1. 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:
Event ID:

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

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

4. 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

5. Poll Everywhere
Text shonaraygrif105 to 22333

6. https://www. polleverywhere

7. Literature Search
Nada
Zero
Zilch

8. 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

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

10. 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

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

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

14. 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).

15. 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 > 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.

16. 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

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

18. 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.

19. https://www. polleverywhere

20. 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

21. 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

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

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