Can’t Sleep? Here Are Some Sleep Treatments That Work

Learn what goes wrong when you can't sleep and what you can do about it

By Charlotte Huff

Tammy Applegate dreams of sleep – when she dreams, that is. Most nights, she can’t sleep soundly; pain rousts her four or five times. She turns over, repositions the pillow under one shoulder – the only position that offers some relief – and waits for slumber to overpower her discomfort. “Sometimes it takes me so long to get comfortable that I stay awake anywhere from 30 minutes to a couple of hours,” says the Fort Worth, Tex., mother of four, who has mixed connective tissue disease and requires sleep treatments to resolve her issues with pain and sleep.

She’s got plenty of company. Insomnia – broadly defined as having trouble falling or staying sleep – affects anywhere from 10 to 40 percent of American adults, at least intermittently, according to population studies. It’s estimated that some 10 to 15 percent have long-term sleep problems (lasting more than a month).

If you have problems with pain and sleep that seem intractable, don’t lose hope.  Arthritis Today will help you understand the sleep process and guide you through sleep treatments that will improve your chances of getting a good night's rest. 

What goes wrong

Adults usually need between seven and nine hours of sleep a night. Ideally, that sleep comes in cycles, played out in roughly 90-minute segments throughout the course of a night. It includes rapid eye movement (REM) sleep, in which you dream, and four stages of non-REM sleep. First you enter several stages of non-REM sleep, descending from stages 1 and 2 into stages 3 and 4 – the deeper and more restorative stages. You then resurface and enter REM sleep. Then another 90-minute cycle starts.

Insomnia – the disruption of the sleep cycle – comes in two forms. Secondary insomnia is a side effect of another condition, illness or behavior (see “Treating Underlying Conditions”). In addition to arthritis or fibromyalgia, for example, it can be caused by poor sleep hygiene; stress; and a range of medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and, for some people, statins (such as Lipitor and Zocor). 

With primary insomnia, however, there is no clear cause as to why people can’t sleep. It may be triggered by a major stressful event or by disruptions in your sleep routine (caused by travel or work). Researchers are also examining whether some people simply are predisposed to insomnia.

Even normal aging takes a toll: As we grow older, we naturally get less restorative sleep and are more likely to wake up in the night – although the amount of sleep we need doesn’t change.

Just worrying about insomnia can make it worse, so that it becomes a self-fulfilling prophecy, says Art Spielman, PhD, a longtime sleep researcher and psychology professor at The City College of The City University of New York. “If you think you are not going to fall asleep, you don’t fall asleep,” he says.

The sleep/pain cycle

Achieving restful sleep can be particularly difficult for people like Applegate who have chronic pain. “Pain is a lump of coal under your mattress,” says Spielman. “Even when you’re asleep, the mind can register pain.”

People may notice obvious signs of pain and sleep problems, such as not being able to fall asleep or waking up frequently due to discomfort, says Michael Smith, PhD, director of the sleep psychophysiology laboratory at Johns Hopkins University in Baltimore. Or – and Smith believes this may be more disabling – they have disruptions in the sleep cycle itself so that they sleep but don’t get enough deep sleep. They may be aroused during sleep and pushed from deep sleep into a lighter stage without ever knowing it. “Their deeper sleep is disrupted by arousals or outright awakenings,” Smith says. “They may sleep 10 hours but feel groggy and unrefreshed the next day.”

That also may be the case for people with fibromyalgia, who tend to have abnormalities in deeper-stage sleep. Researchers have explored whether sleep disorders cause the pain of fibromyalgia or vice versa, but it’s still not clear.

Inflammation, pain and the immune system all appear to be impacted to some degree. In a 2006 study by the University of California, Los Angeles, researchers evaluated the effects of sleep deprivation on 30 healthy adults. After only one night, participants who were kept awake from 11 p.m. to 3 a.m. experienced an increase in inflammatory chemicals the body produces in autoimmune diseases, such as rheumatoid arthritis (RA).

When you can’t sleep because of pain, the process can become a seemingly endless loop. A recent study by Smith found that fragmented sleep resulted in both increased pain sensitivity and more spontaneous pain. Bernard Rubin, chief of rheumatology at the University of North Texas Health Science Center in Fort Worth, says, “It gets to be a vicious cycle. If you don’t sleep well, pain is accentuated.”

That’s because sleep doesn’t just reboot your system, refreshing your body and mind for the next day. It also helps repair your body.

Growth hormone, which the body releases most often in our deepest stages of sleep, helps heal tiny muscle tears that occur naturally during the course of the day, says Daniel Clauw, MD, a rheumatologist and director of the Chronic Pain and Fatigue Research Center at the University of Michigan. As we age, the amount of growth hormone that is secreted declines, along with the amount of time we spend in deep sleep, although scientists aren’t sure if one causes the other. But if your deep sleep is disrupted, your body may not secrete enough growth hormone to heal itself. 

Your waistline may also be at risk if you can’t sleep. A recently published analysis of the Nurses’ Health Study, involving data from nearly 70,000 women, found that those who slept no more than six hours nightly faced a 12 percent higher likelihood of gaining 33 pounds during the 16-year study. The risk jumped to 32 percent if they slept five hours or less. Because the shortchanged sleepers didn’t consume any more calories, the cause remains unknown, according to Sanjay Patel, MD, an assistant professor of medicine at Case Western Reserve University in Cleveland, who led the study. One theory is that sleep deprivation may alter the body’s metabolism.

Ongoing sleep deprivation has also been linked to chronic health problems such as diabetes or hypertension, although the specific mechanisms remain unclear, says Dr. Clauw. “There’s almost no biological function that sleep doesn’t affect in a fairly profound way,” he says. “We used to think of poor sleep as a nuisance, but it’s a legitimate health problem.”

How to fix it

Insomnia is not normal at any age, but there are a number of sleep treatments and therapies that may help. Because it’s not unusual for insomnia to have more than one cause, you may need to combine several fixes.

Keeping a sleep journal, which records your sleep/wake patterns, can help your doctor determine why you can’t sleep. If your physician suspects you have sleep apnea, which causes you to stop breathing briefly many times in a night, or PLMD, in which you experience frequent muscle jerks and spasms (usually in the legs) during sleep, she may send you to a sleep center for a polysomnograph. This overnight test records your brain waves, revealing a picture of your sleep cycles.

Many sleep experts consider stress and anxiety to be a prime cause of short-term insomnia. Anxiety that causes a few sleepless nights can lead, in some people, to a condition called psychophysiologic insomnia, where a person focuses on his sleep problems and develops habits that lead to chronic insomnia.

Chances are good that making modifications to your lifestyle will help you get a good night’s sleep. Most experts say sleep medications should be used only as a last resort, or only short term, to provide relief while you work on implementing lifestyle changes.

Treat underlying conditions

Cause: depression

Treatment: Although antidepressants are not sleep medications, regular doses may improve sleep both by elevating mood and reducing anxiety and by boosting levels of serotonin in the brain. In addition, some antidepressants (such as tricyclics) have sedating effects.

Cause: anxiety

Treatment: Relaxation techniques and behavior modification

Cause: pain

Treatment: Talk to your doctor about medications that can better manage your pain. Stronger drugs, such as opioids and narcotics, are designed for short-term use and can leave you feeling sleepy the next day. For some people with chronic pain, low-dose antidepressants can interrupt the pain cycle and help them sleep better. You may have to try several medications before you find one that resolves your issues with pain and sleep.

Cause: Restless legs syndrome (RLS) or periodic limb movement disorder (PLMD)

Treatment: Medications such as ropinirole (Requip) or pramipexole (Mirapex) that increase the amount of dopamine in the brain

Cause: Sleep apnea    

Treatment: Using a continuous positive airway pressure (CPAP) mask to keep the airway open

Tips for better sleep

Although it’s often dismissed as too simple, creating good sleep habits – known as sleep hygiene – can be an important first-step sleep treatment. The goal is to eliminate any stimulants that may be keeping you up and to train your mind to associate your bedroom with sleep – successful sleep, says Andrew Jamieson, MD, associate clinical professor of psychiatry, the University of Texas Southwestern Medical Center at Dallas.

Good sleep practices include the following:

•    Eliminate caffeine

•    Avoid naps

•    Don’t drink alcohol

•    Don’t eat a large meal near bedtime

•    Exercise

•    Go to bed and get up at the same time every day

•    Reserve your bedroom for sleep and sex – no TV, piles of laundry to sort or even books

•    If you can’t sleep, get up after 20 minutes. Go into another room and read or listen to music until you’re sleepy.

•   Don’t use bright lights or watch TV

OTC medicines, sleeping pills and supplements

There’s no simple cure for insomnia – and it definitely can’t be found in a sleeping pill. Despite that, a National Sleep Foundation survey of 1,003 women found that 29 percent used some kind of sleep aid, either prescription or over the counter, at least a few nights a week. Yvette Taylor, 60, an editor in Boca Raton, Fla., says she relied on Tylenol PM for years for her pain and sleep problems until her fibromyalgia was diagnosed in the late 1990s. “I couldn’t sleep without taking it,” she says.

Still, sleep experts are lukewarm, at best, about the safety and efficacy of over-the-counter (OTC) sleep aids. Most contain antihistamines, which can cause blurred vision, constipation and urinary retention. And antihistamines can leave you feeling sluggish the next day. Tylenol PM and other products contain acetaminophen, which could result in too high a dose, as well as subsequent liver problems, if you’re already taking it for arthritis.

Two of the most popular supplements for sleep, melatonin and valerian, both taken at night, are also not recommended for long-term use. Melatonin is a hormone made by the body that helps regulate its internal clock, telling you when to go to bed and when to wake up, and melatonin supplements have been proposed as a sleep aid. But a comprehensive analysis of research studies, published in 2004, determined that short-term use doesn’t help with most sleep disorders. As for valerian, some studies show it may help halt insomnia with fewer side effects than most drugs, but more research is needed to determine long-term safety and effectiveness.

Two newer classes of prescription medications have come on the market in recent years. One class, called nonbenzodiazepines, includes medications such as eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien). They induce drowsiness by working on a particular receptor in the brain, called GABA, believed to be influential in sleep. Two years ago, the FDA approved ramelteon (Rozerem). It works differently than other prescription sleep medications, affecting the melatonin receptors in the brain, so it may work best for people who have trouble falling asleep. Rozerem is not believed to have the same potential for abuse and dependence as other sleep drugs and is approved for long-term use.

Although the newer medications may be somewhat safer, they aren’t risk-free. The FDA recently required all manufacturers of prescription sleeping pills to strengthen the warnings on their labels about potential risks, including severe allergic reactions, angioedema (severe facial swelling) and odd behaviors such as sleep-driving, making phone calls, and preparing and eating food (while asleep).

In addition to physical side effects, sleeping pills also can reap a psychological price. Users sometimes feel as though they’ve lost control over their sleep, says Smith. “You basically lose the belief that your body can function normally,” he says. “Then people end up taking it longer than they need it.”