There are very few people who have chronic pain who have sweet dreams all night and wake feeling refreshed – having disturbed sleep and waking feeling grouchy seems to come with the territory for so many of the people I’ve seen with chronic pain! If it’s not difficulty staying asleep, it’s difficulty getting off to sleep, and if it’s not that, it’s feeling like the sleep that has been had simply isn’t good enough. So to find an effective approach to managing sleep problems without medication sounds a bit like a Holy Grail. There is good reason to ensure restful sleep – studies show that poor sleep increases pain the following day, while a high pain day increases the risk of even poorer sleep that night.
And yes, there is a way to treat sleep problems in chronic pain without medication – but there is a downside, as always – it’s quite hard work!
Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern. It involves several strategies including:
cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia
Sleep restriction refers to restricting the amount of time spent in bed overall, and can mean reducing the amount of time attempting to sleep. For example, if a person hasn’t been falling asleep until after midnight, and has fairly disrupted sleep with several wakenings during the night, maybe achieving 5 hours sleep in total, sleep restriction would mean not even attempting to go to bed until five hours before he or she wants to wake up. Needless to say this can be pretty challenging for the person!
Stimulus control includes removing things like the clock from the room (too easy to keep looking at the clock and counting the hours awake), staying out of bed if not asleep, taking the radio and TV out of the room and using bed for sleep and sex and nothing else.
Sleep hygiene includes the above, but also introduces things like avoiding coffee or other stimulants before bed, keeping the room temperature warm-but-not-hot, exercising in the afternoon rather than late, avoiding eating in bed or during the night and so on. Relaxation techniques and other soothing strategies are also included.
Finally, cognitive therapy for catastrophic thoughts about not sleeping is used to reduce that sinking feeling about lying awake ‘all night’ and thinking ‘I’ll never cope with the coming day’. Some of the thought challenging that can be used here involves recognising that it’s actually possible to keep going on very little sleep; that while carrying out things like sleep restriction it’s no worse than having insomnia; and using positive statements like ‘it’s only for a while’ and ‘if I just take it easy over the day I’ll get through’.
Jungquist and colleagues conducted CBT-I for people with chronic pain in the study I’ve referred to today. Now while this is a small group of people, this is a group of people with chronic pain – most of the previous studies on CBT-I have been with people who have primary insomnia, or insomnia that is not associated with another medical problem. People with chronic pain often attribute their poor sleep to their pain, rather than any other factors, so it’s interesting that pain intensity didn’t change, although the interference of their pain on everyday life (as measured by the MPI, Multidimensional Pain Inventory) did improve.
This study protocol used an eight-week programme covering the strategies I’ve described above, and I’m immediately jealous because it’s common for me to see people for 12 weeks (once a week) to cover not only poor sleep, but also activity management, understanding chronic pain, developing relaxation responses, communication etc etc! 8 sessions are not a lot of sessions, and by comparison with the short-term effects of taking medication, these skills will last a lifetime.
While this study clearly demonstrates that CBT-I is an effective approach for people with chronic pain who also have the common symptom of poor sleep, I wonder whether this will influence the GP or pain physician tendency to prescribe sleep medication. Taking a medication is a mixed blessing – some people with chronic pain prefer to take a pill because it’s easy, quick, acts fast, and is a known entity. It’s also not a ‘psychological’ treatment. Other people don’t like medications because of fears that it will lead to addiction, disliking side effects, the need to remain alert at times during the night because of children, or because medications can be ineffective.
I have seen that if a simple, quick and easily taken medication is available concurrent with a difficult, long-term, self-managed approach, it’s more probable that the person will take the pill in a high-risk or set-back situation. Self management is not the easy way!
Self management through CBT-I doesn’t have to be carried out by clinical psychologists. Suitably trained and experienced clinicians of many persuasions including, as in this study, nurses, but also occupational therapists, social workers, physiotherapists and others can deliver CBT-I to people with chronic pain. It’s now more a case of GP’s and patients recognising that a non-drug approach is effective, and making sure funding agencies support delivery of this type of treatment. At the very least it should be provided with the same amount of enthusiasm and support as medication for insomnia.
Jungquist CR, O’Brien C, Matteson-Rusby S, Smith MT, Pigeon WR, Xia Y, Lu N, & Perlis ML (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep medicine, 11 (3), 302-9 PMID: 20133188