Chronic Pain & Sleep problems
Around eighty percent of people living with chronic pain experience sleep disturbances. Research also shows that poor sleep patterns make people more sensitive to pain, so a vicious cycle of poor sleep due to pain and intensified pain due to poor sleep easily established. Sleep plays a vital role in emotional well-being in terms of our ability to cope with life in general. It also plays a very important role in our ability to cope with pain. Getting less sleep, or poor-quality sleep, will result in a heightened sensitivity to pain, and a reduced ability to cope. The ability to sleep is somewhat regulated by the actions of neurotransmitters, which are highly effected by stress. As most people in chronic pain are highly stressed by their experience, it makes sense that sleep problems are experienced by most people with this problem. Improving the quality of your sleep is often vital to addressing both acute and chronic pain.
One of the ongoing effects of the car accident in which I was injured as an eighteen-year-old was that I became a relatively poor sleeper. Where I had been a sound sleeper before, after the accident I became a very light sleeper, and for years experienced being awake for hours on-end during the night. It was not unusual for me to wake in the very early hours of the morning, and
stay awake until I needed to get out of bed four or five hours later. Nor was it unusual for me to miss the opportunity to fall asleep easily at the start of the night, and to then remain awake for most of it.
As I never had any recollection of the impact moment in the head-on car accident, I used to tell people it was not unlike going to bed one night believing that everything in your world was safe and under control, and then being shaken awake during the night to be told that you had been in a bad accident and that you were still trapped in the car wreck, in lots of pain and bleeding to death. Needless to say, this was an enormous fright, and perhaps explains why from that time onwards I became a light sleeper. As is typical for people who have experienced trauma, I lost the ability to trust that all would be well. I am still a light sleeper, but since coming across EFT, it has become extremely rare for me to wake up and stay awake for a lengthy time during the night, or to have a problem drifting off to sleep. As a result, I have really had to redefine myself as a person who used to have a problem with sleeping. In addition, most of the clients to whom
I have introduced this procedure have much the same experience: a large improvement in their sleep, often after an entire adulthood of night-time frustration.
Sleep is a multi-factorial issue, and pain is often a significant factor which interferes with it. If you are having an extreme attack of chronic pain, you may need to resort to the temporary use of pain killing medication in order to help. Do this in consultation with your physician, and remember that while it is reasonable to try and control painful symptoms, the real cure is in addressing the ultimate cause. Keep on thinking psychologically about your pain (as long as serious physical health issues have been excluded) and following The Hidden Psychology of Pain program in the ways described in earlier chapters, even if you need to temporarily resort to symptom management with pain medication. In addition to these interventions, you may need to take steps in regards to all of the following issues in order to improve sleep.
The quality of the sleeping environment is very important. If it is too loud, too hot, too cold, too light, too active, etc, you can struggle with sleep. There is a reasonably narrow bandwidth of environmental conditions which some people can sleep in, although there are obvious individual variations in this. Where some people are fussy, others are more easy-going with these conditions. You need to work out for yourself what your requirements for noise, light, background activity, and temperature are, and then do what you can to maximize these factors. This may mean gaining assistance and cooperation from family or friends who live with you. If people care for your well-being, they will usually take your needs somewhat seriously. You mayneed to be assertive in making your requirements clear to others, and you may also need to take some responsibility for your own needs. For example, you may need to explore a different amount of blankets to your bed-partner; ear plugs; eye covers, the use of white noise, etc.
Secondly, our quality and ability to sleep is often a function of what we have been doing prior to going to bed. Rich and spicy foods eaten just before bed time can create sleep problems for some people, as can being too hungry or too full. If you insist on exciting yourself with action packed TV programs, movies or engaging computer games, expect your central nervous system to be highly aroused when you actually want it to settle down. This may also be true for exciting novels that you are reading prior to sleep. Again, if you are exciting yourself, expect to be excited. This is not likely to be conducive to sleep. The exception to this is sexual excitement. If it results in satisfaction of your needs, it will be conducive to sleep; however, if it does not lead to satisfaction, then sexual activity will have the opposite effect, and can make it more difficult to sleep. Take responsibility for what you are exposing yourself to, and manage these forms of stimulation in regards to your goal of sleeping better. Be in charge of what you will or won’t do, and what you will and won’t expose yourself to prior to going to bed.
Substances and sleep
Another pre-bed trap people often unwittingly fall into is relying on substances such as alcohol and/or cannabis to help them sleep. Alcohol is a depressant on the central nervous system, meaning that it will suppress brain functioning. Despite being a depressant, people often act in a highly excitable manner whilst getting drunk at a party, displaying more extroverted behavior. This is because the parts of the brain that are being suppressed first are the parts that usually keep the brakes on their extroversion. As these inhibitory parts are shut down before other brain areas, the net effect is that the person becomes more excited. However, if they keep on drinking, the
rest of the brain will also become progressively shut down, and their behaviour shows signs of obvious suppression of a larger range of brain functions. The active agent in cannabis, THC, is somewhat different than alcohol. Rather than just being a simple depressant, it acts as a stimulant in low doses. However, in medium to higher doses, THC acts as a depressant, and in very high doses, it acts as an hallucinogenic. It is harder to establish the effect of a dose of cannabis as the dose strength varies greatly. One small joint of very powerful cannabis may have the same effect (depression of the central nervous system) as do several joints of less powerful cannabis;
whereas a joint of less powerful cannabis may act as a stimulant. People who are smoking cannabis to assist with sleep are generally aiming for a sedating effect, in which case their brain functioning is being depressed, making sleep more likely in the short term.
When people use alcohol and cannabis together, the effects tend to “cannonball” and intensify beyond the individual effect of either substance alone. This will produce a higher level of sedation via more suppression of brain functioning. This sedation is what people are looking for if they are using depressants to help get them to sleep. The problem is that the effects of these substances is relatively short lived, and people tend to wake up much more alert in the middle of the night, and are then unable to get back to sleep. This comes about as a result of a brain process called the “rebound effect.”
Our brain has an equilibrium level of electrical activity. There are normal variations in this level of excitation, but they tend to fall within a range which is natural for us. When sedation has been caused by a central nervous system depressant (like alcohol or cannabis), then the brain is aware that its normal level of electrical excitation has been artificially suppressed. The level of brain arousal has been dragged downwards in a way which is recognized as externally caused. It appears that the brain’s goal is to maintain its normal level of arousal, and therefore acts to overcome the effects of introduced agents. As such, a brain that is being sedated will react by increasing its own level of excitation in an attempt to overcome the effect of the depressant.There are many brain chemicals for it to change levels of in order to stimulate itself as part of a rebound effect, rather than experience the sedation.
When the hours required for your body to process and metabolize the substance have passed, so that the substance is no longer having the sedating effect, all that you will be left with is your brain’s efforts to stimulate itself. This is the time in which people report they wake up, entirely alert and feel “wired,” with their minds racing a thousand miles an hour. Often, this occurs
in the very early hours of the morning, but the time will depend on a range of factors such as the person’s tolerance for the substance, the amount and strength of the substance, and the time of taking it. If people are taking a very large dose of alcohol and/or cannabis, they may essentially knock themselves out and sleep through the night and avoid an early morning rebound effect, but this just means that other nasty consequences will await them later, e.g. a savage hangover.
Many people who do not have a substance abuse problem, and take just small amounts of depressants in order to help themselves fall asleep, will repeatedly experience this rebound effect and regular waking. For this problem, they often further self-medicate with more depressants, and thereby create a vicious cycle. People who do this are often unaware of how they are actually interfering with their brain’s natural ability to sleep with substances like alcohol or cannabis.
The other problem with relying on substances, including prescription drugs such as minor tranquillizers or sleeping pills, is that any substance that affects the functioning of your central nervous system will also interfere with the natural brain processes associated with dreaming. Researchers in sleep laboratories have demonstrated that alcohol taken on the night of engaging in learning experiments interferes with the natural brain processes responsible for integrating new information. If dreams are our species’ natural process for digesting our experiences, anything that interferes with this ability is likely to have deleterious effects on a range of psychological functions. If emotional stress is keeping you awake at night, and you are relying on substances to help you cope and sleep, then you are likely to be interfering with your natural ability to resolve the emotional component of your problem. This is likely to reduce your overall ability to cope. Most substances like alcohol, cannabis and medically prescribed tranquillizers or antidepressants are double-edged swords, apparently giving us something to help us cope, whilst at the same time taking something away and diminishing our overall ability to cope.
The manufacturers of Prozac acknowledge that up to 33% of people taking this popular SSRI antidepressant report an increase in insomnia as a result of the drug.2 They also acknowledge that up to 5% of people will have an increase in abnormal dreams (often nightmares) as a result of being on the drug. Independent research would suggest that most figures of adverse side effects given by the pharmaceutical companies are likely to be underestimated.3 The real number of people who find it increasingly hard to sleep while on SSRIs could be much higher. The SSRI antidepressants create an increase in the availability of serotonin, and as a result of being on the drug, more serotonin stimulation occurs in the person’s brain. This unnatural increase in serotonin stimulation of brain cells could be responsible for worsening sleep problems.
The rebound effect discussed above is also true for other substances, such as amphetamines and the host of “party drugs” such as Ecstasy, Fantasy, etc. These stimulants may produce euphoria in the period of intoxication; however, as they are artificially increasing the level of brain arousal above the normal baseline level, the brain will fight back with a rebound effect. This time, the brain will alter neurotransmitter levels in order to drag the level of arousal down, closer to its normal level, by depressing itself. Again, when the stimulant has been metabolized and processed by the person’s system, they will be left just with the rebound effect of depressed brain functioning. As such, it is common for people “coming down” from amphetamine and other stimulant use to “crash” in the days that follow, whereby they simply feel an unshakable depression. Louise was a young client of mine who struggled with various issues. For the most part, she was able cope with the challenges with great courage. However, she resorted to using Ecstasy one night to lift her mood after a relationship break-up, and two days later she was so miserable that she attempted suicide. Sadly, this is not an uncommon occurrence. Many people remain unaware of rebound effects, and how recreational drugs can result in utter despair.
If a person’s ability to sleep is being hampered by drug reactions as discussed here, then this is essentially a neurological problem that needs to be addressed at that level. Drug reactions need to be understood and appropriate action taken before sleep is likely to improve. Sedative painkilling drugs are also likely to produce their own rebound effects. As such, they too can interfere with sleep, unless they are taken at such high dosages that they simply render the person unconscious. Doses at such a level are likely to produce a whole raft of other problems, including accidental overdose, thus the importance of developing other means of addressing chronic pain. You should never take yourself off prescription medications without first discussing this with your physician and being alerted to the issues involved. A well thought-out and monitored withdrawal plan is necessary to avoid further problems.
What we do during the day is also likely to either enhance or hinder our ability to sleep. Excessive amounts of caffeine during the day or evening can obviously produce such a level of arousal to make sleep difficult. On the positive side, being physically and psychologically active is important in optimizing the chances of good sleep. If you are able to go to bed physically tired as a result of a high level of activity during the day, then this is likely to help. As such, getting into a good exercise routine is an important part of not only reducing chronic pain, but also of enhancing the chances of sound sleep. Research indicates that increasing your body temperature with vigorous exercise or a hot bath around three hours prior to sleep time will also help to create a physiological readiness for sleep at bed time. If you are going to bed highly anxious about the day’s events, or perhaps anticipating the worst of the next day, then you are less likely to sleep well. If this is a regular occurrence for you, then you should again develop an exercise routine which will help to dissipate the build-up of stress hormones which accumulate in your system during the day. In addition, it would make sense for you to create an evening ritual of being still and quiet in the form of meditation, yoga, prayer or relaxation exercises. Some people will find the same meditative stillness and pleasure in quietly playing an instrument, or listening to enjoyable music. People respond differently to these options, with some feeling that they can most relax in reflective prayer or contemplation, while others prefer to focus just on their breath or yoga, and others respond well to guided imagery as found on relaxation CDs (available from my webpage). Experiment with a range of calming options until you find one that works for you, and then incorporate it in your evening ritual, perhaps as an alternative to watching TV.
Waves of sleep
Sleepiness tends to come to us in waves. If we have taken care of all the factors discussed above and we are in a state of readiness for sleep, then it is likely that the next wave of sleepiness will simply take us with it. The understanding of sleep as coming in waves is totally opposite to the notion of trying to make yourself sleep. Like digestion and circulation, sleep is a function of our organism that requires no conscious effort to make happen. In fact, any effort to make sleep happen will most likely interfere with our ability to be taken by the next wave of sleepiness.
People can make themselves entirely anxious about sleep, such that they end up trying too hard to make it happen. Being taken by a wave of sleepiness does not always occur, particularly if you have become anxious about sleep, and have incorporated into your self-concept “I have a sleeping problem.” Fortunately, EFT is an excellent remedy for this, once you have created the right conditions to allow sleep to occur. As with other problems, when your experiences have led you to the view that you have a sleep problem, you will also have pathways of neurons which reflect both this experience and the self-concept of being a poor sleeper. On trying to sleep, this pathway of neurons will be highly activated to the extent that you are anxious about not being able to sleep. As such, it becomes something of a self-fulfilling prophecy which is constantly being reinforced in a circular manner. The longer it goes on, the more deeply entrenched these pathways become, and the more difficult you find it to get to sleep. Again, EFT can act as a perfect circuit-breaker, allowing the next wave of sleepiness to take you with it.
These type of drugs are also increasingly prescribed to help with sleep, with a nearly 25% increase in prescription in the U.S. over the last few years. The prescription of sleeping tablets are still the most common medical response to sleeping problems, despite what the evidence says about them. Research in Australia has recently shown that 95% of people complaining of sleep problems to their GPs are prescribed sleeping tablets. As with many pharmaceutical drugs, there is often a downside which goes along with the potential upside.
All sleeping tablets and minor tranquillizers, such as Valium, have been demonstrated to interfere with various stages of sleep, including REM sleep. While they may help you to spend more hours sleeping, you will usually wake up still feeling like you have not had enough sleep, as the drugs interfere with the normal sleep cycle. People will often respond to this increasing daytime fatigue by increasing the dosage level of the sleeping tablet that night, which further interferes with deep stage and REM sleep. Keep in mind how important dreams are for our emotional well-being, so anything that interferes with your natural ability to dream can be considered potentially problematic. People who are relying on substances to increase the amount of hours spent asleep are running the risk of becoming REM-deprived. The result of this can be a worsening psychological state, lower mood and poorer mental functioning. Not what one generally hopes to get from a medicine.
People’s central nervous systems will usually habituate to the ‘hypnotic’ sleeping tablets and minor tranquillizers (benzodiazepines), so an ever increasing amount is required to get the same result of sleeping more hours— this is a recipe for addiction. As such, rather than getting better, the sleep problem can just become worse, with the person feeling even more worn out and despairing. There is also the increased risk of accidental overdose with each new increase in dosage level. When people have been using drugs for a long time to aid with sleeping, and then decide to cease using them, a rebound effect, as described with alcohol, can occur. This can go on for weeks, and may lead the person to feel even more agitated and unable to sleep, as well as increase the frequency of their nightmares. Some people also report odd and unusual experiences while taking hypnotic sleeping tablets. Zolpidem, marketed Stilnox in Australia and Ambien in America, is the most prescribed hypnotic sleeping tablet in the world. It is also sold under generic drugs names such as Dormizol, Stildem, and Somidem.
A recent review of violent or unexpected deaths of people who were taking Stilnox in the Australian state of New South Wales between 2001 and 2011 reported that in around a third of cases, zolpidem contributed to the deaths. The study leader, Shane Darke from the National Drug and Alcohol Research Centre at the University of New South Wales, states that such a high prevalence of incidences render zolpidem an unsafe drug to take. It has been linked to bizarre and confusional behaviour, often with reports of no conscious awareness or memory, sleep walking, violence, and suicide. The evidence of such ill-effects are so strong that the study authors suggest that it should now be routinely tested for in all violent and unexpected deaths. GPs often prescribe zolpidem in the belief that the short-term inducement of sleep by hypnotics is better than no sleep at all. The effects of these drugs are particularly dangerous when taken in combination with alcohol, opiates and major tranquilisers; and when people take the drug but don’t then go to bed. Obviously, the false perception of safety with hypnotic drugs needs to change. In addition to these potential dangers, recent research has revealed that sleeping tablets are also associated with increased risk of death from cancer, heart disease and other serious ailments.
Researchers from San Diego studied a range of sleeping tablets on the market, including both zolpidem and temazepam (a benzodiazepine), which have been considered safer than older hypnotics because of their shorter duration of action. Their study matched 10,531 sleeping tablet users (average use time of 2.5 years) with 23,674 people who were not using the drugs, but were similar in other factors such as age, gender, and health status. Even relatively low use of these tablets was found to be associated with higher mortality rates, with an overall 4.6 times greater chance of death for the tablet users. People who took only 1-18 tablets per year were still at 3.6 times more risk of death during the course of the study when compared to matched subjects who did not take the pills. For people who took up to 132 doses of the drug each year, their risk of contracting new cancers increased by 35% when compared to matched subjects not taking the pills. The British Medical Journal Open article, in which this research was reported, concludes with urging physicians to encourage their patients to use nonpharmaceutical and psychological approaches to address sleep problems.
If you decide that you would like to come off sleeping tablets, then discuss this with your doctor. If there is no compelling medical reason for you to remain on them, she may agree to assist you in working out a gradual withdrawal program. If not, then there is the chance that she has been overly influenced by the relentless marketing efforts of the drug companies that sell these products. Most physicians have not been trained in nondrug approaches to sleep problems or other psychological issues, such as depression and anxiety. As a consumer of health services, you are perfectly entitled to thank him/her for their advice, and then disagree if there is not sufficient reason to remain on the drugs. Although the attitudes of some will suggest that it is the other way around, you are actually employing the physician.
Each year, the old paternalistic attitude of medicine is changing a little, and more physicians are able to recognize that they are there to provide a service, not to impose their authority on their patients. They will often be in a good position to offer you advice on a range of health issues; however, you will be best served by becoming a well-informed health consumer who can do your own research. Sometimes, you may arrive at conclusions which are different from your physician. Unfortunately, the quality of advice found on the Internet can vary widely. You will need to develop an ability to discriminate between various sources of information—a reasonable rule of thumb is to always look for research-based evidence in support of any health suggestion. If the health advice is just based on people’s personal philosophy, or on their own unique experience, this may not suffice as a reasonable ground on which to accept their suggestions. Look for the evidence. The same is true for selecting any health professional, or evaluating their advice. Some of the characteristics of a good health professional are the ability to listen to your concerns, and to respect your choices, even if this differs from their advice. Become a well-informed consumer of health services who expects accurate information and respect for your choices.
You will be more confident in taking yourself off sleeping tablets, either with or without your physician’s support, if you have alternative strategies in place. This chapter has presented a range of strategies which work very well. Hold off with your gradual withdrawal program from sleeping tablets or minor tranquillizers until you are confident enough in these strategies. Ideally, you can become so confident with these strategies that you no longer believe that you need to use the drugs to assist with sleep. Then begin by reducing in small amounts. If you experience withdrawal effects, or a severe rebound effect which may make sleep a lot more difficult, then you have probably reduced by too much, and need to go back to your most recent dosage level in order to stabilize. Then recommence your withdrawal program, but at a lower rate of reduction. There is an amount of trial and error involved in finding the right withdrawal levels for you so that you do not experience withdrawal or rebound effects. If need be, seek open and knowledgeable health professionals who are willing to help and support you in this process. There is an increasing willingness amongst physicians to acknowledge the downsides of psychiatric drugs, and to help people successfully withdraw from them.
Herbal products which can aid with sleep also deserve a mention. There are often less toxicity problems associated with plant products than pharmaceuticals, however they are never entirely risk free. If any product induces a slower, more relaxed state in you, it is acting on your central nervous system. This settling effect may be just what is required to assist you with sleep, but it can also carry the same consequences in regards to rebound effects, and hampering of REM sleep as do pharmaceuticals. Some people’s system may also be just as unable to metabolize natural products as herbs (see Chapter 15—pharmacogenetics). However, such products can be considered a viable short term option to manually “shift” your circadian cycle when used for no more than two weeks. Consult with a qualified herbalist, naturopath or herb-aware physician and stick with their dosage suggestions.