My patient with chronic pain complains of difficulty sleeping. Would improving her sleep hygiene impact her pain medication requirement?

Most likely!

We should routinely assess for poor sleep as a potential impediment to adequate pain control in our patients. Substantial research supports a bidirectional relationship between pain and sleep.  That is, not only can pain disrupt sleep but sleep quality can also adversely affect pain.1   In fact, even a short-term disturbance in a stable sleep pattern may lower the pain threshold 2 and the ability to tolerate previously controlled pain.3

These observations are thought to result from activated stress responses from poor sleep hygiene which in turn produce cellular oxidative stress and inflammation of tissues and the nervous system. 4 This process can result in a vicious cycle between increasing pain and persistent insomnia.4,5  Breaking this cycle can reduce pain and improve function, among other desired outcomes.

Ongoing insomnia may also be a sign of a variety of other conditions that should be treated, such as mood disorder and sleep apnea. For example, besides standard non-pharmaceutical measures to improve sleep hygiene, continuous positive air pressure (CPAP) can reduce pain and opioid use in the setting of sleep apnea .2,6

Remember also that controlling pain with opioids in hopes of improving sleep may be counterproductive as opioids can contribute to sleep apnea.7,8  Melatonin may be a better sleep aid in this setting. 9

References

  1. Wei Y, Blanken TF, Van Someren EJW. Insomnia really hurts: effect of a bad night’s sleep on pain increases with insomnia severity. Front Psychiatry 2018;9:377. doi: 10.3389/fpsyt.2018.00377. https://www.ncbi.nlm.nih.gov/pubmed/30210367
  2. Charokopos A, Card ME, Gunderson C, Steffens C, Bastian LA. The association of obstructive sleep apnea and pain outcomes in adults: a systematic review. Pain Med 2018;19(suppl_1):S69-S75. doi: 10.1093/pm/pny140. https://www.ncbi.nlm.nih.gov/pubmed/30203008
  3. Sivertsen B, Lallukka T, Petrie KJ, et al. Sleep and pain sensitivity in adults. Pain. 2015;156:1433-9. https://www.ncbi.nlm.nih.gov/pubmed/25915149
  4. Iacovides S, George K, Kamerman P, Baker FC. Sleep fragmentation hypersensitizes healthy young women to deep and superficial experimental pain. J Pain. 2017;18:844-854. doi: https://doi.org/10.1016/j.jpain.2017.02.436. https://www.ncbi.nlm.nih.gov/pubmed/28300651
  5. Edwards RR, Almeida DM, Klick B, Haythornthwaite JA, Smith MT. Duration of sleep contributes to next-day pain report in the general population. Pain. 2008;137:202-7. doi: 10.1016/j.pain.2008.01.025. https://www.ncbi.nlm.nih.gov/pubmed/18434020
  6. Edwards RR, Almeida DM, Klick B, Haythornthwaite JA, Smith MT. Duration of sleep contributes to next-day pain report in the general population. Pain. 2008 Jul;137(1):202-7. doi: 10.1016/j.pain.2008.01.025. https://www.ncbi.nlm.nih.gov/pubmed/18434020
  7. Marshansky S, Mayer P, Rizzo D, Baltzan M, Denis R, Lavigne GJ. Sleep, chronic pain, and opioid risk for apnea. Prog Neuropsychopharmacol Biol Psychiatry 2018 20;87:234-244. https://www.ncbi.nlm.nih.gov/pubmed/28734941
  8. Jungquist CR, Flannery M, Perlis ML, Grace JT. Relationship of chronic pain and opioid use with respiratory disturbance during sleep. Pain Manag Nurs 2012;13:70-9. doi: 10.1016/j.pmn.2010.04.003. https://www.ncbi.nlm.nih.gov/pubmed/22652280
  9. Landis CA. Is melatonin the next “new” therapy to improve sleep and reduce pain? Sleep 2014; 37: 1405–1406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153056/

Contributed by Paul Arnstein, PhD, RN, FAAN, Mass General Hospital, Boston, MA.

My patient with chronic pain complains of difficulty sleeping. Would improving her sleep hygiene impact her pain medication requirement?

What role can hospital medicine physicians play in treating patients with opioid use disorder?

Opioid use disorder is a common comorbidity in hospitalized patients, but may pose a challenge to hospital-based providers who often care for patients with this chronic conditions only for a few days. Recent evidence suggests, however, that hospitalists can play an important role in helping these patients with their addiction problems.  A study that implemented screening, brief intervention, and referral to treatment (SBIRT) in hospital settings concluded that illicit drug use decreased by 67.7% at 6 months in patients who underwent such intervention (1). Opioid substitution therapy may also be an option in hospitalized patients. A randomized-controlled trial of patients who underwent hospital-initiated buprenorphine/naloxone therapy followed by referral to primary care providers found a 41% increase in patient engagement with addiction treatment at 30 days in the intervention group compared to the group that received only referral for treatment (2).

1. Madras B, Compton W, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-295.

2. D’Onofrio G, O’Connor P, Pantalon M, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA 2015;313:1636-44.

 

Contributed by Ethan Balgley, Harvard Medical Student

What role can hospital medicine physicians play in treating patients with opioid use disorder?