Ep. 22 Sleep and Pain: What's Driving What?
Dan and Juz dive into the significant relationship between pain and sleep, and how it drives sensitization. They cover sleep basics, how lack of it long-term negatively impacts patients cognitively, and share a helpful analogy you can use as a patient to better explain what chronic pain feels like - especially with regards to increasing buckets of central sensitization. Dan then delves into the medical side of sleep, covering disorders including snoring, as well as various medications used to treat sleep. On the next episode, Juz will cover the conservative management strategies on the patient end, so you can further improve fatigue and cognitive dysfunction.
Episode Overview: Understanding Sleep, Sleep Disorders, and Medications
This overview provides valuable insights for both medical professionals and individuals struggling with sleep issues.
The Basics of Sleep
Sleep Stages
Sleep is not a uniform state but consists of several distinct stages, each playing a crucial role in rest and recovery:
1. **Non-REM Stage 1**: Light sleep, easily awakened
2. **Non-REM Stage 2**: Deeper sleep, body temperature drops, heart rate slows
3. **Non-REM Stage 3**: Deep sleep, also known as slow-wave sleep, crucial for physical recovery
4. **REM (Rapid Eye Movement) Sleep**: Associated with vivid dreams, important for cognitive function and memory consolidation
A typical sleep cycle lasts about 90-120 minutes, and these cycles repeat throughout the night.
Minimum Sleep Requirements
While individual needs may vary, general guidelines for sleep duration include:
- Adults: 7-9 hours per night
- Teenagers: 8-10 hours per night
- School-age children: 9-11 hours per night
- Preschoolers: 10-13 hours per day (including naps)
- Infants: 12-16 hours per day (including naps)
Consistently getting less than the recommended amount of sleep can lead to sleep debt and associated health problems.
Understanding Sleep Disorders
Sleep disorders are conditions that significantly impact an individual's ability to get restful sleep on a regular basis. These disorders can be categorized into several main types:
Insomnia
Insomnia is characterized by difficulty falling asleep, staying asleep, or both, despite having adequate opportunity for sleep. It can be acute (short-term) or chronic (long-term). Management strategies include:
- Cognitive Behavioral Therapy for Insomnia (CBT-I)
- Improving sleep hygiene
- Relaxation techniques
- In some cases, short-term use of sleep medications
Sleep Apnea
Sleep apnea involves pauses in breathing or periods of shallow breathing during sleep. The two main types are obstructive sleep apnea (OSA) and central sleep apnea (CSA). Treatment options include:
- Continuous Positive Airway Pressure (CPAP) therapy for OSA
- Weight loss for overweight individuals
- Positional therapy
- Surgical interventions in some cases
- Treating underlying conditions for CSA
Narcolepsy
Narcolepsy is a chronic neurological disorder affecting the brain's ability to control sleep-wake cycles, characterized by excessive daytime sleepiness and sudden sleep attacks. Management approaches include:
- Stimulant medications (e.g., modafinil, methylphenidate)
- Sodium oxybate for cataplexy and excessive daytime sleepiness
- Lifestyle adjustments, including scheduled naps
- Antidepressants for cataplexy
Restless Legs Syndrome (RLS)
RLS is a neurological disorder causing an irresistible urge to move the legs, often accompanied by uncomfortable sensations. Treatment options include:
- Iron supplementation if deficient
- Dopaminergic agents (e.g., pramipexole, ropinirole)
- Alpha-2-delta ligands (e.g., gabapentin, pregabalin)
- Lifestyle modifications
Circadian Rhythm Sleep-Wake Disorders
These disorders involve a misalignment between a person's sleep pattern and the desired or socially normative sleep schedule. Management strategies include:
- Light therapy
- Melatonin supplementation
- Chronotherapy
- Maintaining consistent sleep-wake schedules
Medications for Sleep Disorders
While non-pharmacological approaches are often the first line of treatment, medications can play a crucial role in managing sleep disorders. Here's an overview of common sleep medications:
Benzodiazepines
Examples: temazepam, triazolam, estazolam
Mechanism: Enhance GABA effect at GABA-A receptors
Efficiency: Effective for short-term insomnia treatment
Complications: Risk of dependence, tolerance, and other side effects
Non-Benzodiazepine Receptor Agonists (Z-drugs)
Examples: zolpidem, zaleplon, eszopiclone
Mechanism: Selectively bind to α1 subunit of GABA-A receptor
Efficiency: Effective for short-term insomnia treatment
Complications: Lower risk of dependence than benzodiazepines, but still present
Melatonin Receptor Agonists
Example: ramelteon
Mechanism: Binds to MT1 and MT2 melatonin receptors
Efficiency: Modestly effective for sleep onset insomnia
Complications: Generally well-tolerated
Orexin Receptor Antagonists
Examples: suvorexant, lemborexant
Mechanism: Block orexin receptors
Efficiency: Effective for both sleep onset and maintenance insomnia
Complications: Daytime somnolence, potential for complex sleep behaviors
Antidepressants
Examples: trazodone, doxepin, mirtazapine
Mechanism: Varies, often involving serotonin and/or histamine antagonism
Efficiency: Moderately effective, especially with comorbid depression
Complications: Anticholinergic effects, weight gain, daytime sedation
Atypical Antipsychotics
Example: quetiapine (Seroquel)
Mechanism: Antagonist at multiple neurotransmitter receptors
Efficiency: Moderately effective, particularly with comorbid psychiatric conditions
Complications: Weight gain, metabolic disturbances, potential for tardive dyskinesia
Considerations and Cautions
It's crucial to note that while these medications can be effective for short-term management of sleep disturbances, they all carry potential risks and side effects. The choice of medication should be individualized based on the specific sleep disorder, patient characteristics, and potential drug interactions. Long-term use of sleep medications is generally not recommended, and cognitive-behavioral therapy for insomnia (CBT-I) remains the first-line treatment for chronic insomnia.
Conclusion
Understanding the basics of sleep, including sleep stages and minimum requirements, is crucial for maintaining good sleep health. When sleep disorders arise, a comprehensive approach involving both non-pharmacological and, when necessary, pharmacological interventions can be effective. As always, it's essential to consult with a healthcare professional for personalized advice and treatment plans.
References:
Certainly. Here are the references for the information on sleep disorders and medications in APA 7th edition format:
Abbott, S. M., Reid, K. J., & Zee, P. C. (2015). Circadian rhythm sleep-wake disorders. Psychiatric Clinics of North America, 38(4), 805-823. https://doi.org/10.1016/j.psc.2015.07.012
Anderson, S. L., & Vande Griend, J. P. (2014). Quetiapine for insomnia: A review of the literature. American Journal of Health-System Pharmacy, 71(5), 394-402. https://doi.org/10.2146/ajhp130221
Dauvilliers, Y., Evangelista, E., Barateau, L., Lopez, R., Chenini, S., Delbos, C., Beziat, S., & Jaussent, I. (2017). Measurement of symptoms in idiopathic hypersomnia: The Idiopathic Hypersomnia Severity Scale. Neurology, 88(11), 1146-1154. https://doi.org/10.1212/WNL.0000000000003737
Holsboer-Trachsler, E., & Prieto, R. (2013). Effects of pregabalin on sleep in generalized anxiety disorder. International Journal of Neuropsychopharmacology, 16(4), 925-936. https://doi.org/10.1017/S1461145712001174
Howell, M. J. (2012). Parasomnias: An updated review. Neurotherapeutics, 9(4), 753-775. https://doi.org/10.1007/s13311-012-0143-8
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Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2016). The assessment and management of insomnia: an update. World Psychiatry, 15(2), 125-137. https://doi.org/10.1002/wps.20323
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Matheson, E., & Hainer, B. L. (2017). Insomnia: Pharmacologic therapy. American Family Physician, 96(1), 29-35.
Neubauer, D. N., Pandi-Perumal, S. R., Spence, D. W., Buttoo, K., & Monti, J. M. (2018). Pharmacotherapy of insomnia. Journal of Central Nervous System Disease, 10, 1179573518770672. https://doi.org/10.1177/1179573518770672
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307-349. https://doi.org/10.5664/jcsm.6470
Scammell, T. E. (2015). Narcolepsy. New England Journal of Medicine, 373(27), 2654-2662. https://doi.org/10.1056/NEJMra1500587
Schroeck, J. L., Ford, J., Conway, E. L., Kurtzhalts, K. E., Gee, M. E., Vollmer, K. A., & Mergenhagen, K. A. (2016). Review of safety and efficacy of sleep medicines in older adults. Clinical Therapeutics, 38(11), 2340-2372. https://doi.org/10.1016/j.clinthera.2016.09.010
Slowik, J. M., & Collen, J. F. (2020). Obstructive sleep apnea. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459252/
Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9), 63. https://doi.org/10.1007/s11920-017-0816-4
Wijemanne, S., & Ondo, W. (2017). Restless Legs Syndrome: Clinical features, diagnosis and a practical approach to management. Practical Neurology, 17(6), 444-452. https://doi.org/10.1136/practneurol-2017-001762