Myth or fact?: Cognitive behavioral therapy for insomnia will work only if chronic pain is first addressed.

Interview by Alyx Arnett

Physical pain can be a significant obstacle to a good night’s sleep, particularly for individuals with comorbid insomnia. Research reveals that half of those affected by insomnia also experience chronic pain.1 Many healthcare professionals believe that addressing pain is a prerequisite for improving sleep, but is this perception valid? 

Alexander Erickson, PhD

To shed light, Alexander Erickson, PhD, and co-investigators conducted a comparative effectiveness trial with 149 women veterans with insomnia that explored the impact of two behavioral insomnia treatments on sleep, while also gathering data on participants’ pain levels. They aimed to determine whether pain severity and pain interference in daily life moderate the effects of behavioral treatments for insomnia on sleep outcomes. 

Erickson was surprised to find that neither pain severity nor interference significantly impacted the benefits of the behavioral treatments—cognitive behavior therapy for insomnia (CBT-I) or acceptance and behavioral changes to treat insomnia (sometimes known as ABC-I)—suggesting such treatments help even in the presence of chronic pain. 

Erickson, an advanced fellow in geriatrics at the Greater Los Angeles VA Geriatric Research, Education, and Clinical Center, discussed the study, which was presented at SLEEP 2023 and is currently under review for publication, with Sleep Review over email.

[Editor’s Note: Read the abstract, Pain in your day? Get sleep treatment anyway! The benefits of behavioral treatments for insomnia despite pain symptoms, in Sleep.]

Were there any unexpected results?

In treatments like CBT-I, changing thoughts and behavior around sleep is the biggest force for change and often involves interventions like helping people develop sleep schedules, practice using their bed only for sleep, and practice skills to target sleep-interfering thoughts. Chronic pain can lead to thoughts or behaviors that can be challenging for this process, including people spending excessive time in bed awake because of pain, having unhelpful stress-inducing thoughts about pain and sleep, and having their sleep routines broken apart by pain. Given these issues, we initially hypothesized that pain would play some sort of role in limiting treatment benefits. 

To our surprise, no matter what kind of statistics we ran, we kept finding the same result: Having pain did not influence the effects of insomnia-focused psychotherapy in a meaningful way, regardless of the severity of that pain or how interfering that pain was to the participant’s day-to-day living.

Importantly, these findings are in the context of a sample of women veterans with generally mild to moderate levels of physical pain. For these veterans, the benefits of insomnia-focused psychotherapies on sleep lasted at least three months after they finished the treatments. These benefits stayed consistent even when pain was present and not formally addressed or treated within the study, lending to how robust these behavioral insomnia treatments can be.

How do your findings contribute to the existing understanding of the effectiveness of non-pharmacological interventions for insomnia in the presence of chronic pain?

CBT-I and similar insomnia-focused psychotherapies have long been shown to promote significant and long-lasting improvements to insomnia. Though multiple studies have tested these treatment effects in the context of individuals who have chronic pain conditions, few have looked at how pain severity and interference with day-to-day life specifically can impact these effects.

What are the clinical implications for sleep medicine professionals?

The largest and most important clinical implication we can convey to sleep medicine professionals is this: If you have a patient with comorbid insomnia and chronic pain, do not let the presence of chronic pain stop you from referring that patient to psychological insomnia treatments like CBT-I. This implication also extends beyond our fellow colleagues in sleep medicine, particularly to providers specializing in the treatment of chronic pain. 

As this study and many other studies have found, psychotherapeutic treatments for insomnia are time-limited, approachable, and can support long-lasting benefits for individuals with insomnia disorder, including those with chronic pain. Helping a person sleep better can also help them get better in other ways.

How do you envision the findings translating into improved patient care?

The call for non-pharmacological treatments to support individuals with chronic pain is a high priority, especially in the continued wake of the US opioid epidemic. Our findings lend to a continuing conversation around whether psychotherapeutic insomnia treatments like CBT-I should have a standard place in the context of interdisciplinary pain care. Evidence-based psychotherapy already has some presence in interdisciplinary pain care, often in the form of treatments like cognitive behavioral therapy for chronic pain. 

However, just as treatments that directly address chronic pain are important, treatments that address factors like sleep, which contribute to the severity and interference of pain, are also incredibly important to help patients with pain. Given that pain likely does not appear to interfere with insomnia treatment outcomes based on this study, CBT-I and addressing insomnia symptoms could be implemented in pain treatment settings and serve to bolster care for individuals with comorbid chronic pain and insomnia. However, future research of CBT-I in pain management settings is needed.

What future research should be done?

Our study helps open the door for future research exploring the implementation of insomnia-focused behavioral health care in settings serving individuals with chronic pain. It supports future efforts of replicating the findings of this study with different groups of people. This can include individuals with different pain conditions and more severe pain. This work might be particularly relevant for older adults who disproportionately experience chronic pain compared to other age groups. 

Reference

  1. Taylor DJ, Mallory LJ, Lichstein KL, et al. Comorbidity of chronic insomnia with medical problems. Sleep. 2007;30(2):213-8. 

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