I have made it as clear as I can that sleep seems to be the number one factor to be addressed in solving your chronic pain. It was the first variable that I happened upon that helped my patients begin to feel better. I took an aggressive approach and by presenting basic sleep hygiene concepts and adjusting medications, I could get most of my patients to have a consistently restful night’s sleep within four to six weeks. Real progress did not happen until this bridge was crossed. I have thought that people in chronic pain could not sleep because of their pain. There is a revealing study out of Israel that shows that it is lack of sleep that induces chronic pain. It also demonstrated that the reverse was not true – that pain caused insomnia. (1) Another study demonstrated that lack of sleep was a bigger predictor becoming disabled than the severity of back pain. Even more interesting to me was that is was also true for leg pain (sciatica), which surgeons feel is the problem that is the most disabling. Not true. It is insomnia. (2) My Ambien adventure I missed my plane last night. I take an Ambien for overnight red-eye flights and I sleep well enough so I can enjoy the following day. My wife has repeatedly told me not to take Ambien before the flight takes off. I had a challenging week and had not slept well. I was finishing it off with a Friday night red-eye so I decided to take the Ambien just as I was boarding the flight. I sat down and fell asleep – until the crew announced that the plane was broken and we had to get off of the plane, go to the next gate and catch a flight about 45 minutes later. I seemed to feel fine and sat down to read. The next thing I knew was that the boarding area was empty. The plane was just leaving the gate. The attendants had tried to track me down but I was unresponsive. I slept on the floor of the airport last night (Ambien was still working) until I caught the first flight out this morning. Sleep was a major issue during my struggle with chronic pain. Ambien was a major factor in getting me through it although it was a relief to be able to come off of it. I also had some other close calls. I was not aware of the role of sleep in chronic pain at the time. I was just desperate. I read a book, The Promise of Sleep, which was an autobiography of Willam Dement, the founder of the Stanford sleep lab. He pointed out that at the time (60’s) that only about 5% of doctors addressed sleep. I felt that it was a definable problem that could and should be aggressively treated. I was surprised how many people would improve their mood and pain with just getting a better night’s sleep. It was the beginning of the DOC project, as I had always thought chronic pain was not solvable. I will still use Ambien with my patients who simply cannot sleep using simpler measures. If they are still struggling, I will add a sedating anti-depressant called Remeron. However, I am clear regarding the risks in that you cannot think clearly while the Ambien is on board. I never did give it to mothers with young children if there was not another adult in the house. It is also intended only for short-term use. With careful use I have not seen major problems with this approach. Get some sleep Sleep is number one and I ask all my patients with insomnia to work with their primary care doctors to find a solution – and quickly. There are many other ways to get a good night’s sleep and most physicians are comfortable with their own combination strategies and medications to induce sleep. Most physicians do not initially include Ambien (or one of the similar drugs) although it may eventually be needed. It is a drug with risks. Regardless of the approach, not sleeping is not an option. This is especially true if you are considering an invasive procedure of any kind. Video: Get it Right the First Time Approaches to Insomnia There are also other additional ways to help obtain a good night’s sleep: Sleep hygiene – set of well-known basics to optimize sleep Stress management at bedtime – i.e. don’t read business emails while you are trying to fall asleep Exercise – It is not helpful to exercise late in the evening but overall physical conditioning helps sleep Expressive writing – has been shown to help decrease the time it takes to fall asleep. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep. Over the counter sleep aids – I do not have specific recommendations and should not be used long-term. May be helpful. You also should make your physician aware you are using them. Under the guidance of a physician Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with fairly strong sleep meds. Once your nervous system quiets down you can and should come off of them relatively soon. I would also add that using narcotics for sleep is not recommended and creates many additional problems. Diagnosed and treated by a sleep specialist Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded and you are gasping for air. Sleep quality is poor and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications. I have used the metaphor of fighting a forest fire to become pain free. All aspects of chronic pain must be addressed simultaneously with you taking control of your own situation. Sleep is one of the more defined and solvable issues. It is a great starting point in your taking charge of your care and life. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.