How pain and analgesics disturb sleep

Perioperative Sleep Quality Disturbances in Total Joint Arthroplasty is Multifactorial

BACKGROUND

Sleep quality following arthroplasty procedures is important for patient recovery and satisfaction, but remains poorly understood. The purpose of this study was to report risk factors for sleep disturbances in the perioperative period in patients undergoing primary total joint arthroplasty procedures.

METHODS

Sleep surveys were prospectively collected on 751 consecutive patients undergoing total joint arthroplasty at our institution between June 2019 and February 2021 at their preoperative and postoperative visits (2 and 6 weeks). Data were collected on patient demographics, opioid use (preoperatively and postoperatively) as well as tobacco and alcohol use, and specific medical diagnosis that may influence sleep patterns (ie, depression). Statistical analyses were performed using the Student's t-tests and 1-way analysis of variances.

RESULTS

For both total hip and total knee patients, worse sleep patterns preoperatively were found in patients who used opioids prior to surgery (P < .001), were current smokers (P < .001), and were aged less than 65 years (P < .001). Postoperative persistent opioid use (more than 3 months) was seen in patients who had worse reported sleep quality preoperatively (P < .001). In comparison to total hip arthroplasty, patients who underwent total knee arthroplasty were more likely to report less sleep in the postoperative period. Patients who were current smokers (compared to nonsmokers or previous smokers) (P = .014) had worse sleep quality at all time points that persisted at 6 weeks, although these differences were seen more in total hip patients than in total knee patients (P = .006 versus P = .059).

CONCLUSIONS

Sleep quality disturbances around the time of surgery appear to be multifactorial.

LEVEL OF EVIDENCE

Therapeutic Level III.

Sleep quality and psychological health in patients with pelvic and acetabulum fractures: a cross-sectional study

BACKGROUND AND OBJECTIVES

It is known that difficulty sleeping after a fracture can have negative effects on both mental and physical health and may prolong the recovery process. The objective of this study is to explore how sleep quality and psychological health are linked in patients with pelvic and acetabulum fractures.

METHODS

A study was conducted on 265 patients between 2018 and 2022 who had suffered pelvic and acetabulum fractures. The study examined various factors, including age, gender, cause of injury, post-operative complications, and injury severity. The study employed ordinal logistic regression to examine the relationship between various pelvic fractures and seven subscales of the Majeed Pelvic Score (MPS), as well as the Sleep Disorder Questionnaire (SDQ) and Beck Depression Inventory (BDI). The study focused on the postoperative outcome one year after surgery, and each patient was assessed at the one-year mark after surgical intervention. Additionally, the study evaluated the functional outcome, sleep quality, and psychological disorders of the patients.

RESULTS

From 2018 to 2022, a total of 216 patients suffered from pelvic and acetabulum fractures. Among them, 6.6% experienced borderline clinical depression, and 45.2% reported mild mood disturbances. Anxiety was found to be mild to moderate in 46% of Tile C and posterior acetabulum wall fracture patients. About 24.8% of patients reported insomnia, while 23.1% reported sleep movement disorders. However, no significant correlation was found between fracture types and sleep disorders. The mean Majeed pelvic score (MPS) was 89.68.

CONCLUSIONS

Patients with pelvic and acetabular fractures typically experience functional improvement, but may also be at increased risk for insomnia and sleep movement disorders, particularly for certain types of fractures. Psychological well-being varies between fracture groups, with signs of borderline clinical depression observed in some cases. However, anxiety levels do not appear to be significantly correlated with pelvic and acetabular fractures.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Non-inflammatory pain in inflammatory arthritis

'Non-inflammatory' pain, pain that is not associated with measures of inflammation, is common in patients with inflammatory arthritis including RA. One important cause of non-inflammatory pain is concomitant fibromyalgia. Systematic review has shown that fibromyalgia is common in inflammatory arthritis including RA affecting 1 in 5 patients and is associated with higher disease activity scores due to inflated tender joint count and patient global assessment. Consequently, many patients with RA and concomitant fibromyalgia may fail to reach treatment target and switch to alternate disease modifying drugs frequently. European Alliance of Association for Rheumatology has highlighted that concomitant fibromyalgia is an important consideration in assessing difficult-to-treat RA. The incidence and prevalence of fibromyalgia are higher in RA than the general population, raising the possibility that fibromyalgia may be 'secondary' to RA rather than a concomitant disease. The precise mechanisms whereby patients with RA develop fibromyalgia are unknown. In this review, we discussed fibromyalgia in RA, its clinical impact and epidemiology as well as data suggesting fibromyalgia might be 'secondary'. Lastly, we reviewed potential pathogenic mechanisms which included inflammatory cytokines sensitizing nociceptive neurones, temporal summation, also known as windup, from chronic pain and impaired coping from poor quality sleep and mental well-being. Deciphering the exact mechanisms may lead to treatment strategies that prevent development of secondary fibromyalgia and will address a common factor associated with difficult-to-treat RA.

Sleep disorders in chronic pain and its neurochemical mechanisms: a narrative review

Chronic pain (CP) is a prevalent problem, and more than half of patients with CP have sleep disorders. CP comorbidity with sleep disorders imposes immense suffering and seriously affects the patient's quality of life, which is a challenging issue encountered by clinicians. Although the reciprocal interactions between pain and sleep have been studied to some degree, there is still a lack of awareness and comprehensive description of CP comorbidity with sleep disorders. In this narrative review article, we summarize the current knowledge about the present estimates of the prevalence of comorbid sleep disorders in CP patients, sleep detection methods, sleep characterization in CP, and the effect of sleep disorders on CP and current therapies. We also summarize current knowledge of the neurochemical mechanisms of CP comorbidity with sleep disorders. In conclusion, insufficient attention has been paid to the role of sleep disorders in CP patients, and CP patients should be screened for sleep disorders in the clinic. Special attention should be given to a possible risk of drug-drug interaction when using two types of drugs targeting pain and sleep simultaneously. The current insight into the neurobiological mechanisms underlying CP comorbidity with sleep disorders is still rather limited.

Evaluation of Sleep Quality and Its Relationship With Pain, Mood, and Physical Function After Orthopaedic Trauma Surgery: A Prospective Cohort Study

INTRODUCTION

Sleep disturbances are associated with pain and mental health. We prospectively compared a cohort of patients with orthopaedic trauma with a control group to establish the prevalence and duration of sleep disturbance and associations between sleep disturbance and pain, mood scores, and functional outcome scores.

METHODS

Subjects were patients with orthopaedic trauma undergoing in-patient surgical procedures and healthy control subjects from the community. Questionnaires completed by all subjects included the VAS numerical pain rating scale, the abbreviated profile of mood states, Patient-Reported Outcomes Measurement Information System Physical Function, and Patient-Reported Outcomes Measurement Information System Sleep Disturbance. Control subjects completed the surveys once, and subjects with trauma completed them at 2, 6, and 24 weeks postoperatively.

RESULTS

Healthy control subjects (28.6 ± 13.2) were significantly younger than patients with trauma (41.8 ± 18.9) ( P < 0.001). Compared with control subjects, at 2-week follow-up visit, patients with trauma had worse sleep ( P < 0.001) and worse mood ( P = 0.006). Across the study period, patients with trauma showed improvements in physical function ( P < 0.001) and pain (at rest [ P = 0.02], during activity [ P = 0.02], and at night [ P = 0.002]). In patients with trauma, better sleep disturbance scores were associated with better mood and less pain for all pain metrics ( P < 0.001).

DISCUSSION

Patients with orthopaedic trauma have worse sleep disturbance scores at 2 weeks postoperatively compared with normal control subjects; this difference attenuated at 6 weeks. Sleep disturbance was found to markedly correlate with pain and mood, with worse sleep quality associated with higher pain and worse mood. Improvement in sleep quality across 24 weeks postoperatively was associated with improvement in mood scores.

CONCLUSION

Patients should be counseled about the likely development of sleep disturbance and the possible association with worse emotional/mental health with worse sleep. Physicians should consider incorporating a multidisciplinary approach to the management of these select patients.

Sleep hygiene strategies for individuals with chronic pain: a scoping review

OBJECTIVES

Up to a quarter of the world's population experience chronic pain, which, in addition to interfering with daily activities and waking function, is often associated with poor sleep. Individuals experiencing poor sleep are often encouraged to implement sleep hygiene strategies. However, current sleep hygiene strategies have not been developed considering the unique challenges faced by individuals with chronic pain and therefore they might not be as effective in this population. The aim of this scoping review is to map the state of the existing literature examining sleep hygiene strategies in individuals with chronic pain.

DESIGN

This scoping review included a search of four online databases (Medline, Embase, PsycINFO and CINAHL) to identify articles examining the use of sleep hygiene strategies in populations with chronic pain.

RESULTS

Thirty articles investigated at least one sleep hygiene strategy in individuals with chronic pain, with improvements to sleep reported for six sleep hygiene strategies (education, exercise, limiting alcohol use, limiting tobacco use, prebed state and sleep environment). However, the timing of these strategies was often not reported which limits the degree to which these strategies can be generalised for use as a presleep strategy.

CONCLUSION

This scoping review examined the existing literature focusing on sleep hygiene strategies for people with chronic pain. There are limitations to the methodology of the existing literature and gaps in our understanding of sleep hygiene strategies in some chronic pain conditions that must be addressed in future research before the effectiveness of these strategies can be understood.

Sleep and fatigue among youth with sickle cell disease: A daily diary study

Youth with sickle cell disease (SCD) experience disease effects including vaso-occlusive pain crises, poor sleep quality, and fatigue. The present study examines how sleep quality and pain medications impact fatigue in youth with SCD. Daily diaries assessing pain, fatigue, sleep quality, mood, and use of pain medications from 25 youth with SCD ages 11 to 18 years were collected for eight consecutive weeks. Poor sleep quality predicted increases in next-day fatigue levels while controlling for pain and mood. Sleep quality did not moderate the existing temporal relationship between pain and next-day fatigue established by Reinman et al. (2019) as predicted. Non-opioid medications affected ratings of next-day fatigue but opioid medications did not. Sleep quality appears to play an important role in predicting next-day fatigue levels and may be an important target for intervention. Pain medication use did not substantially contribute to prospective fatigue levels among youth, but requires further study.

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

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There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.

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The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.

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Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.

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Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.

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Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.

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Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids.

Drug-Induced Insomnia and Excessive Sleepiness

Undesirable side effects of insomnia and/or sleepiness may occur with many prescribed drugs, psychotropics as well as non-psychotropics. These central nervous system effects can be explained by the interactions of the drug with any of the numerous neurotransmitters and receptors that are involved in sleep and wakefulness. Also a close - sometimes bidirectional - relationship between disease and (disturbed) sleep/wakefulness is often present e.g. in chronic pain; drug effects may lead this vicious circle in both ways. Besides the importance for health and quality of life, effects on sleep or waking function can be a potential source of non-compliance.

Correlation Between Pre-Operative Sleep Disturbance and Post-Operative Pain in Patients With Rotator Cuff Tear

Objectives

This study aims to investigate the relationship between preoperative sleep disturbance and postoperative pain in patients with a rotator cuff tear, and to provide a theoretical basis for taking corresponding interventions to alleviate postoperative pain in patients with rotator cuff tear.

Methods

A total of 87 patients, who had undergone shoulder arthroscopy due to rotator cuff injury in Hunan Provincial People‘s Hospital from January to October 2021, were selected as the research subjects. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the sleep quality of patients with rotator cuff tears. All patients were divided into the low sleep quality group (PSQI score >7 points, n = 61) and the high sleep quality group (PSQI score ≤7 points, n = 26). Postoperative pain was assessed by using the Numerical Rating Scale (NRS). General clinical data of the patients were collected 1 day, 2 days, and 1 month after surgery. Univariate and multivariate analyses of influencing factors were performed in patients with moderate or above pain at 1 month after surgery.

Results

The score of postoperative pain of patients in the high sleep quality group was significantly lower than that of patients in the low sleep quality group (P < 0.05). A total of 35 patients (40.2%) had moderate or above pain 1 month after surgery, including 5 patients (19.2%) in the high sleep quality group and 30 patients (49.2%) in the low sleep quality group. The incidence rate of the low sleep quality group was significantly higher than that of the high sleep quality group (P = 0.009). After controlling confounding factors, preoperative sleep disturbance of patients was still independently associated with the occurrence of moderate or above pain 1 month after surgery (OR = 3.794, 95% CI: 1.261–11.409, P = 0.018).

Conclusion

Preoperative sleep disturbance can increase the risk of postoperatively moderate or above pain threshold in patients with rotator cuff tear. Paying more attention to and actively improving preoperative sleep disturbance can effectively promote postoperative pain management in patients with rotator cuff tears.

Why It Is Important to Consider the Effects of Analgesics on Sleep: A Critical Review

We review the known physiological mechanisms underpinning all of pain processing, sleep regulation, and pharmacology of analgesics prescribed for chronic pain. In particular, we describe how commonly prescribed analgesics act in sleep-wake neural pathways, with potential unintended impact on sleep and/or wake function. Sleep disruption, whether pain- or drug-induced, negatively impacts quality of life, mental and physical health. In the context of chronic pain, poor sleep quality heightens pain sensitivity and may affect analgesic function, potentially resulting in further analgesic need. Clinicians already have to consider factors including efficacy, abuse potential, and likely side effects when making analgesic prescribing choices. We propose that analgesic-related sleep disruption should also be considered. The neurochemical mechanisms underlying the reciprocal relationship between pain and sleep are poorly understood, and studies investigating sleep in those with specific chronic pain conditions (including those with comorbidities) are lacking. We emphasize the importance of further work to clarify the effects (intended and unintended) of each analgesic class to inform personalized treatment decisions in patients with chronic pain. © 2021 American Physiological Society. Compr Physiol 11:1-31, 2021.

The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications.

SETTING

Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites.

DESIGN

Cross-sectional, secondary analyses.

MAIN MEASURES

The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index.

RESULTS

After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids.

CONCLUSION

Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Associations Among Sleep Disturbance, Pain Catastrophizing, and Pain Intensity for Methadone-maintained Patients With Opioid Use Disorder and Chronic Pain

OBJECTIVE

This study examined the cross-sectional associations among pain intensity, pain catastrophizing, and sleep disturbance among patients receiving methadone maintenance treatment (MMT) for opioid use disorder (OUD) and reporting co-occurring chronic pain.

MATERIALS AND METHODS

Participants were 89 individuals with OUD and chronic pain drawn from a larger cross-sectional study of 164 MMT patients who completed a battery of self-report measures. The authors conducted 6 mediation models to test all possible pathways (ie, each variable tested as an independent variable, mediator, or dependent variable).

RESULTS

The only significant mediation effect was an indirect effect of sleep disturbance on pain intensity through pain catastrophizing. That is, greater sleep disturbance was associated with greater pain catastrophizing, which in turn was associated with greater pain intensity.

DISCUSSION

Altogether, findings suggest that the sleep disturbance to pain catastrophizing to pain intensity pathway may be a key mechanistic pathway exacerbating pain issues among MMT patients with OUD and chronic pain. These results suggest that interventions targeting sleep disturbance may be warranted among MMT patients with OUD and chronic pain. Future work in this area with longitudinal data is warranted.

Sleep disturbances and related disordered breathing after hip replacement surgery: A randomised controlled trial

INTRODUCTION

Mechanisms of postoperative sleep architecture disturbances and sleep-disordered breathing are uncertain. The authors hypothesised that patients undergoing surgery under regional anaesthesia without opioids used for postoperative analgesia would experience lesser changes in these parameters than patients operated under general anaesthesia with per- and postoperative opioids.

PATIENTS AND METHODS

After ethical approval and informed consent, patients undergoing total hip replacement were included in a prospective, randomised trial comparing 3 groups of patients: (1) S-LPB group receiving spinal anaesthesia and postoperative analgesia by lumbar plexus block; (2) GA-PCA group receiving general anaesthesia and postoperative analgesia by morphine patient-controlled analgesia; (3) GA-LPB group receiving general anaesthesia and postoperative analgesia by lumbar plexus block. Outcome measurements were polysomnographic parameters of sleep architecture and sleep-disordered breathing.

RESULTS

Eighteen patients completed the 5-night study protocol (preoperative night: N-1, postoperative nights: N1 to N4). The percentage of rapid eye movement (REM) sleep decreased by 49% and 47% during N1 in the GA-PCA and GA-LPB groups respectively. A rebound phenomenon of more than 40% in the GA-PCA group and 25% in the GA-LPB group was observed during N2 and N3. Apnoea hypopnoea index (AHI) and the number of arousals per hour were significantly increased during N2 and N3 when compared with N-1 in the GA-groups. No sleep architecture disturbances and no sleep-disordered breathing were measured in the S-LPB group.

CONCLUSION

Postoperative sleep architecture and breathing pattern were disturbed in GA groups. Both were preserved under spinal anaesthesia associated with a free opioid postoperative analgesia.

Systems and Circuits Linking Chronic Pain and Circadian Rhythms

Research over the last 20 years regarding the link between circadian rhythms and chronic pain pathology has suggested interconnected mechanisms that are not fully understood. Strong evidence for a bidirectional relationship between circadian function and pain has been revealed through inflammatory and immune studies as well as neuropathic ones. However, one limitation of many of these studies is a focus on only a few molecules or cell types, often within only one region of the brain or spinal cord, rather than systems-level interactions. To address this, our review will examine the circadian system as a whole, from the intracellular genetic machinery that controls its timing mechanism to its input and output circuits, and how chronic pain, whether inflammatory or neuropathic, may mediate or be driven by changes in these processes. We will investigate how rhythms of circadian clock gene expression and behavior, immune cells, cytokines, chemokines, intracellular signaling, and glial cells affect and are affected by chronic pain in animal models and human pathologies. We will also discuss key areas in both circadian rhythms and chronic pain that are sexually dimorphic. Understanding the overlapping mechanisms and complex interplay between pain and circadian mediators, the various nuclei they affect, and how they differ between sexes, will be crucial to move forward in developing treatments for chronic pain and for determining how and when they will achieve their maximum efficacy.

Positive airway pressure therapy for chronic pain in patients with obstructive sleep apnea-a systematic review

PURPOSE

Obstructive sleep apnea (OSA) is prevalent in patients with chronic non-cancer pain. OSA may lead to low sleep quality and an increase in pain sensitivity. Patients reporting greater sleep impairment tend to experience higher pain intensity and vice versa. Positive airway pressure (PAP) is the current gold standard treatment for OSA. This review aims to evaluate the efficacy of PAP therapy in patients with comorbid chronic pain and OSA in influencing pain outcomes like pain intensity, tolerance, threshold, and sensitivity.

METHODS

We performed a systematic literature search for studies published after 1990, utilizing the following databases: Medline, Medline In-Process/ePubs, Embase, Cochrane CENTRAL, and the Cochrane Database of Systematic Reviews. Search terms included "chronic pain," "sleep disorders," and "positive airway pressure."

RESULTS

Of 1982 initial studies, ten studies met the study inclusion criteria. Seven of these studies examined the effect of PAP therapy on chronic pain, of which five demonstrated improved pain outcomes, specifically, headache pain. The effect of PAP therapy on chronic non-headache pain was found to be inconclusive. When examining the three studies that did not involve chronic pain patients, PAP therapy effectively increased pain threshold and tolerance in two studies (p = 0.03 and p = 0.01).

CONCLUSION

An association exists between PAP therapy and decreased chronic headache outcomes in patients with OSA. Additionally, research shows that PAP therapy may increase pain tolerance and threshold. Future high-quality evidence is required to further investigate the association between PAP and non-headache chronic pain.

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial

OBJECTIVE

Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy.

DESIGN

Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120).

METHODS

We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups.

RESULTS

The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164).

CONCLUSIONS

Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.

Sleep spindles as a diagnostic and therapeutic target for chronic pain

Pain is known to disrupt sleep patterns, and disturbances in sleep can further worsen pain symptoms. Sleep spindles occur during slow wave sleep and have established effects on sensory and affective processing in mammals. A number of chronic neuropsychiatric conditions, meanwhile, are known to alter sleep spindle density. The effect of persistent pain on sleep spindle waves, however, remains unknown, and studies of sleep spindles are challenging due to long period of monitoring and data analysis. Utilizing automated sleep spindle detection algorithms built on deep learning, we can monitor the effect of pain states on sleep spindle activity. In this study, we show that in a chronic pain model in rodents, there is a significant decrease in sleep spindle activity compared to controls. Meanwhile, methods to restore sleep spindles are associated with decreased pain symptoms. These results suggest that sleep spindle density correlates with chronic pain and may be both a potential biomarker for chronic pain and a target for neuromodulation therapy.

The relationship between sleep and opioids in chronic pain patients

BACKGROUND

Sleep problems are common among chronic pain patients who take opioids. There are documented effects of opioids on sleep architecture; however, the long-term effects of opioids on sleep remain unknown. This study examined whether opioid-naïve participants have better sleep quality than current and previous chronic users of opioids. We also explored whether sleep differed between methadone and buprenorphine users, and whether amount of time since abstaining from opioids was associated with sleep quality.

METHOD

Participants were 120 people with chronic pain (84.2% Caucasian, M_age = 42.0 years, SD = 11.44). They were in one of four groups of 30 participants each: (1) current users of methadone for opioid use disorder (OUD); (2) current users of buprenorphine for OUD; (3) a history of medication-assisted therapy for OUD but currently opioid-abstinent for at least 6 months; (4) those who have less than one month of cumulative lifetime opioids (opioid-naïve group). Only participants in group 1 and group 2 were taking opioids during the time of the study. Participants completed the Pittsburgh Sleep Quality Index and the SF-36.

RESULTS

A MANCOVA revealed that all three groups with current or previous opioid use (i.e., groups 1-3) differed significantly from the opioid-naïve group (group 4) on sleep quality, sleep duration, sleep disturbances, and daytime dysfunction after controlling for sleep medications (all p < .05). For group 1 (methadone users), 2 (buprenorphine users), and 3 (prolonged abstinence), there were no statistically significant differences between each group. There was also a significant relationship between opioid-abstinent weeks and sleep disturbances in the opioid-abstinent group (r = - 0.604, p < .001).

DISCUSSION

The results of this study suggest that opioids interfere with sleep quality, even after months of abstention. Further research into the long-term effects of opioids is warranted and may contribute further to the importance of addressing sleep problems in this population.

Short-Term Effects of Early Postoperative Celecoxib Administration for Pain, Sleep Quality, and Range of Motion After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

We hypothesized that early postoperative administration of celecoxib would reduce pain scores and improve sleep quality and active range of motion after total knee arthroplasty (TKA) under general anesthesia.

METHODS

Patients in the celecoxib group received 400 mg of celecoxib 2 hours after TKA, followed 6 hours later by 200 mg of celecoxib. Patients in the control group received 400 mg of celecoxib the second day after surgery. Patients in both group had access to patient-controlled analgesia fentanyl. The primary outcome measure was the patient-reported visual analog scale (VAS) pain score the second day after TKA. The secondary outcome measure was sleep quality (days 1, 2, and 7 postoperatively). Active knee joint range of motion was assessed on days 2 and 7 postoperatively, and VAS pain scores were evaluated on postoperative days 1 to 7. Total fentanyl consumption was also assessed.

RESULTS

Compared to the control group, the celecoxib group had significantly lower median VAS pain scores on postoperative days 1 and 2, significantly less nocturnal awakening (in minutes) and frequency of body motion, and better sleep efficacy on postoperative day 1. The celecoxib group also had a significantly better median flexion angle (°) on postoperative days 2 and 7, and lower cumulative fentanyl consumption.

CONCLUSION

Early administration of celecoxib after TKA was associated with significantly reduced early VAS pain scores and improved sleep quality and active knee flexion angles. Thus, the early administration of celecoxib after TKA under general anesthesia may reduce pain and improve sleep quality and functional recovery.

LEVELS OF EVIDENCE

Level II, therapeutic study.

TRIAL REGISTRATION

UMIN-CTR 000014624 (July 23, 2014).

Systematic Review of Sleep Quality Before and After Arthroscopic Rotator Cuff Repair: Are Improvements Experienced and Maintained?

Background:

Poor sleep quality is prevalent among patients with rotator cuff tears (RCTs) and negatively influences the potential for healing and quality of life. However, there is a paucity of literature describing the magnitude and timing of changes in sleep quality after arthroscopic rotator cuff repair (RCR).

Purpose:

(1) To evaluate the prevalence of poor sleep quality in patients undergoing arthroscopic RCR and (2) to determine the timing and magnitude of changes in sleep quality after RCR.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

PubMed, OVID/Medline, and Cochrane databases were queried in January 2020 for literature investigating the prevalence of poor sleep quality in patients with RCTs or changes in sleep quality after arthroscopic RCR. Data pertaining to study characteristics, risk of bias, sleep quality assessments, and clinical outcomes were extracted. A qualitative analysis of the prevalence of poor sleep quality and changes in sleep quality was performed.

Results:

A total of 8 studies (1034 patients) were included. The mean Pittsburgh Sleep Quality Index (PSQI) ranged from 5.2 to 15.0 preoperatively among all studies, while the frequency of patients experiencing poor sleep quality ranged from 40.8% to 89.0% in 4 studies. Four studies reported the mean PSQI at a minimum of 6 months postoperatively, which ranged from 4.2 to 7.1. Four studies did not report the PSQI score or the proportion of patients who experienced poor postoperative sleep quality. One study evaluated the PSQI at 12 months postoperatively, which decreased to 4.2 from 5.8 at 6 months. One study evaluated the PSQI at 24 months postoperatively, which decreased to 5.5 from 6.2 at 6 months.

Conclusion:

Patients with RCTs have a high prevalence of poor sleep quality. Consistent improvements in sleep quality are observed in the 6 months after arthroscopic RCR, but there is limited evidence based on the available data to characterize changes in sleep quality beyond this time. More evidence is needed to characterize changes in sleep quality beyond 6 months and how these changes are perceived by this patient population.

Psychoactive drug and medication use among patients referred to a tertiary sleep laboratory population

Psychoactive drugs including alcohol, caffeine, and prescription medications are commonly consumed to alter sleep/wake states, however the prevalence and impact of these drugs among populations seeking assessment from sleep physicians are unknown. We investigated the prevalence of commonly used drugs (alcohol and caffeine), and medications in a population (N=120; 50 females and 70 males) attending a tertiary sleep clinic for diagnostic polysomnography (PSG) assessment. In addition to objective sleep assessment, participants completed questionnaires assessing sleep quality (Pittsburgh Sleep Quality Index, PSQI), daytime sleepiness (Epworth Sleepiness Scale, ESS), depression and anxiety (Hospital Anxiety and Depression Scale, HADS), alcohol use (Alcohol Use Disorders Identification Test, AUDIT), caffeine and medication use, as well as their experience of adverse events (motor vehicle accidents and near-miss crashes). Caffeine was consumed by 90% of the population and was associated with a reduction in excessive sleepiness symptomology; while high AUDIT scores were associated with increased near-miss crashes. Polypharmacy was common, with a greater number of medications associated with poorer sleep quality, and changes in sleep architecture. This study maps commonly used drugs in those attending a tertiary sleep clinic, and demonstrates associations between drug use and sleep outcomes assessed objectively and subjectively.

Identification and treatment of obstructive sleep apnea by a primary care team with a subset focus on chronic pain management

BACKGROUND

Patients diagnosed with obstructive sleep apnea (OSA), who also consume prescription opioids, have a greater likelihood of morbidity and mortality. This study evaluated whether a primary care team, focused on chronic pain care management, could use a validated questionnaire (STOP-Bang) and motivational follow-up, to increase identification and treatment of OSA.

METHODS

This study was a retrospective, dual arm, pre/post controlled study. Participants of this study included the complete chronic pain management sub group treated by this primary care team. Participants were ≥ 18 years old and prescribed daily opioids for treatment of chronic pain. All participants had a multifaceted, individualized, educational meeting that included completing a STOP-Bang questionnaire. Participants who received a score ≥ three were advised to follow up with their primary care physician. Participants were seen quarterly throughout the study.

RESULTS

The primary outcome of this study was that 65% of participants with likely OSA were using CPAP for a minimum of 12 months (range of 12-25 months, 18-month average) post-intervention vs. 37% CPAP-use in the control group (12 months of observation), both groups were chronic opioid users with OSA. This was a 28% relative improvement (p = 0.0034). A secondary outcome was that 8.9% of non-prior CPAP users obtained CPAP post- intervention; a 56.7% pre-post improvement (p = 0.0064, x2 = 10.08 with 1 degree of freedom). Also, participants who were likely to have OSA (STOP-Bang score ≥ 3 or had a positive polysomnography (AHI >5 with comorbidities)) compared to those unlikely to have OSA (STOP-Bang score <3 or had a negative polysomnography (AHI <5)) in this study were more likely to be male, have a higher BMI, have hypertension, have cardiovascular disease and/or have diabetes (all types).

CONCLUSION

Team based care management for participants taking prescription opioids, where STOP-Bang questionnaires were completed, were associated with an increase in the identification and treatment of OSA.

Parental Behaviors, Emotions at Bedtime, and Sleep Disturbances in Children with Cancer

Background

Poor sleep is common for children during cancer treatment, but there is limited understanding of the nature of children’s sleep throughout the treatment trajectory. The current exploratory study used an explanatory sequential mixed method approach to examine quantitative associations among sleep problems in children with cancer, parental behavior, and children’s sleep hygiene, with follow-up qualitative characterizations of children’s sleep across cancer treatment stages.

Procedure

Eighty parents of children with cancer (aged 2–10 years; in active treatment, maintenance treatment, or off treatment) completed an online survey querying the child’s sleep quality (Sleep Disturbance Scale for Children—Disorders of Initiating and Maintaining Sleep subscale) and behaviors (Child Sleep Hygiene Scale) and sleep-related parenting behaviors (Parental Sleep Strategies). A subsample (n = 17 parents) participated in qualitative interviews to better characterize the processes of children’s sleep and parents’ sleep-related behaviors.

Results

Children’s sleep quality, sleep hygiene, or parental sleep strategies were not significantly different by cancer treatment groups. Greater sleep disturbance in children was associated with their parents’ tendency to accommodate the child’s bedtime requests. Qualitatively, cancer treatment-related anxiety in both children and parents influence the onset of these disruptive sleep behaviors.

Conclusion

Parents’ sleep-related behaviors affect children’s sleep during cancer treatment. Parents’ accommodation may start during active treatment to alleviate cancer-related challenges, and these behaviors may continue into maintenance therapy and off treatment to reinforce sleep disturbance. Behavioral interventions targeting unhelpful parental behaviors may improve sleep in children with cancer during and after cancer treatment.

Excessive daytime sleepiness in adults with spinal cord injury and associations with pain catastrophizing and pain intensity

STUDY DESIGN

Pre-post cohort mixed factorial design.

OBJECTIVE

Excessive daytime sleepiness (EDS) and chronic pain are major problems for people with spinal cord injury (SCI). However, the relationship between chronic pain and EDS requires clarification. The goal of the study was to determine associations between pain catastrophizing (PC) and pain intensity (PI) with EDS in adults with SCI.

SETTING

New South Wales, Australia.

METHODS

Participants included 45 adults with SCI and 44 able-bodied controls. The relationship between PI, PC, and EDS was explored by determining the influence of PC and PI on the performance of both groups in a behavioral test of EDS called the Oxford Sleep Resistance Test. PC and PI were assessed by self-report. The association between EDS, pain, and other relevant factors like fatigue and mood was established using multidimensional scaling in the SCI group data.

RESULTS

PC was found to have a significant association with EDS, with 33.3% falling asleep in the SCI group with low PC, compared with 70% in those with high PC. Only 10% of the controls fell asleep regardless of PC. PI did not significantly influence EDS in either group. Multidimensional scaling showed EDS was closely related to PC, PI, pain interference, fatigue, and mood.

CONCLUSIONS

PC appears to be strongly associated with EDS in SCI. Findings suggest significant sleep benefits may occur in adults with SCI by treating cognitive biases like PC, as well as addressing associated factors like fatigue, pain interference, low mood, and so on.

Poor preoperative sleep quality is a risk factor for severe postoperative pain after breast cancer surgery: A prospective cohort study

The aim of this study was to assess the effect of preoperative sleep quality on acute postoperative pain in breast cancer patients.The Pittsburgh Sleep Quality Index questionnaire (PSQI) was used to assess the overall sleep status of women scheduled for unilateral modified radical mastectomy in the past month. Based on the responses, patients were allocated to good sleep group or poor sleep group. Postoperatively, acute pain was assessed using the numerical rating score in the first 24 hours; in addition, the requirement of analgesics and the incidence of postoperative complications were recorded.A total of 108 breast surgery patients were enrolled. Based on the PSQI results, 55 (51%) patients were allocated to poor sleep group and 53 (49%) to good sleep group. Pain scores were similar in the 2 groups at the end of surgery (P = .589); however, poor sleep group reported higher postoperative pain scores than the good sleep group at 2 (P = .002), 6 (P < .001), 12 (P < .001), and 24 (P = .002) hours after surgery. The incidence of severe pain in the poor sleep group was higher than that in the good sleep group (27% vs 8%, P = .018), and the ratio of participants who required rescued analgesics was greater in the poor sleep group (52% vs 22%, P = .002). In addition, patients with poor sleep quality had more postoperative complications and longer hospital stay.In this study, breast cancer patients with poor preoperative sleep quality reported more severe postoperative pain, required more analgesics, experienced more complications, and had longer hospital stay.

Sleep disturbances in orthopaedic trauma patients

Objectives

To determine the prevalence of sleep disturbances in orthopaedic trauma patients 3 months following surgery and to identify any subset(s) of patients at high risk for prolonged sleep disturbance.

Design

Prospective cohort.

Setting

Level 1 Trauma Center.

Patient/Participants

All patients at an orthopaedic trauma clinic from May 3, 2016 to Feb 23, 2017.

Main outcome measurements

Baseline patient Pittsburgh Sleep Questionnaire (PSQI) and Insomnia Severity Index (ISI) scores compared to PSQI and ISI scores 3-months postoperatively. Both gender and age stratified data analyses were performed.

Results

Sixty-six patients met our inclusion criteria and completed both baseline and 3-month surveys. There were 44 males and 22 females. There was a significant increase in PSQI and ISI scores from baseline to 3 months across all patients. Further analysis revealed significant increases from baseline to 3 months in both PSQI and ISI scores for female patients but not male patients. There was a significant difference from baseline to 3 months in patients 50 years old and under but not for patients above 50 years old. No patients required revision surgery in the first 3 months.

Conclusions

More than half of all patients reported continued sleep disturbance 3 months postoperatively. Females are at particularly increased risk for sleep disturbance. These findings demonstrate that sleep disturbances merit attention in the early stages of the postoperative recovery process.

Level of evidence

Therapeutic Level II.

Sleep disturbance and cancer-related fatigue symptom cluster in breast cancer patients undergoing chemotherapy

PURPOSE

Sleep disturbance and cancer-related fatigue (CRF) are among the most commonly reported symptoms associated with breast cancer and its treatment. This study identified symptom cluster groups of breast cancer patients based on multidimensional assessment of sleep disturbance and CRF prior to and during chemotherapy.

METHODS

Participants were 152 women with stage I-IIIA breast cancer. Data were collected before chemotherapy (T1) and during the final week of the fourth chemotherapy cycle (T2). Latent profile analysis was used to derive groups of patients at each timepoint who scored similarly on percent of the day/night asleep per actigraphy, the Pittsburgh Sleep Quality Index global score, and the five subscales of the Multidimensional Fatigue Symptom Inventory-Short Form. Bivariate logistic regression evaluated if sociodemographic/medical characteristics at T1 were associated with group membership at each timepoint.

RESULTS

Three groups (Fatigued with sleep complaints, Average, Minimal symptoms) were identified at T1, and five groups (Severely fatigued with poor sleep, Emotionally fatigued with average sleep, Physically fatigued with average sleep, Average, Minimal symptoms) at T2. The majority of individuals in a group characterized by more severe symptoms at T1 were also in a more severe symptom group at T2. Sociodemographic/medical variables at T1 were significantly associated with group membership at T1 and T2.

CONCLUSIONS

This study identified groups of breast cancer patients with differentially severe sleep disturbance and CRF symptom profiles prior to and during chemotherapy. Identifying groups with different symptom management needs and distinguishing groups by baseline sociodemographic/medical variables can identify patients at risk for greater symptom burden.

Key Components of Pain Management for Children and Adults with Sickle Cell Disease

Sickle cell disease pain manifests as severe acute pain episodes and a debilitating chronic pain syndrome. Acute pain episodes are the most common reason for health care use; however, acute pain episodes are also frequently managed at home. Chronic pain syndrome develops in 30% to 40% of individuals with sickle cell disease, with an increasing incidence and severity with age. We review the critical aspects of pain management that are integral to the comprehensive approach to sickle cell disease pain and are rooted in the biopsychosocial model. The review focuses on opioid pharmacology and psychosocial comorbidities.

Postoperative sleep disorders and their potential impacts on surgical outcomes

Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.

Effects of Sleep Fragmentation and Induced Mood on Pain Tolerance and Pain Sensitivity in Young Healthy Adults

Background: Experimental research exploring the sleep/pain-relationship has typically focused on total or partial sleep deprivation, hereby failing to reproduce the mere fragmented sleep pattern typically observed in patients with chronic pain. Further, little research is done on how affect moderates the sleep–pain relationship after sleep fragmentation. The present study sought to clarify the relationship between pain, sleep and positive and negative affect.

Methods: In an experimental counterbalanced crossover design, 35 healthy young adults were subjected to several pain measures after one night of fragmented sleep, compared to one control night of normal sleep, both conducted in their own homes, and respectively, positive and negative affect induction using validated film clips and facial feedback procedures. Sleep was monitored using sleep diaries.

Results: Increased pain sensitivity after one night of experimentally induced sleep fragmentation was found, compared to after one control night of undisturbed sleep. No main effects of induced affect on pain were found, and sleep x induced affect interaction was not significant.

Conclusion: The present study supports the adverse effect of sleep fragmentation on pain sensitivity, however, affect was not found to be a moderator in the sleep–pain relationship. The results underline the need for further research within this field.

Sleep Quality in Patients With Rotator Cuff Disease

BACKGROUND

Little is known about the influence of rotator cuff pathology on sleep. The purpose of this study was to determine which patient-reported factors correlate with sleep disturbance in patients with rotator cuff disease.

METHODS

A nonrandomized, cross-sectional cohort study was performed to evaluate the effects of rotator cuff disease on sleep quality. Data collected at time zero (before any treatment) included the Single Assessment Numeric Evaluation rating, the American Shoulder and Elbow Surgeons score, the Pittsburgh Sleep Quality Index, patient demographics, and medical comorbidities. Statistical analysis included the Pearson correlation and multiple regression analysis to determine which patient-reported factors were associated with sleep disturbance.

RESULTS

Nocturnal pain was reported by 91% of the 391 participants (274 with tendinitis and 117 with rotator cuff tears). Participants had a mean age of 57 years. Pearson correlation coefficients determined that poor sleep quality in one group or both the tendinitis and the rotator cuff tear groups was associated with higher pain visual analog scale scores (0.27 and 0.31; P = 0.004 and P < 0.0001, respectively), depression (0.27 and 0.30; P < 0.01), female sex (0.24 and 0.27; P < 0.001), presence of low back pain (0.25 and 0.27; P < 0.01), diabetes mellitus (0.24 in the rotator cuff tear group; P < 0.01), and increased body mass index (0.22 and 0.27; P = 0.02).

DISCUSSION

The status of the rotator cuff did not correlate with increasing symptoms of shoulder pain or with worse sleep quality as measured by the Pittsburgh Sleep Quality Index. These results support the theory that worsening symptoms of shoulder pain may not be clearly associated with rotator cuff disease severity.

CONCLUSION

Worse sleep quality scores in patients with rotator cuff disease are associated with pain, depression, female sex, low back pain, diabetes mellitus, and high body mass index. Overall, sleep quality did not differ among patients with varying rotator cuff disease severity. Only hypertension (in patients with rotator cuff tears) and concurrent cervical pathology (in patients with tendinitis) were uniquely related to the disease classification. Further investigation is needed to better define how these factors interact and influence nocturnal shoulder pain and sleep quality in patients with rotator cuff disease.

LEVEL OF EVIDENCE

Level III prognostic cohort study.

Long-Term Pain Treatment Did Not Improve Sleep in Nursing Home Patients with Comorbid Dementia and Depression: A 13-Week Randomized Placebo-Controlled Trial

Objective: Previous research indicates that pain treatment may improve sleep among nursing home patients. We aimed to investigate the long-term effect of pain treatment on 24-h sleep patterns in patients with comorbid depression and dementia.

Design: A 13-week, multicenter, parallel-group, double-blind, placebo-controlled randomized clinical trial conducted between August 2014 and September 2016.

Setting: Long-term patients from 47 nursing homes in Norway.

Participants: We included 106 patients with comorbid dementia and depression according to the Mini Mental Status Examination (MMSE) and the Cornell Scale for Depression in Dementia (CSDD).

Intervention: Patients who were not using analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets. Those who already received pain treatment were randomized to buprenorphine transdermal system (maximum 10 μg/h/7 days) or placebo transdermal patches.

Measurements: Sleep was assessed continuously for 7 days by actigraphy, at baseline and in week 13. Total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), early morning awakening (EMA), and number of wake bouts (NoW) were evaluated. In addition, daytime total sleep time (DTS) was estimated. Pain was assessed with Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2).

Results: The linear mixed model analyses for TST, SE, SOL, WASO, EMA, NoW and DTS showed no statistically significant differences between patients who received active pain treatment and those who received placebo. Post hoc subgroup analyses showed that there were no statistically significant differences between active treatment and placebo from baseline to week 13 in patients who were in pain (MOBID-2 ≥ 3) at baseline, or in patients who had poor sleep (defined as SE < 85%) at baseline. Patients who received active buprenorphine showed an increase in TST and SE compared to those who received active paracetamol.

Conclusion: The main analyses showed that long-term pain treatment did not improve sleep as measured with actigraphy. Compared to paracetamol, TST and SE increased among patients who received buprenorphine. This could indicate that some patients had beneficial effects from the most potent pain treatment. However, based on the present findings, long-term pain treatment is not recommended as a strategy to improve sleep. Clinical Trial https://clinicaltrials.gov/ct2/show/NCT02267057.

The prevalence and awareness of sleep apnea in patients suffering chronic pain: an assessment using the STOP-Bang sleep apnea questionnaire

PURPOSE

Some patient subsets are at higher risk of sleep apnea, including patients with chronic pain. However, it is unclear whether patients and their caregivers are aware of the possibly increased risk of sleep apnea in this population. Chronic pain is often treated with opioids which may decrease both the central respiratory drive and the patency of the upper airway, potentially contributing to this sleep disorder. Using a self-reporting questionnaire approach in the chronic pain population, this study surveyed patient and caregiver awareness surrounding the risk of sleep apnea. In addition, we looked at the influence of opioid therapy on the prevalence of sleep apnea.

PARTICIPANTS AND METHODS

Consecutive patients presenting to a pain clinic were invited to participate anonymously in a survey that included the STOP-Bang sleep apnea questionnaire, which assesses patients' knowledge, testing, diagnosis, or treatment of sleep apnea and whether their caregivers had discussed with them their increased risk of sleep apnea and opioid use.

RESULTS

Among 305 participating patients, 58.2% (n=173) screened positive for sleep apnea. Among the 202 patients on opioid therapy, 59.2% (116/202) were STOP-Bang positive (score ≥3). However, only 37.5% (n=72/173) of these patients had discussed their risk of sleep apnea with a caregiver and only 30.7% (n=59) underwent testing. Against expectation, opioids did not increase the prevalence of sleep apnea in our study population.

CONCLUSION

Chronic pain patients had a high risk of sleep apnea, regardless of opioid prescription. Most patients were unaware of their increased risk and denied undergoing the necessary testing. Greater attention to screening, testing, and education for sleep apnea needs to be paid in chronic pain patients, especially given the potentially dangerous ramifications of opioid-induced sleep apnea.

Can we improve pain and sleep in elderly individuals with transcranial direct current stimulation? - Results from a randomized controlled pilot study

Background

The prevalence of chronic pain and sleep disturbances substantially increases with age. Pharmacotherapy remains the primary treatment option for these health issues. However, side effects and drug interactions are difficult to control in elderly individuals.

Aims

The objective of this study was to assess the feasibility of conducting a randomized sham-controlled trial and to collect preliminary data on the efficacy of transcranial direct current stimulation (tDCS) to reduce pain and improve sleep in older adults suffering from chronic pain.

Methods

Fourteen elderly individuals (mean age 71±7 years) suffering from chronic pain and sleep complaints were randomized to receive either anodal tDCS, applied over the primary motor cortex (2 mA, 20 minutes), or sham tDCS, for 5 consecutive days. Pain was measured with visual analog scales, pain logbooks and questionnaires, while sleep was assessed with actigraphy, sleep diaries and questionnaires.

Results

There were no missing data for pain and sleep measures, except for actigraphy, that generated several missing data. Blinding was maintained throughout the study, for both the evaluator and participants. Active but not sham tDCS significantly reduced pain (P<0.05). No change was observed in sleep parameters, in both the active and sham tDCS groups (all P≥0.18).

Conclusion

The present study provides guidelines for the implementation of future tDCS studies in larger populations of elderly individuals. M1 anodal tDCS in this population appears to be effective to reduce pain, but not to improve sleep.

Factors associated with prescription opioid misuse in a cross-sectional cohort of patients with chronic non-cancer pain

OBJECTIVE

To examine demographic features, psychosocial characteristics, pain-specific behavioral factors, substance abuse history, sleep, and indicators of overall physical function as predictors of opioid misuse in patients presenting for new patient evaluation at a tertiary pain clinic.

METHODS

Overall, 625 patients with chronic non-cancer pain prospectively completed the Collaborative Health Outcomes Information Registry, assessing pain catastrophizing, National Institutes of Health Patient-Reported Outcomes Measurement Information System standardized measures (pain intensity, pain behavior, pain interference, physical function, sleep disturbance, sleep-related impairment, anger, depression, anxiety, and fatigue), and substance use history. Additional information regarding current opioid prescriptions and opioid misuse was examined through retrospective chart review.

RESULTS

In all, 41 (6.6%) patients presented with some indication of prescription opioid misuse. In the final multivariable logistic regression model, those with a history of illicit drug use (odds ratio [OR] 5.45, 95% confidence interval [CI] 2.48-11.98, p<0.0001) and a current opioid prescription (OR 4.06, 95% CI 1.62-10.18, p=0.003) were at elevated risk for opioid misuse. Conversely, every 1-h increase in average hours of nightly sleep decreased the risk of opioid misuse by 20% (OR 0.80, 95% CI 0.66-0.97, p=0.02).

CONCLUSION

These findings indicate the importance of considering substance use history, current opioid prescriptions, and sleep in universal screening of patients with chronic non-cancer pain for opioid misuse. Future work should target longitudinal studies to verify the causal relationships between these variables and subsequent opioid misuse.

Neuropathic pain after breast cancer treatment and its impact on sleep quality one year after cancer diagnosis

OBJECTIVES

Data regarding the impact of breast cancer treatment-related neuropathic pain (NP) on sleep quality are scarce. Therefore, we aimed to assess the impact of breast cancer treatment-related NP on patients' sleep quality, during the first year after cancer diagnosis.

MATERIALS AND METHODS

A total of 501 breast cancer patients were followed prospectively. Incident NP was identified through systematic evaluations after treatments and one year after enrolment. NP severity was quantified using the Brief Pain Inventory severity subscale and sleep quality was evaluated through the Pittsburgh Sleep Quality Index (PSQI), at baseline and after one year. Adjusted regression coefficients (β) and 95% confidence intervals (95%CI) were used to quantify the relation between NP and the variation in the PSQI z-scores.

RESULTS

The occurrence of NP was associated with a deterioration in sleep quality during the first year of follow-up, more pronounced among those with good sleep quality (PSQI≤5) than those with poor sleep quality at baseline (PSQI>5) (β = 0.44, 95%CI: 0.11 to 0.77 versus β = 0.33, 95%CI: 0.08 to 0.59). These differences were accentuated when only the cases of NP with greater severity were considered (β = 0.86, 95%CI: 0.37 to 1.35 versus β = 0.31, 95%CI: -0.08 to 0.64). Within the PSQI components, daytime dysfunction and sleep duration were the most impaired by NP.

CONCLUSION

Our findings highlight the importance of the promotion of sleep hygiene among breast cancer patients diagnosed with NP, especially among those with good sleep quality before treatments.

Sleep Fragmentation Hypersensitizes Healthy Young Women to Deep and Superficial Experimental Pain

The effect of sleep deprivation on pain sensitivity has typically been studied using total and partial sleep deprivation protocols. These protocols do not mimic the fragmented pattern of sleep disruption usually observed in individuals with clinical pain conditions. Therefore, we conducted a controlled experiment to investigate the effect of sleep fragmentation on pain perception (deep pain: forearm muscle ischemia, and superficial pain: graded pin pricks applied to the skin) in 11 healthy young women after 2 consecutive nights of sleep fragmentation, compared with a normal night of sleep. Compared with normal sleep, sleep fragmentation resulted in significantly poorer sleep quality, morning vigilance, and global mood. Pin prick threshold decreased significantly (increased sensitivity), as did habituation to ischemic muscle pain (increased sensitivity), over the course of the 2 nights of sleep fragmentation compared with the night of normal sleep. Sleep fragmentation did not increase the maximum pain intensity reported during muscle ischemia (no increase in gain), and nor did it increase the number of spontaneous pains reported by participants. Our data show that sleep fragmentation in healthy, young, pain-free women increases pain sensitivity in superficial and deep tissues, indicating a role for sleep disruption, through sleep fragmentation, in modulating pain perception.

PERSPECTIVE

Our findings that pain-free, young women develop hyperalgesia to superficial and deep muscle pain after short-term sleep disruption highlight the need for effective sleep management strategies in patients with pain. Findings also suggest the possibility that short-term sleep disruption associated with recurrent acute pain could contribute to increased risk for future chronic pain conditions.

Characteristics of new depression diagnoses in patients with and without prior chronic opioid use

Chronic use (>90 Days) of opioid analgesics significantly increases the risk of development of new depression episodes (NDE). It is unclear whether depression that develops in this manner is similar to or different from NDE in persons not exposed to opioid analgesic use (OAU).

METHODS

VA patients were classified into two groups, those who did not receive an opioid and developed depression (non-OAU+NDE, n=4314) and those that had >90 days OAU and developed NDE (OAU+NDE, n=444). OAU+NDE patients were compared to non-OAU+NDE in terms of depression severity (PHQ-9 scores), incidence of PTSD, other anxiety disorders and substance use disorders after NDE, receipt of acute phase antidepressant treatment, dual antidepressant treatment, mood stabilizers and atypical antipsychotics. Prior to computing bivariate analysis, the prevalence of pain conditions and average maximum pain scores were equalized between the two groups using propensity scores and inverse probability of treatment weighting.

RESULTS

Controlling for pain, OAU+NDE patients had more depression symptoms (p=.012), more incident PTSD (p=.04) and opioid abuse/dependence and were more likely to receive 12 weeks of antidepressant treatment (p<.0001). Last, non-OAU+NDE were more likely to have incident diagnoses for any other anxiety disorder (p=.014).

CONCLUSIONS

Within the limitations of electronic medical record data, results indicate OAU+NDE patients have more depression symptoms, greater treatment adherence and different comorbid psychiatric conditions compared to non-OAU+NDE, independent of pain. Overall OAU related depression is as severe as non-OAU related depression and repeated depression screening in chronic opioid therapy may be warranted for pain patients, regardless of pain severity.

Measuring Treatment Outcomes in Comorbid Insomnia and Fibromyalgia: Concordance of Subjective and Objective Assessments

STUDY OBJECTIVES

In insomnia, actigraphy tends to underestimate wake time compared to diaries and PSG. When chronic pain co-occurs with insomnia, sleep may be more fragmented, including more movement and arousals. However, individuals may not be consciously aware of these arousals. We examined the baseline concordance of diaries, actigraphy, and PSG as well as the ability of each assessment method to detect changes in sleep following cognitive behavioral therapy for insomnia (CBT-I).

METHODS

Adults with insomnia and fibromyalgia (n = 113) were randomized to CBT-I, CBT for pain, or waitlist control. At baseline and posttreatment, participants completed one night of PSG and two weeks of diaries/actigraphy.

RESULTS

At baseline, objective measures estimated lower SOL, higher TST, and higher SE than diaries (ps < 0.05). Compared to PSG, actigraphic estimates were higher for SOL and lower for WASO (ps < 0.05). Repeated measures ANOVAs were conducted for the CBT-I group (n = 15), and significant method by time interactions indicated that the assessment methods differed in their sensitivity to detect treatment-related changes. PSG values did not change significantly for any sleep parameters. However, diaries showed improvements in SOL, WASO, and SE, and actigraphy also detected the WASO and SE improvements (ps < 0.05).

CONCLUSIONS

Actigraphy was generally more concordant with PSG than with diaries, which are the recommended assessment for diagnosing insomnia. However, actigraphy showed greater sensitivity to treatment-related changes than PSG; PSG failed to detect any improvements, but actigraphy demonstrated changes in WASO and SE, which were also found with diaries. In comorbid insomnia/fibromyalgia, actigraphy may therefore have utility in measuring treatment outcomes.

Effects of dexmedetomidine administered for postoperative analgesia on sleep quality in patients undergoing abdominal hysterectomy

STUDY OBJECTIVE

To evaluate the effects of postoperative dexmedetomidine infusion on sleep quality in patients undergoing abdominal hysterectomy.

DESIGN

Randomized, double-blind study.

SETTING

Postoperative recovery area and ward.

PATIENTS

Sixty patients of American Society of Anesthesiologists physical status I or II scheduled for elective hysterectomy were enrolled.

INTERVENTIONS

Patients in group C received sufentanil infusion (a continuous dosage of 0.02 μg kg^-1 h^-1, a bolus dose of 0.02 μg/kg, a 10-minute lockout interval), and patients in group D received combined infusion of sufentanil with dexmedetomidine (a continuous dosage of sufentanil 0.02 μg kg^-1 h^-1 with dexmedetomidine 0.05 μg kg^-1 h^-1, a bolus doses of sufentanil 0.02 μg/kg with dexmedetomidine 0.05 μg/kg, a 10-minute lockout interval).

MEASUREMENTS

Polysomnography (PSG) was performed on the following 3 nights: the night before surgery (PSG1), the first night after surgery (PSG2), and the second night after surgery (PSG3). Postoperative pain scores using visual analog scoring scale, levels of sedation, and cumulative sufentanil consumptions were also recorded.

RESULTS

After surgery, patients suffered from significant sleep disturbance with a lower sleep efficiency index and subjective sleep quality and a higher arousal index at PSG2 and PSG3. Compared with group C, postoperative administration of dexmedetomidine significantly improved the sleep efficiency index and subjective sleep quality. Although the rapid eye movement and N3 stage sleep did not differ between the 2 groups, the N1 stage and arousal index were lower and the N2 stage in group D at PSG2 and PSG3 was higher. Compared with group C, patients in group D have better pain relief with a lower visual analog scoring scale and cumulative sufentanil consumptions at 6, 24, and 48 hours after surgery.

CONCLUSIONS

Dexmedetomidine infusion not only offers effective analgesia but also improves postoperative sleep quality in patients undergoing hysterectomy.