| One-Minute Clinician

Sleep and Pain in Older Adults--Looking for a Better Way to Treat

Chronic pain patients tend to be a little older and that in and of itself leads to a decrease in quality of sleep. Loss of quality sleep makes the pain seem a little worse and more difficult to deal with. So how can we treat both pain and sleep issues to break that cycle?  And to make matters even more complicated, some of the drugs used to treat chronic pain, such as the opioids, have a deleterious effect on quality of sleep.  The benzodiazepines work at a special receptor that’s on a much larger receptor, and the mechanism of action is well defined.  It increases the activity of the gaba-A receptor and that decreases the reactiveness, I’ll say, of neurons and that’s why the benzodiazepines are so good for anxiety.  They don’t decrease the nerves physiology, but what they do is make that nerve less likely to overreact. They also calm a person, allowing them to sleep a little better.

Unfortunately, they have their own downsides when they’re used in combination with other CNS depressants, like opioids.  The FDA has now come down pretty strongly against the concomitant use of benzodiazepines plus opioids.  That’s sort of the place we find ourselves now.  There are some newer non-benzodiazepine chemical drugs, sometimes called the Z drugs or the Z plus C drugs, but pharmacologically, they work the exact same way the benzodiazepines do.  They're a little safer, but still not the answer.  Some other approaches involve the melatonin mechanism, our natural way of falling asleep and getting good rest.  We're looking for how does the body normally have restful sleep?  So, you tend to look for the neurotransmitters that might be involved.  A lot of times you don’t want to take traditional antihistamines because they make you a little drowsy.  But if used properly in the right patients and at the right time of day, it could actually be pretty beneficial and could be a way to get away from the benzodiazepines. Clinicians should hear what FDA is saying about benzodiazepines, but also should not forget that their patients with pain need help with what is almost certainly going to be some adverse effect on their quality of sleep.