Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Chapter 14. Improving Sleep

Sleep problems are often reported by people with chronic pain. It can be trouble getting to sleep or staying asleep (or both). Many report broken sleep, where they wake up every hour or two through the night. Others say they often wake up early in the morning and can’t get back to sleep.

Some say, they just can’t get to sleep until very late at night and then they sleep in late the next morning. Others find they almost become nocturnal, being unable to sleep at night but dozing off during the day.

Many blame these sleep problems on their pain (“the pain wakes me when I roll over”), or they have trouble getting comfortable. Others say that troubling thoughts interfere with getting to sleep. In these cases, they may be worrying about financial matters or worrying about not getting a decent sleep again.

Effects of lack of sleep

Ongoing poor sleep can leave us feeling quite run down and generally tired or ‘out of sorts’ for much of the time. We can become more irritable and our pain more of a burden. We all know how much easier it is to deal with day to day hassles and pain when we have had a good night’s sleep. Many people with chronic pain end up sleeping whenever they can, even in the middle of the day. This can compound the problems of chronic pain leading to more social withdrawal and worse night time sleep.

Poor sleep can lead to worse sleep, especially if we start to worry whether or not we will get to sleep each night. That can become a self-fulfilling prophesy (making it even more likely that there will be a problem).

What to do about it

You may have tried all sorts of remedies, such as drinking hot milk at night, avoiding coffee, counting sheep or listening to relaxation tapes. None may seem to make any real difference. If you have seen your doctor about it, you may have been given some medication to see if that might help. You might have tried many different types of medication. Some may seem to work for a while, but then wear off. Sometimes, when you have the odd good night it can be difficult to work out why it happened. It may have been just luck. Before we look at your options, let’s quickly think about normal sleep.

Normal sleep

Many people say they need 8 hours a night, but normal sleep patterns change with age. Typically, the main changes occur from around 20 to 60 years of age when they tend to stabilise, especially in healthy people. Older adults usually go to bed earlier and wake earlier than younger adults. They also have more trouble adjusting to time changes like shift work and jet-lag. Older people also tend to be more easily disturbed while sleeping.

Normal sleep has different stages, from light to deeper sleep (when it is harder to be awoken). Each stage lasts about 90 minutes and the deepest stage is usually in the first half of the night. We can also have periods of wakefulness which vary in length and frequency, but they often increase with age. So, it is normal to sleep deeply at times and have periods of being slightly awake as well. We need to recognise this and not see it as a problem. If we over-react to the wakeful periods we risk undermining the quality of our sleep. Let’s consider the options for improving the quality of our sleep.

(1) Medication

Drugs for sleep should only be used after consulting your doctor. It is very important that you don’t use drugs prescribed for someone else. The most obvious reason for this is that the drugs may be dangerous for you to take. It is also quite possible that someone else’s drugs are not the best way for you to deal with your sleep problems. Discussing the issues with your doctor will help you to make an informed decision. It may well be the case that medicationis not the only or best way for you to deal with your sleep problems.

There are two main groups of medications that are often used to help with sleep.

(i) The tricyclic anti-depressants

These come under a number of brand names. These drugs are normally used to help improve mood. But one of their side effects is drowsiness. This means that if this medicine is taken at night it can help us to get to sleep. This can be achieved with smaller doses than those normally used for when people feel depressed. Like all medication, before you decide to take them it is important to be aware of any possible side effects and precautions. In the case of tri-cyclic antidepressants many find that they feel “hungover” or have difficulty “getting going” the next day. Other side effects are blood pressure falling, dry mouth and difficulty passing water.

(ii) Benzodiazepines

These are a group of drugs which include diazepam(Valium), temazepam(Temaze) and lorazepam(Ativan). While they can help you to get some sleep, they should be used carefully and usually for no longer than about one week. They are habit-forming and it can be difficult to stop taking them. They can become less effective after a few weeks or they can make your sleeping pattern even more disturbed. In fact, the sleep you get may not be as restful as normal sleep and many people report waking up the next morning feeling groggy or hungover. However, you could argue that some is better than none. That may be true for a short period, but it is not recommended as a long-term option. It is usually better to look at possible reasons for your poor sleep and other options for dealing with them.

Another problem with these drugs is that they can stay in your body for a couple of days and cause side effects, such as affecting the way you think. Clearly not a good idea! If you are trying to learn the approaches in this book we strongly advise that you take these drugs only for a short period of time and work closely with your doctor on limiting their use.

Other drugs and alcohol

It shouldn’t need to be said, but using alcohol (with or without the other drugs mentioned here) as a means of improving sleep is to be strongly discouraged. It is not helpful and risks potentially dangerous interactions with other drugs. The resulting sleep is seldom restful and usually leaves you feeling ‘hungover’ the next morning.

Some other drugs for pain do contain a calmative agent (eg. Syndol), and may be used to help sleep. Caution is recommended in these cases as you are really taking three other drugs (Codeine, caffeine and Paracetamol) that you may not need, especially on a long-term basis.

(2) Other options – does anything work?

To answer this question a good place to start is to keep a record of your current sleep patterns. If you do this for a week or so, it can help you to see where you are having trouble and whether or not there is any pattern to it. Sometimes, we may be surprised to learn that we actually are sleeping more than we thought. The problem in these cases may be more one of the quality of the sleep, how refreshing it was, for example. Some people report than even a long medication-induced sleep can leave them feeling quite hung-over the next morning. Whereas others seem to find a short cat-nap gives them a bit of a lift.

Copy this sleep chart onto a piece of paper or into a diary and monitor your sleep pattern for a week or so.

SLEEP CHART

Day/Date

Lights out time

Wake up time

No. of times 

How rested? (0–10 rating)

Comments

       

Rate from 0–10 where 0 = not rested and 10 = fully rested

anything relevant

Example: Monday, April 10

10.45pm

6.30am

3

4

couldn’t get comfortable, too much noise outside

           
           

Keep track of your sleep by filling it in each morning. It is usually best to keep it beside your bed, so you will fill it in soon after waking.

After recording your sleep pattern for a few days you should have a clearer idea of where the problems lie. It might be repeated waking through the night, or having trouble getting to sleep. This observation should help you to work out the best way to deal with the problem. A list of common reasons for poor sleep and recommended good sleep habits is set out below, but before you try ways of improving your sleep it is important to realise there are no “quick fixes” for sleep problems. Most attempts to improve long-term sleep problems will take up to several weeks of consistent application of the strategies before improvements may be seen. It can help to remember that your sleep may well have taken some time to get to where it is now, expecting to overcome the effects of this quickly is generally unrealistic. More likely, it will be a process of trial and error until you find what suits you best.

Common Causes of poor sleep

Options

Daytime naps

Avoid them, restrict sleep to evenings

Too much resting during the day

Try to keep generally active, physically and mentally, through the day

Worries, stress

Deal with worries before bed, or write them down and decide to address them tomorrow. Use your relaxationtechnique and mental distractions. If you can’t sleep after 20–30 minutes get up and do something peaceful until feeling ready for sleep again, then return to bed

Medication (misuse or withdrawal

If you stop your pain killers or tranquilisers, it can take a few days to a week or so before they are out of your system. So remind yourself that these effects will pass and that you are OK.

Stimulants before bed (coffee, tea)

If these are a problem, stop taking them in the evenings (replace them with warm drinks which don’t contain caffeine).

Pain, discomfort

If you have paced your activities during the day your pain will not usually be as bad as when you overdo things, so you could prevent some of the pain. Often pain seems to feel worse at night anyway, partly due to there being no distractions for us to focus on. In this case, using relaxation and desensitizing can help. Dealing with any distressing thoughts with thought challenging is also important.

Alcohol or large meals in the evening

Avoid or limit the amount and only drink with dinner Reduce the amount of food eaten at night.

Depression, anxiety

Long-standing depression will take a while to resolve, but thought challenging is helpful and may be supplemented by antidepressant medication. Anxiety can be addressed by using relaxation, desensitization, and thought challenging. You can use the strategies outlined in this book (or the others we have recommended) to deal with both depression and anxiety.

Trying too hard to sleep (lying in bed tossing and turning, getting frustrated)

Use your relaxation technique, but if it’s not working get up and do something relaxing or peaceful until ready to return to bed. You may need to repeat these several times, but try to stay as calm as possible. Remember, if you are relaxing you are still getting rest.

Engaging in activities late at night which get your brain going too fast more (e.g. preparing your income tax return)

Try to plan to avoid these types of tasks at night if at all possible. Plan to do more relaxing, pleasant tasks last in the day (reading, listening to music, etc.).

Going to bed at irregular hours or often sleeping in late in the mornings

Try to establish a regular routine at (eg. getting ready to go to bed about the same time each night, first clean your teeth, then have a glass of water, then get undressed for bed and avoid watching TV or reading in bed). Try to get up at about the same time each day, regardless of how you feel.

Bedroom too warm/cold; or used for too many non-sleep activities.

Adjust temperature to slightly cool; use bedroom mainly for sleep and sex – not as an office

Good sleeping habits

In addition to the points listed above, there are a number of basic guidelines for getting enough sleep. These points are not going to be equally helpful for everyone, but amongst this list you should find something that could help.

1. Establish a regular routine before retiring for the night.

This can help you prepare for sleep. Try to go to bed around the same time each night. For example, put the cat out, turn out the lights through the house, clean your teeth, undress for bed, get into bed and do your last relaxation or desensitization session for the day.

2. If you are often kept awake by worry, try these steps:

• The first rule is that telling yourself to stop worrying is usually unsuccessful. Instead, it usually helps to do something else.

• Get a pen and some paper. Write down the worries or problems that are on your mind

• Then write down the next step you think you could take towards sorting out the problem and leave it until the morning.

• If you wake up during the night worrying about the problem, remind yourself that you have the matter in hand, and that going over it now will not help. If a new worry crops up in the night, write it down and deal with it the next day.

• Practice your relaxation and desensitization techniques. If you prefer you could also and try to focus your mind on a distracting image or scene (eg. remembering a previous holiday or imagining somewhere that you would like to go).

• If these steps are not helping within 20–30 minutes, it may be better to get up for a while and do something relaxing (so avoid stimulating activities like computer games, Crosswords, or an exciting TV program). Options include reading, listening to music, practising your relaxation technique. When you are ready, return to bed and see what happens (remember, don’t try to sleep). After a while, if you still find yourself lying there feelingrestless, get up again and repeat the same types of activities.

• If possible, make sure the room temperature is cooler rather than hotter.

3. Make your bed and bedroom as associated with sleep as possible

• try not to use your bedroom during the day, except for relaxing.

• go to bed or turn the lights out only when you are sleepy and within a limited time period, such as 9 pm to midnight.

• if possible, make sure the room temperature is cooler rather than hotter.

• If after 20 minutes or so you haven’t fallen asleep, it could be worth getting up and leaving the bedroom for a while (see section above).

• Apart from sleeping and sex, try to avoid doing other things in bed, like watching TV, phone calls or writing letters.

4. Try not to “clock watch”

This will only make things worse. Turn your clock’s face away from you.

5. If you are coming off some tablets

Check if this could cause temporary sleep problems. This information could help you to prepare for such problems and to reassure you that they will settle as your body is cleared of the tablets. With some tablets (especially tranquillisers), this may take time.

6. Establish a regular routine for the mornings.

To help your ‘biological clock’ get into a regular pattern it can help to try to get up at the same time each day, even when you don’t feel like it.

7. When you do have a difficult night (and they will happen)

Try to put some thought into why it might have happened. Rather than jump to conclusions (such as, “Oh, it’s no good, see I do need my tablets”), it could well be that the poor night was due to the withdrawal effects of the sleeping tablets or perhaps you overlooked some of the points mentioned above. Sometimes, of course, it will just be one of those nights that happens to all of us. Whatever the case may be, by not over-reacting you will be less worried about it the next night, which will help to make that night more successful. Remember, like relaxation, you can’t force yourself to sleep, but we can do a great deal to improve it.

8. Keep a record of your progress each night (using the sleep chart).

This can help to remind you that overall your sleep is improving, even if it doesn’t always feel like it. After a week or two you can look back and you will usually see that things are gradually getting better, while the problem nights are getting fewer. If this is not happening then try to work out why. If you feel unsure how to proceed, perhaps you could discuss it with your doctor or psychologist.

REMEMBER,

It will take time for these methods to help you improve your sleep.

It is vital, therefore, that you stick to these methods for some time, even if progress is slow.