Chronic Pain & Insomnia - Treatments

In this post I'm going to look again at the disturbance to sleep caused through chronic pain and the treatments sometimes used to address the issue. Often one of the cruelest symptoms of chronic pain is the lack of sleep it causes. It's bad enough that you find yourself in pain when going to bed and on rising in the morning, but to be unable to get any sleep at all compounds the situation and, in turn, leads to a worsening of other symptoms such as depression. Insomnia will often improve by making changes to your bedtime habits. If these don't help, your GP may be able to recommend other treatments.
If you've had insomnia for more than four weeks, your GP may recommend cognitive and behavioural treatments or suggest a short course of prescription sleeping tablets as a temporary measure.
If we assume that the underlying cause of your sleeping difficulties is your fibromyalgia / chronic pain condition, treating this may be enough to return your sleep to normal. But, as we all know, finding an effective treatment for this is difficult!

The various treatments for insomnia are outlined below. You can also read a summary of the pros and cons of the treatments for insomnia,* allowing you to compare your treatment options.

Good sleeping habits

I've discussed this issue previously on this blog but it's worth repeating. There are seven 'rules' for developing a healthy sleep pattern:

• establishing fixed times for going to bed and waking up
• creating a relaxing bedtime routine
• only going to bed when you feel tired
• maintaining a comfortable sleeping environment that's not too hot, cold, noisy or bright
• not napping during the day
• avoiding caffeine, nicotine and alcohol late at night
• avoiding eating a heavy meal late at night

Read more about self-help tips for insomnia.

Cognitive and behavioural treatments

If changing your sleeping habits doesn't help, your GP may be able to refer you for a type of cognitive behavioural therapy (CBT) that's specifically designed for people with insomnia (CBT-I).
The aim of CBT-I is to change unhelpful thoughts and behaviours that may be contributing to your insomnia. It's an effective treatment for many people and can have long-lasting results.
CBT-I may include:

• stimulus-control therapy – which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern
• sleep restriction therapy – limiting the amount of time spent in bed to the actual amount of time spent asleep, creating mild sleep deprivation; sleep time is then increased as your sleeping improves
• relaxation training – aims to reduce tension or minimise intrusive thoughts that may be interfering with sleep
• paradoxical intention – you try to stay awake and avoid any intention of falling asleep; it's used if you have trouble getting to sleep, but not maintaining sleep
• biofeedback – sensors connected to a machine are placed on your body to measure your body's functions, such as muscle tension and heart rate; the machine produces pictures or sounds to help you recognise when you're not relaxed 

CBT-I is sometimes carried out by a specially trained GP. Alternatively, you may be referred to a clinical psychologist.
The therapy may be carried out in a small group with other people who have similar sleep problems, or one-to-one with a therapist. Self-help books and online courses may also be used.

Sleeping tablets

Sleeping tablets (hypnotics) are medications that encourage sleep. In the past, they were frequently used to help with insomnia, but they're used much less often nowadays.
They will generally only be considered:

• if your insomnia is severe
• as a temporary measure to help ease short-term insomnia
• if the good sleep habits and cognitive and behavioural treatments mentioned above don't help

Doctors are usually reluctant to recommend sleeping tablets in the long-term because they just mask the symptoms without treating the underlying cause.
They can also cause potentially dangerous side effects, such as drowsiness the following morning, and some people become dependent on them.
If they are recommended, you should have the smallest effective dose possible for the shortest time (usually no more than two to four weeks). 

Over-the-counter sleeping pills

A number of sleeping tablets are available to buy over the counter (OTC) from pharmacies. These are usually a type of antihistamine medicine that causes you to feel drowsy.
Taking OTC sleeping tablets regularly isn't usually recommended if you have insomnia, because it's not clear how effective they are, they don't tackle the underlying cause of your sleeping difficulties and they can cause side effects.
In particular, they can cause you to feel drowsy the next morning, which can make activities such as driving and operating machinery dangerous.
Speak to your GP for advice if you find yourself needing to take OTC sleeping tablets regularly.

Benzodiazepines

Benzodiazepines are prescription medicines that can reduce anxiety and promote calmness, relaxation and sleep. Your GP may prescribe them for a short time if you have severe insomnia or it's causing extreme distress.
Examples of benzodiazepines include temazepam, loprazolam, lormetazepam, diazepam and nitrazepam.
Long-term treatment with benzodiazepines isn't usually recommended because they can become less effective over time and some people become dependent upon them.
They can also cause a number of side effects, including:

• drowsiness and dizziness, which can persist into the next day
• finding it difficult to concentrate or make decisions
• depression 
• feeling emotionally numb
• irritability

You should avoid driving if you feel drowsy, dizzy, or unable to concentrate or make decisions, as you may not be able to do so safely.

Z-drugs

Z–drugs are a newer type of medicine that work in a similar way to benzodiazepines and are similarly effective. They include zaleplon, zolpidem and zopiclone.
As with benzodiazepines, long-term treatment with Z–drugs isn't normally recommended because they can become less effective over time and some people become dependent on them.
They're usually only prescribed for a maximum of two to four weeks.
Side effects of Z-drugs can include:

• drowsiness and dizziness, which can persist into the next day
• feeling and being sick
• diarrhoea 
• increased snoring and breathing problems during sleep
• dry mouth
• confusion

Z–drugs can also sometimes cause psychiatric reactions, such as delusions, nightmares and hallucinations. Contact your GP if you experience any of these effects.
Read the National Institute for Health and Care Excellence (NICE) guidance on zaleplon, zolpidem and zopiclone for the short-term management of insomnia for more information.

Melatonin (Circadin)

For adults aged 55 or over, a medication called Circadin is sometimes used to help relieve insomnia for a few weeks. It contains a naturally occurring hormone called melatonin, which helps to regulate the sleep cycle.
Circadin is usually only recommended for three weeks at first, but it can be continued for a total of 13 weeks if it helps.
It is unlikely to be prescribed to patients with chronic pain conditions as common side effects of Circadin include:

• headaches
• cold-like symptoms
• back pain
• joint pain

Treatments that aren't recommended

The following treatments aren't normally recommended for insomnia, because it's not clear how effective they are and they can sometimes cause side effects:

• antidepressants (unless you also have depression)
• chloral hydrate
• clomethiazole
• barbiturates
• herbal remedies, such as valerian extract
• complementary and alternative therapies, such as acupuncture, hypnotherapy and reflexology

It is also worth pointing out that long term insomnia and the treatments used to remedy it can have a negative effect on your ability to drive safely, so you should avoid driving if you feel sleepy.

It's not necessary to inform the Driver & Vehicle Licensing Agency (DVLA) unless your insomnia is caused by a diagnosed sleep disorder, such as narcolepsy.
GOV.UK has more information about telling the DVLA about a medical condition or disability.

*Source - http://www.nhs.uk/pages/home.aspx