Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID:33150-30782

Insomnia in Chronic Pain Shona Ray-Griffith, MD Assistant Professor University of Arkansas for Medical Sciences

Disclosures I receive clinical trial support from Neuronetics. I have received clinical trial support from Sage Therapeutics. Neither will be discussed today.

Objectives Identify factors influencing sleep in patients experiencing chronic pain Provide a general overview of the impact of opioids on sleep Review treatment options for insomnia

Poll Everywhere Text shonaraygrif105 to 22333

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Literature Search Nada Zero Zilch

Sleep and Pain Pain Study Findings Limitations Sleep disturbance Hyperanalgesia Study Findings Reduced sleep quality is consistently reported Pain severity may be a significant predictor of proximal and long-term sleep disturbance Limitations Studies done with acute pain and not chronic pain Studies utilize sleep disruptions disproportionate to those with chronic pain Subjective vs Objective Measures of sleep Rated scales, actigraphy, and polysomnography

Chronic Pain Sedentary lifestyle Medical Comorbidities Overweight/Obese Obstructive Sleep Apnea Comorbid mood and anxiety disorders Cognitive distortions Rumination Catastrophizing Medication side effects

Opioids and Sleep Side effects Opioid-induced respiratory depression fatigue and/or daytime sleepiness Opioid-induced respiratory depression Compounded by presence of sleep-disordered breathing Acute administration Decrease deep sleep (stages 3 and 4 and REM) Increase stage 2 sleep No affect on total sleep time, sleep efficiency, sleep latency, sleep awakenings Chronic use has scant literature

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Before you consider treatment options… Trouble falling asleep? Trouble staying asleep? Waking up early? Naps? Sleep duration? Caffeine Use?

Treatment Behavioral Pharmacological Sleep hygiene CBTi or cognitive behavioral therapy for insomnia Progressive muscle relaxation Z hypnotic drugs Benzodiazepines Tricycle Antidepressants Gabapentin

Sleep Hygiene Do’s Establish a regular, relaxing bedtime routine that includes going to bed at the same time each day. Keep your bedroom at a comfortable temperature, quiet, and dark to facilitate sleep. Use a relaxation exercise just before going to sleep or use relaxing imagery. Even if you don’t fall asleep, this will allow your body to rest and feel relaxed. Get up from bed at the same time each day. Get regular exercise each day, preferably in the morning. Get regular exposure to outdoor or bright lights, especially in the late afternoon. Use your bed only for sleep (and sexual activity).

Sleep Hygiene Don’ts Exercise just before going to bed. Try to keep it no closer than 3-4 hrs before bed. Engage in stimulating activity just before bed. Have caffeine or alcohol in the evening. Go to bed too hungry or too full. Take another person's sleeping pills or OTC sleeping pills, without doctor's knowledge. Command yourself to go to sleep. Watching the clock causes anxiety, which keeps you up. Lie in bed awake for > 20-30 mins. Instead, get up, go to a different room, participate in a quiet activity, and then return to bed when you feel sleepy. Do this as many times as needed. Change your daytime routine the next day if you didn’t sleep well. No daytime naps.

CBTi CBT is useful to target pain and insomnia CBTi utilizes stimulus control and sleep restriction therapies Stimulus control: breaking the conditioned association between bedroom environmental stimuli and sleep interfering states of psychophysiological arousal thought to perpetuate insomnia Retiring to the bedroom when in pain Sleep restriction therapy: a controlled form of partial sleep deprivation designed to rapidly consolidate sleep and systematically increase sleep opportunity when adequate sleep consolidation (efficiency) is achieved Results are comparable to use of benzodiazepine receptor agonist and hypnotic medications

Progressive Muscle Relaxation Systematically tensing and releasing the major muscle group while focusing attention on the physical sensation of tension contrasted with relaxation

The substantial degree of learning and behavior change continues beyond the acute treatment phase and does not become entirely consolidated until after substantial practice over the course of 6 months to a year.

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Fuentes AV, Pineda MD, Venkata KCN Fuentes AV, Pineda MD, Venkata KCN. “Comprehension of Top 200 Prescribed Drugs in the US as a Resource for Pharmacy Teaching, Training and Practice” Pharmacy (Basel) 2018;6(2):43

Pharmacological Options Z-Hypnotics Benzodiazepines Zolpidem Eszopiclone Zaleplon Short-term use is indicated Alprazolam Clonazepam Temazepam Most helpful for reduced sleep fragmentation (middle insomnia) Consider rapidity of onset and half-life

Pharmacological Options Antidepressants Trazodone (orthostatic hypotension) Mirtazapine Tricyclic antidepressants Nortriptyline Amitriptyline Doxepin Antihistamines Diphenhydramine Hydroxyzine Anticonvulsants Gabapentin Topirimate Atypical Antipsychotics

Continuing Education Credit: TEXT: 501-406-0076 Event ID:33150-30782