Sleep and Insomnia

Jacob Teitelbaum, M.D.

To eliminate muscle and many other sources of pain, it is critical to get 8 to 9 hours of solid, deep sleep each night on a regular basis. Disordered sleep is, in my opinion, a major underlying process that perpetuates fatigue and pain.

Inadequate sleep can occur for a number of reasons. Many Americans simply do not make enough time for adequate sleep. One hundred years ago, the average American was getting 9 hours of sleep a night. Anthropologists tell us that 5000 years ago, the average night's sleep was 11 to 12 hours a night. When the sun went down, it was dark, boring, and dangerous outside, so people went to bed. When the sun came up, they woke up. The average time from sunset to sunrise is 12 hours. The use of candles initially shortened sleep time. Then light bulbs were developed followed by radio, TV, computers, etc. We are now down to an average of six and one half to seven hours of sleep a night, and this is simply not adequate to allow proper tissue repair.

Some people get inadequate sleep because of poor sleep hygiene, often occurring because pain keeps them awake. Others have insomnia because the sleep center in the brain (called the hypothalamus) is suppressed by the same process that is causing the pain.

A 2001 poll conducted by the National Sleep Foundation found that 58 percent of Americans had sleep difficulties. This had increased from 51 percent the year before. Fifteen percent of Americans use a prescription or over-the-counter sleep aid. In addition, those who slept less than six hours a night felt more stressed, angry, sad and tired than the people who got more sleep. The survey of over 1000 adults also found that only 30 percent of people reported getting the recommended 8 hours of sleep a night, down from 38 percent the year before. The average amount of sleep also decreased to under seven hours.

Good Sleep Hygiene

These are some important things to consider which enhance good sleep hygiene:

  • Do not consume alcohol near bedtime.
  • Do not consume any caffeine after 4:00 pm.
  • Do not use your bed for problem solving or doing work.
  • Take a hot bath before bed.
  • Keep your bedroom cool.

If your partner snores, sleep in a separate bedroom (after tucking in or being tucked in by your partner) or get a good pair of earplugs and use them. The wax plugs that mold to the shape of the ear are often the best ones.

If you frequently wake up to urinate during the night, do not drink a lot of fluids near bedtime. Most pain patients wake during the night because their sleep center is not working properly or because of the pain. Because they also have a full bladder, they think they are waking up because they have to urinate. This is not the case. They are waking up because of their pain syndrome.

There is a simple way to remedy this problem. If and when you wake up during the night and you notice your bladder is full, just talk to it (in your mind, so your spouse doesn't think you're nuts) and tell it, "Nighttime is for sleeping. We will go to the bathroom in the morning when it is time to wake up." Then roll over and go back to sleep. If you still have to urinate five minutes later, go to the bathroom. Most of you will find that your bladder will happily go back to sleep, and when you wake up in the morning, you won't even have to urinate as badly as you did when you woke up in the middle of the night.

Put the bedroom clock out of arm's reach and facing away from you so you can't see it. Looking at the clock frequently aggravates sleep problems and is frustrating.

Have a light snack before bedtime. Hunger and hypoglycemia cause insomnia in all animals, and humans are no exception. For your snack, eat foods high in the amino acid tryptophan, such as milk and turkey, which contributes to sleep.

Sleep Medications

Although I much prefer natural remedies to prescription medications, the sleep disorder in some pain patients may be too severe to be dealt with by natural remedies alone. However, even if you are someone who needs prescription sleep aids, adding natural remedies can be very helpful and usually decreases the amount of medication that you will need, resulting in fewer side effects. In addition, once you come off the sleep medications (usually after 9 to 18 months, although they can be used indefinitely if needed) you may find that all you require are the natural remedies.

Whatever treatments you use, though, it is important that they not only increase the duration of sleep but also maintain or improve the deep stages (stages 3 and 4) of sleep. Unfortunately, most sleeping pills in common use (for example, Dalmane®, Halcion®, and Valium®) may actually worsen the quality of sleep by increasing the amount of light stage (especially stage 2) sleep and decreasing the deep stages of sleep even further. You want to be certain that the treatments and medications you use leave you feeling better the next day, not worse.

There are several approaches to sleep when treating pain patients. Some doctors prefer to use a single medication or treatment and push it up to its maximum level. If that works, great; if not, they stop it and switch to another medication. Other doctors prefer to use low doses of many different treatments together until the patient is getting good, solid sleep regularly. I strongly prefer the latter approach. Most of a medication's benefits occur at low doses and most of the side effects at high doses. In addition, if you combine low doses of a few different sleep aids, each of them will be cleared out of your body by morning — so you won't be hung over.

Meanwhile, the effective blood levels that you have during the middle of the night from each treatment are cumulative and will keep you asleep for eight to nine hours of solid sleep each night without waking or hangover. To see which medications I recommend for sleep, scroll down to the sleep section on our SHINE treatment protocol

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