Insomnia and pain—a vicious circle
As a pharmacists you will often be the first port of call for customers with pain and sleep-related disorders. However, the interrelation between the two may not always be recognised. In fact, it can be part of a vicious circle where pain leads to sleep disorders and lack of sleep increases the perception of pain.
The connection between pain and sleep
Compared with those without chronic pain, nearly twice as many people with chronic pain report sleep disturbances. In addition, there is a moderately positive correlation between pain intensity and sleep quality. It is hard to get to sleep and harder to stay asleep the more the severe the pain.
The number of hours sleep on the previous night predicts the current day’s pain frequency. Obtaining either less than 6 hours or more than 9 hours is associated with greater pain the next day. On the other hand, pain predicts sleep duration.
A number of mediating factors have been suggested that might explain the nexus between pain and sleep disturbances include depression (up to 87% of patients with chronic pain have symptoms of depression); psychiatric disorders (around a quarter of patients with chronic pain have a mental health issue); and pain medication (eg. opioids can upset the sleep-wake cycle and cause delirium).
This last point is interesting in light of the rescheduling of codeine. Customers who previously relied on a fixed-dose combination of a short-term sedative such as doxylamine and codeine for pain and/or as a sleep aid may not realise that codeine may have been contributing to their insomnia. It is probably worth advising them that the actual sedative component of these compounds is still available over-the-counter for assistance in sleep in the short-term.
Evaluating the problem
People with disturbed sleep because of chronic pain invariably find their social functioning curtailed, experience poor quality of life, and higher levels of disability.
Below are some useful steps to follow when evaluating a customer with chronic pain and insomnia:
Try to identify precipitating factors other than pain for the insomnia
Attempt to determine if there is any link between pain, insomnia, and psychological state
If an underlying disease or mental health problem appears to be present, advise the customer to consult their GP
Discuss sleep hygiene measures
Consider pharmacological treatment if the problem persists
First of all, suggest they to talk to their GP who may refer them to a sleep specialist or psychologist who can help sort out the problem. In the meantime, advise them to:
Not try too hard to sleep—let sleep coming when the timing is right
Keep a regular daily routine when possible
Learn some relaxation techniques
Realise that part of the reason why they might not sleep well is that they worry too much about sleep
Not blame everything that goes wrong during the day on poor sleep
Not to lie awake for too long—after 20 minutes, get up and sit in a quiet, dark room somewhere, not doing anything, until they feel sleepy again
Recognise that they may actually be getting more sleep than they think they are
Make sure they don’t drink too much alcohol and caffeine