavior, using an over-the-counter pain relief/sleep product or trying behavioral methods may help. If these methods do not ease your pain and give you a good night's sleep, it's time to seek professional help. Your physician can help you identify the source of your pain and sleep problems. Talk to your doctor about all of your symptoms, so that together, you can develop a plan that leads you on the road to better health.

FOR MORE INFORMATION

For more information about sleep (including lists of accredited sleep centers), contact the:

• National Sleep Foundation
  1522 K St., NW, Suite 500
  Washington, DC 20005

Or visit the NSF Web site at:

• www.sleepfoundation.org.

OTHER PUBLICATIONS AVAILABLE FROM NSF

• When You Can't Sleep: The ABCs of ZZZs
• Sleep & Aging
• Sleep and the Traveler
• Wake Up!
• Sleep Apnea
• Melatonin: The Facts
• Strategies for Shift Workers
• Living with Narcolepsy

Text: Joan Rachel Goldberg Design: Mary Ann Bruce Illustration: Lisa Toji

The National Sleep Foundation thanks the following for their review of the material in this brochure:

• Thomas Roth, PhD
• Harvey Moldofsky, MD

return to National Sleep Foundation home page