MARCH 3 - 2008 - DESERT DISPATCH
By JACKIE RANDA

One of the most common complaints I hear from my patients is that they cannot sleep well. Pain causes insomnia — insomnia, in return, causes increased pain. While this vicious pattern cycles round and round, you become more depressed, more withdrawn, life seems more difficult to manage. Worst of all, going without sleep makes it difficult for you to cope with your pain. A well rested patient may report his pain to be worth three points on a ten point scale; the same patient, three days later and without sleep, will report the same pain to be nine or ten points. Insomnia describes difficulty sleeping which may result from a variety of conditions. Pain is the top cause of insomnia. You think to yourself that you need more pain medication to get to sleep and then, to your dismay, you find that many pain medications make it very difficult to get to sleep. If you do manage to get to sleep, medications can cause you to have vivid and disturbing dreams which keep you restless. Pain then not only robs you of the sleep quantity, but the pain — or the medication you take for it — costs you sleep quality as well.

When I say that pain causes insomnia, I don’t mean that you are necessarily going completely without sleep. Pain makes it difficult to get to sleep and difficult to stay asleep. You may be so tired from dealing with your day that you fall asleep quickly when you lay down, but then you may wake often during the night. Many people complain that the pain wakes them whenever they move in their sleep. You might even be able to get back to sleep, but still, your sleep was disturbed. You may also find that after a few hours restless sleep that you are awake earlier than you want to be. All these symptoms — difficulty falling asleep, restlessness, waking early — are symptoms of insomnia. Some of the common cures suggested for insomniacs don’t apply to you if pain is keeping you awake. We tell folks struggling with sleep to make a sort of personal ceremony out of the “off to bed” process. We suggest moving the TV out of the bedroom, do relaxation exercises, turn off the lights and any other noises. If you are in pain, this process of removing all distractions can be counterproductive.

Without the other distractions, all the brain has to focus on is pain. During the day, your activities distract you from the pain. Quieting the house and settling in to bed in the evening leaves you with nothing but pain to think about. The longer you lay there trying to go to sleep, the more you focus on the pain and the intensity of the pain seems to increase as the minutes the tick by. To address problems with sleep problems associated with pain, both conditions must be addressed. Folks in pain often have more than one doctor. There is the doctor you see for the flu and regular checkups and then there’s the doctor managing whatever condition is causing your pain. The problem becomes even more complex when your pain results from a worker’s compensation injury. Often the doctor handling your injury will be reluctant to address your sleep issues. Your general practitioner, on the other hand, doesn’t want to prescribe medications for a problem he sees related to a condition being treated by another physician.

A sleep disorder caused by pain requires a multi-disciplinary approach. In other words, you not only need the advice of a physician who specializes in pain management, but you need access to psychologists who are trained in behavioral medicine. Unfortunately, you may have to insist that you be referred to a comprehensive pain management center where you can be helped. Pain management, in my opinion, has been relegated to the position of “last chance” medicine. Folks are not referred to these valuable centers until their doctors decide there’s nothing else that can be done. I think that pain management should be part of your care all along if you have a condition which will cause significant pain. Behavioral medicine can be quite effective in helping not only to improve your quality of sleep, but can help you manage your pain more effectively without using the narcotics that rob you of your quality of life. The secret is consistency. You are going to have to really want to get better. Recovery will require scrupulous attention to your behavior for awhile, but a good pain clinic will be there all along to help you. Like with my own profession, they cannot do the work for you, but they will be there to show you the way and cheer you along. 

There are a number of effective sleep medications which might help you get some rest in the mean time, but for a long term solution, behavioral medicine is best. The lessons you learn will last your entire lifetime without adverse affects.

ABOUT THE WRITER:
Jackie Randa is a physical therapist who owns Back on Track in Barstow. She can be contacted at jranda@aol.com

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