Pharmaceutical Treatment of Insomnia In Intractable Pain Patients

Pharmaceutical Treatment of Insomnia In Intractable Pain Patients

Insomnia is a profound problem in patients with severe, intractable pain that is poorly controlled.

These patients invariably have centralized pain with autonomic nervous system hyperactivity and a multitude of neurotransmitter abnormalities. These central disturbances may interrupt sleep to the point that patients cannot sleep longer than a few hours at a stretch. The lack of sleep in these individuals may be so severe that it not only increases pain but also produces mental confusion, depression, anxiety, anorexia, malnutrition, and severe fatigue—among other problems. Consequently, addressing both the patient’s chronic pain and secondary insomnia may require a complex regimen of treatments.

Discussed here are treatment options for patients with severe insomnia secondary to centralized, intractable pain—and who have not benefited from the usual therapies for primary insomnia.

The hallmark of centralized, intractable pain is a patient who describes his/her pain as severe, debilitating, and constant.

In addition to insomnia, excess cerebral autonomic activity caused by intractable pain may cause mental confusion, memory loss, depression, anxiety, and fatigue.

The reason(s) for the autonomic hyperactivity is unclear.

In centralized pain there are inflammation, tissue destruction, sensitization, and deficiencies of neurotransmitters, which may interfere with sleep.

As always, careful review of the patient’s pain regimen should be addressed to make sure that their pain is being adequately treated

the safest and less toxic antidepressants, antiseizure agents, and nonbenzodiazepine agents should generally be the first selections. Reserve the more hazardous agents for when the safer agents prove ineffective. I try to initiate treatment with an antidepressant or antihistamine accompanied by melatonin, tryptophan, or valerian.

Another factor to keep in mind is that the usual recommended starting dose might be woefully inadequate. It is not uncommon to require a dosage 2 to 4 times the standard starting dose.

Despite the use of a potent treatment agent(s), the length of sleep is woefully short in some patients. On the other hand, some patients simply take a regular opioid dosage before bedtime and find this adequate for sleep. Many take an opioid dosage when they awake during the night. Not surprisingly, most say their pain is better controlled the next day if they get a good night’s sleep. A number of studies document that sleep deprivation in pain patients is associated with increased pain and may interfere with other cerebral functions.