Does pain make me sleep worse, and what can you do about it?
Pain and poor sleep reinforce each other, with sleep deprivation typically aggravating pain more than the other way around. The treatment with the strongest evidence is cognitive behavioural therapy for insomnia (CBT-i), which demonstrably improves sleep, although the pain does not automatically disappear as a result.
Pain and poor sleep reinforce each other, but the relationship is not symmetrical. Both population studies and experimental research show that sleep problems more reliably predict the onset and worsening of chronic pain than the other way around. Pain disrupts your sleep, but sleep deprivation is the stronger driver of the two.
Why sleep deprivation worsens pain probably has to do with the body's own pain-suppressing systems. Experimental research suggests that sleep disruption interferes with that suppression, causing you to feel pain more intensely. Possible mechanisms include the opioid system, the immune system, and melatonin. This is not yet an established clinical fact, but the evidence is consistent enough to take seriously.
People who sleep poorly in addition to having chronic pain have a harder time of it. People with both complaints simultaneously report more pain, function worse during the day, and more often have emotional complaints than people with pain but no sleep problems. These are associations, not proven causal chains, but the pattern is clear.
The treatment with the strongest evidence is cognitive behavioural therapy for insomnia, abbreviated CBT-i. A meta-analysis of 67 randomised studies in people with chronic conditions, including chronic pain, showed large improvements in how severely insomnia is experienced, and moderate improvements in how quickly you fall asleep and how efficiently you sleep. Dropout was low and serious side effects were rare. CBT-i consists of sleep education, sleep restriction, associating bed with sleep (and not with lying awake worrying), and reframing negative thoughts about sleep.
CBT-i does not automatically reduce your pain as well. In a randomised study of chronic back pain with insomnia, sleep improved clearly, but pain intensity at twelve months did not decrease significantly more than with pain treatment alone. CBT-i therefore concretely helps with sleep, fatigue, and low mood, but do not expect it to act as a direct painkiller. Pain medications themselves can, incidentally, further disrupt sleep: opioids such as morphine have the most adverse effect on sleep quality of all pain medications. A standard pain rehabilitation programme without specific sleep therapy does help to some extent: 62% of participants saw sleep complaints decrease after ten weeks, but only one third reached a clinically meaningful improvement. For more serious sleep problems, a targeted approach such as CBT-i is needed.
Claims based on multiple PMIDs, including a meta-analysis of 67 randomised studies and population studies. Number of participants from the meta-analysis: 5232. Causal direction of the pain-sleep relationship is well supported; mechanisms have not yet been fully elucidated.
What can I do to sleep better?
CBT-I is the most powerful approach for persistent sleep problems; if you do not have access to it, ask your general practitioner about a shorter behavioural treatment of four sessions. Fixed sleep times, less caffeine and alcohol in the evening, and regular exercise are the best-supported self-help steps.
Do I sleep worse if I am often alone or feel lonely?
Yes, loneliness is clearly associated with poorer sleep: you have more difficulty falling asleep, wake up more often during the night, and feel more tired during the day. Working on social connection is therefore also a concrete step toward better nights.
What are the best ways to fall asleep more easily?
Cognitive behavioural therapy for insomnia works best and lasts longest; sleeping pills are a short-term solution and are even dangerous in older adults. A digital version of the therapy is a good, accessible first step.
Do I sleep worse when I am stressed, and does that create a vicious cycle?
Stress worsens your sleep, and poor sleep raises your stress levels: that cycle is well documented. Anyone who notices that stress and sleep deprivation are accumulating would be wise to intervene early, for example through stress management or sleep hygiene, before the cycle becomes entrenched.
Why do you sleep worse as you get older, and do hormones play a role in that?
Sleeping worse with age is well documented and has multiple causes, including brain changes and, in women, the menopause. Hormones play a role, but often indirectly, such as through hot flushes, so hormone therapy is not a straightforward answer for everyone.
What does alcohol do to the quality of my sleep, and is there anything that can be done about it?
Alcohol helps you fall asleep faster, but measurably disrupts the rest of your night, even with just two drinks. If you want to sleep better, drinking less or no alcohol before bed is the most effective step.