If you are sleep deprived, you will not get better.

Nothing else matters if you don’t get adequate rest.

PREVALENCE OF SLEEP DEPRIVATION

According to the National Sleep Foundation’s 2005 Sleep in America poll, 60% of adult drivers – about 168 million people – say they have driven a vehicle while feeling drowsy in the past year, and more than one-third, (37% or 103 million people), have actually fallen asleep at the wheel! In fact, of those who have nodded off, 13% say they have done so at least once a month. Four percent – approximately eleven million drivers – admit they have had an accident or near accident because they dozed off or were too tired to drive.

 

The National Highway Traffic Safety Administration conservatively estimates that 100,000 police-reported crashes are the direct result of driver fatigue each year. This results in an estimated 1,550 deaths, 71,000 injuries, and $12.5 billion in monetary losses. These figures may be the tip of the iceberg, since currently it is difficult to attribute crashes to sleepiness.

 

Alaska is one of the most sleep deprived states, with about 1 out of every 4 men and almost 1 out of every 3 women reporting inadequate sleep. Sleep disturbances are highly prevalent in chronic pain patients, much higher than in the general population. In fact if you have chronic pain, it is more likely than not, that you are sleep deprived.

 

HOW MUCH SLEEP DO WE NEED?  HOW MUCH SLEEP ARE WE GETTING?How much sleep we need varies between individuals but generally changes as we age. The National Institutes of Health suggests that school-age children need at least 10 hours of sleep daily, teens need 9-10 hours, and adults need 7-8 hours. According to data from the National Health Interview Survey, nearly 30% of adults reported an average of ≤6 hours of sleep per day in 2005-2007. In 2009, only 31% of high school students reported getting at least 8 hours of sleep on an average school night.

 

IMPACT OF SLEEP DEPRIVATION

Americans are so sleep deprived that the Centers for Disease Control and Prevention two years ago stated that:

 

 insufficient sleep is a national

“public health epidemic.”

 

Health organizations such as the National Institutes of Health, the American Psychological Association and the Mayo Clinic have warned for years that Americans aren’t getting enough sleep, stating sleep deprivation causes:

  1. increased hypertension,

  2. diabetes,

  3. depression,

  4. obesity,

  5. osteoporosis,

  6. cancer,

  7. increased mortality,

  8. reduced quality of life and productivity,

  9. motor vehicle crashes, and increased workplace accidents.  

 

“Adequate sleep improves daytime functioning and concentration, and may improve the body’s immune system,” said Dr. Larry Ayers, a pulmonary diseases physician.

 

Another lesser known fact is that sleep deprivation tends to interfere with exercise. Sleep deprived individuals are far less likely to successfully implement an aerobic exercise program. One of the first positive changes when they improve their sleep is that their exercise participation generally improves.

 

SLEEP DEPRIVATION AND PAIN

Sleep deprivation causes hyperalgesia. Hyperalgesia means that you will hurt everywhere. Any sore joint or painful area will become much more painful if you are sleep deprived. Mild low back pain or neck stiffness will become a major problem if you don’t get adequate sleep. In fact, medical studies show that even people with no pain will begin to hurt all over, often after just one night of total sleep deprivation. When you consider how many people are chronically sleep deprived it begins to explain why so many Americans fight pain every day.

 

Pain also disrupts sleep and so we have to ask which comes first, pain or sleep disruption? Initially you may hurt your back and can’t sleep for a few nights. Then the sleep disruption causes hyperalgesia and that makes the back pain even worse. As the pain worsens the sleep gets even worse, and spiral down continues. Unless the spiral is stopped it may end in disability. In other cases a patient may become sleep deprived due to any number of reasons, and the sleep deprivation may trigger low back pain. The low back pain makes the sleep even worse and the patient ends up on the same spiral down.

 

Sleep disruption also triggers migraines and chronic headaches. Sleep deprivation appears to cause fibromyalgia, the painful condition that causes people to hurt everywhere.

 

A recent study showed a 150% increased risk of back pain for people that get poor sleep, and an even higher risk for women.

 

SLEEP DEPRIVATION INTERFERES WITH PAIN TREATMENT

Medical studies have proven that opioid pain medications are less effective with sleep deprived patients. Not only are narcotics less effective, other types of analgesic medications don’t work as well in the sleep deprived patient. Sleep deprivation also prevents people from implementing the exercise program that is necessary to overcome their chronic pain.

 

Hence sleep deprivation:

  1. may cause pain in a person who had no pain previously

  2. may make existing pain worse

  3. may make pain medications less effective

  4. may prevent implementing necessary treatment programs such as aerobic exercise

 

SLEEP HYGIENE

The promotion of good sleep habits and regular sleep is known as sleep hygiene. The following sleep hygiene tips can be used to improve sleep.

 

 

1.     Reinforce the natural 24 hour circadian rhythm of the body. Most people with chronic insomnia have disrupted their natural circadian rhythm. By reinforcing the natural day/night rhythm most people can correct their sleep. The natural circadian rhythm makes your body want to sleep at night and to be awake during the day. By re-synchronizing the circadian rhythm you can restore natural sleep. But you have to be willing to do what it takes to get back to normal, using light, sound, activity and consistency.

a.     Let’s start with consistency. You need to get on a consistent schedule that does not vary. Let’s say your schedule is to bed at 11:00 PM and up at 7:00 AM. Stick with the schedule every day. No exceptions. Get up at 7:00 no matter how long it took you to get to sleep. Don’t stay up late and sleep in on weekends. Every day, same schedule, no exceptions. If you stay up late for some unavoidable reason, you still get up on time.

b.     Light. You need bright lights in the morning and afternoon. Bright lights should come on at 7:00 AM and stay on all morning and afternoon. Curtains open all day to allow sunlight in, and spend time outside every day under the sun, even in the winter. In the evening the lights should be dim, curtains closed, and all screens, TV, computer, whatever, go off at least 1-2 hour before bedtime. At 11:00 PM, total darkness until 7:00 AM. Use blackout curtains, eye mask, etc, if needed. And DON’T turn on the light in the middle of the night if you have to get up to empty your bladder. If you need a night light to see where you are going, get one. But there are a lot of differences between night lights. Some are 3 watts or even more, and they are way too bright. The night lights I use, I bought at Lowes, and they are just 0.25 watts. They give off just a very dim orange glow, just enough to see what you are doing but not strong enough to suppress your melatonin production.  

c.     All sound makers have to be off at night. No radio, no TV going. Use ear plugs if needed.

d.    Activity. A general rule of thumb is: the more active you are during the day, the better you will sleep at night. You can't be sedentary all day and hope to sleep well at night. In the morning when it is time to get up, you should get dressed and get busy, engaging in many activities during the day. One of the activities should be aerobic exercise (a half hour of walking or 15 minutes of jogging), and you should complete the aerobic exercise by no later than mid afternoon. You should be busy enough all morning and afternoon, that you are worn out by the end of the day. You should transition to sedentary activities in the evening. This allows your body and mind to slow down and get ready for restful sleep.

e.     No naps. Teach your body to sleep at night. Taking naps prevents your circadian rhythm from getting back in sync. Follow this pattern each day:

 

 

 

 

 

 

 

 

 

 

 

 

If you follow this pattern each day, your circadian rhythm will resynchronize and your sleep will improve. 

2.     Avoid stimulants such as caffeine, nicotine, and alcohol. If you use these substances, QUIT. If you will not quit, at the very least avoid them for 6 hours before bedtime. Alcohol does speed the onset of sleep, but it disrupts sleep as the body begins to metabolize the alcohol, causing you to wake up early.

3.     Turn Your Bedroom into a Sleep-Inducing Environment. A quiet, dark, and cool environment is best. Keep the temperature comfortably cool—between 60 and 68°F—and the room well ventilated. Make sure you have a comfortable mattress and pillows

 

NATURAL SLEEP MEDICINE

There are a number of natural sleep medicines that can be quite effective. Here are 2 of my favorites.

 

Kava is also known as Piper Methysticum. The Kava plant is a member of the pepper family, and has been used for thousands of years to relieve anxiety and promote sleep. One review of six studies showed reduced anxiety among patients who took kava, compared with those who got a placebo and another study showed that kava improved sleep in people with insomnia.

 

Kava is an interesting medicine because it seems to act as a sedative without reducing mental alertness or slowing reflexes. One study compared Kava to a drug called oxazepam which is part of the Valium and Xanax family and found that it produced equivalent reduction in stress, but did not slow reaction time in driving tests. Both oxazepam and Kava reduced symptoms of anxiety equally as measured by both the Self-Rating Anxiety Scale and the Anxiety Status Inventory. This study made it clear that the kavalactones possess anti-anxiety activity comparable to the benzodiazepines, but without the hazards. In another study, a battery of tests were given to forty subjects. In this study, Kava extract administered to volunteers did not impair their performance driving an automobile or operating heavy machinery.

 

Other studies have shown it does not reduce mental functioning. For example in a double-blind, placebo-controlled study of eighty-four patients suffering from anxiety, a daily dose of 400 mg of purified kavain actually improved vigilance, memory and reaction time. In a word recognition test, oxazepam slowed reaction time and reduced the number of correct answers, whereas the kava extract slightly increased reaction time and recognition. This supports the oft-repeated claim of Kava users that even when enough Kava is consumed to cause sedation, there is no impairment of mental function, including memory or clarity of thought.

 

The American Academy of Family Physicians says that short-term use of Kava is okay for patients with mild to moderate anxiety -- but not if you use alcohol or take medicines metabolized in the liver, including many cholesterol medicines and Tylenol (acetaminophen). In fact, the FDA has issued a warning that using Kava supplements has been linked to a risk for severe liver damage. The FDA warning about the liver is based on 32 cases of liver injury that have been reported in Kava users. It is unknown if these people were using other drugs, or if they had liver disease before beginning Kava. It is known that Kava has been used for thousands of years without liver problems, so these recent reports are kind of an enigma.

 

In any event you should get clearance from your Primary Care Provider before using Kava, especially if you have liver disease, or use drugs metabolized in the liver. Signs of liver injury include nausea, vomiting, abdominal pain, skin or eyes turning yellow, or dark urine. If you experience any of those symptoms you would want to discontinue the Kava and report to your Primary Care Provider.

 

For most people, Kava offers a safe, effective alternative to prescription drugs for anxiety and insomnia, and in some cases provides relief for depression. The most significant anti-anxiety studies show that an effective daily dose of kavalactones ranges between 210 - 280 milligrams of kavalactones. To promote sleep, a dose of approximately 140 - 210 milligrams of kavalactones taken thirty to sixty minutes prior to retiring is recommended.

 

Valerian root has been used as a sedative and anti-anxiety treatment for more than 2,000 years. Valerian is a powerful nervine, stimulant, carminative and antispasmodic (muscle relaxant). The drug allays pain and promotes sleep.

 

A review of 16 studies suggests that valerian may help people fall to sleep faster. It also may improve the quality of sleep. Valerian becomes more effective over time, so it's best to take it every night for a short period of time. Valerian is considered safe to take for four to six weeks.

 

In one study 128 volunteers were given an aqueous extract of valerian or a placebo. Compared with the placebo, the valerian extract resulted in a statistically significant subjective improvement in time required to fall asleep, sleep quality, and number of nighttime awakenings.

 

In another study, eight volunteers with mild insomnia were evaluated for the effect of valerian on sleep onset. Results were based on nighttime motion measured by activity meters worn on the wrist and on responses to questionnaires about sleep quality, latency, depth, and morning sleepiness filled out the morning after each treatment. The valerian extract reduced average sleep onset from about 16 to 9 minutes, which is similar to the activity of prescription benzodiazepine medication (used as a sedative or tranquilizer).

 

A 28 day study looked at longer-term effects in 121 participants with documented nonorganic insomnia. Participants received either dried valerian root or placebo for 28 days. After 28 days, the group receiving the valerian extract showed a decrease in insomnia symptoms on all the assessment tools compared with the placebo group.

 

In a randomized, double-blind study, 75 participants with documented nonorganic insomnia were randomly assigned to receive 600 mg of a standardized commercial valerian extract or 10 mg oxazepam (a benzodiazepine medication) for 28 days. Both groups had the same improvement in sleep quality but the valerian group reported fewer side effects than did the oxazepam group.

 

In a randomized, double-blind, placebo-controlled crossover study, researchers evaluated sleep parameters with polysomnographic techniques. Valerian caused a decrease in slow-wave sleep onset (13.5 minutes) compared with placebo (21.3 minutes). During slow-wave sleep, arousability, skeletal muscle tone, heart rate, blood pressure, and respiratory frequency decreased. Increased time spent in slow-wave sleep may decrease insomnia symptoms. The valerian group reported fewer adverse events than did the placebo group.

 

Of the two, I would favor Valarian more with muscle spasms, tremours and headaches and if only night time use is needed. Kava I would favor more if daytime use is needed and if depression and anxiety are more of a concern. Both will help sleep but Valarian more for help falling asleep and Kava more for help staying asleep.

 

SLEEP DRUGS

There are a number of drugs that may help pain and improve sleep. We are generally willing to prescribe drugs that benefit pain AND sleep. If patients need a drug that only benefits sleep, and not pain, we suggest they see their Primary Care Provider about it. Here are some of the drugs we commonly use.

  1. Remeron (mirtazapine) is an antidepressant that reduces pain, prevents headaches, improves digestion, may correct sexual dysfunction caused by certain drugs, and is great for helping sleep.

  2. Trazadone is an old antidepressant that may have a modest effect on pain and reliably promotes sleep.

  3. Elavil (amitriptyline) is an old tri-cyclic antidepressant that has near universal side affects, but does quite reliably promote sleep, prevents headaches, and reduces pain. Unfortunately it has many drug to drug interactions, should be avoided in older patients, those taking multiple medications and people with heart disease, and it does tend to cause weight gain.

  4. Neurontin (gabapentin) is used by many sleep specialists for its excellent influence on sleep. It also prevents headaches and reduces nerve pain. It is an old, reliable standby, that unfortunately causes weight gain for some patients.

  5. Zanaflex (tizanidine) is an excellent muscle relaxant that will reduce muscle spasms and the related muscular pain for 24 hours after a single dose for most patients, while causing drowsiness for around 4 hours. Hence many patients can use this drug just at night time to improve sleep and reduce low back or neck pain related to muscular spasm the next day. It also prevents headaches and in some patients that wake up after 3-4 hours, a second dose can be taken to try and get a full nights sleep.

 

There are many other drugs that may help your sleep and your pain that we are happy to discuss with you.

 

SLEEP STUDY

Some people have sleep apnea and a sleep study is necessary to diagnose the condition. After the condition is diagnosed patients can use a CPAP and the sleep may make a remarkable improvement. Any patient who has made a good faith attempt to improve their sleep and has not been successful should ask for a referral to a sleep clinic to be assessed for sleep apnea. Other indications that you may have sleep apnea include snoring, being overweight, and any observed moments of breathing stopping momentarily in your sleep.

 

WHAT IS THE BOTTOM LINE?

  1. Sleep deprivation is serious:

    • It will ruin your health

    • It will cause pain

    • It will make your pain worse

    • It will make treatment of your pain less effective

  2. You should be willing to work hard and sacrifice to improve your sleep.

  3. The sleep hygiene guidelines above, IF FOLLOWED, will improve your sleep.

  4. There are a number of medications, natural or otherwise that may help, but they should be tried AFTER a serious attempt at implementing correct sleep hygiene.

  5. A sleep clinic referral and possible sleep study may be needed by some patients.

  • Wake up and arise at the same time each morning.

  • Start the day with lots of bright lights and open curtains to allow sunlight in.

  • Get dressed and be active all day, and do your aerobic exercise.

  • Be active enough that you are naturally worn out at the end of the day.

  • In the evening start the transition to restful sleep by dimming the lights, and engaging in sedentary activities.

  • An hour or two before bedtime turn off all screens.

  • Go to bed at the same time each night

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