Written by Jay Lee
Today we explore answers to questions like “why does pain keep me awake?” and “can poor sleep make pain worse?” Indeed, pain and sleep are closely linked.
Chronic pain (also known as persistent pain) is typically defined as pain that persists beyond the usual healing time, often longer than 3 months. Today, it affects more than 3.5 million people in Australia, or approximately 1 in 5 adults. Chronic pain significantly impairs daily functioning, the ability to work, social relationships, and overall quality of life (Australian Institute of Health and Welfare, 2020). In addition, many people with chronic pain also experience sleep problems which results in them being at higher risk of developing insomnia, or other mental health concerns such as anxiety and depression.
Relationship between Chronic Pain and Sleep Difficulties
Chronic pain and sleep have been found to have a bidirectional relationship where persistent pain interrupts sleep, and poor sleep can increase pain sensitivity and worsen chronic pain (Seiger et al., 2024). Chronic pain often makes it difficult for people to find a comfortable sleeping position or may also cause frequent nighttime awakenings. This disrupts an individual’s typical sleep architecture and can reduce time spent in deeper, more restorative stages of sleep (Mathias et al., 2018). Consequently, many people with chronic pain experience daytime lethargy, emotional distress, significant fatigue, and reduced physical activity.
Similarly, poor sleep and insomnia can also affect pain. There is growing evidence to suggest that disrupted sleep reduces an individual’s pain threshold, which can in turn increase sensitivity to pain and impact one’s pain perception (Li et al., 2022). Sleep helps regulate neurobiological systems involved in pain modulation. When this process is repeatedly disturbed, an increased pain sensitivity may arise the next day (Li et al., 2022). Additionally, poor sleep is closely linked to cognitive changes such as poorer memory and concentration, and increased symptoms of depression and anxiety, which may further impact pain management (Whibley et al., 2019).
So, a vicious cycle results: pain disrupts sleep, and poor sleep increases pain sensitivity, fatigue, and impairment over time. Quality of life can reduce and make everyday activities feel more challenging. Emerging evidence suggests that poor sleep may increase pain in several ways, including making the nervous system more sensitive, reducing the body’s natural ability to dampen pain, and increasing emotional distress.
Research suggests that individuals with chronic pain are diagnosed with insomnia at significantly higher rates compared to those without pain (with some studies suggesting rates exceeding 70%: Mathias et al., 2018). People living with chronic pain may spend more time in bed, rest during the day, or develop worry about sleep, all of which can unintentionally contribute to insomnia. In addition, the same study also found that individuals experiencing pain were at higher risk of developing other sleep disorders such as restless leg syndrome (RLS) and obstructive sleep apnea (OSA) as compared to people without chronic pain (Mathias et al., 2018).
An important question is what can individuals living with chronic pain and sleep difficulties do to manage their situation?
Many people find that sleep medications provide short-term relief, but they can also be associated with side effects such as increased fatigue, difficulties concentrating, poorer memory, and drowsiness (Fitzgerald & Vietri, 2015). Additionally, they may also notice that these medications lose their effectiveness over time which may result in higher doses in future, alongside existing pain medication.
Beyond medications? There exists a non-drug treatment that has been found to be effective in treating sleep difficulties in people experiencing persistent pain and also maintains its benefits in the long term: Cognitive Behavioural Therapy for Insomnia (CBT-I).
How to sleep better with chronic pain
If you are struggling with sleep and chronic pain, some helpful starting points include:
- Keeping a consistent rising time (up to 1hr variation is OK)
- Avoiding long periods in bed when you’re not asleep
- Gradually building daytime activity
- Learning strategies to manage worry about sleep
Structured treatments such as CBT-I are often the most effective way to address ongoing difficulty sleeping.
Treatment that works: Cognitive Behavioural Therapy for Insomnia (CBT-I)
CBT-I is a structured, evidence-based treatment that is the current gold standard for chronic insomnia (Klyne et al., 2024), even when chronic pain is present. It has been found that CBT-I is as effective as, if not superior to, medication in the management of sleep difficulties such as insomnia (Sivertsen et al., 2006).
Unlike medication, CBT-I focuses on changing unhelpful thoughts and behaviours that are maintaining sleep problems and typically involve:
- Learning about sleep (including how pain and sleep interact)
- Optimising sleep habits (including sleep hygiene where relevant) Limiting time in bed
- Making positive changes to daytime routine
- Challenging unhelpful thoughts about pain or sleep
- Relaxation skills
CBT-I has been found to be highly effective. Many people experience significant improvements in falling asleep quicker, staying asleep longer, and feeling more refreshed upon waking up. These changes also impact more than just sleep quality. Treatment of insomnia is associated with reductions in pain catastrophising better mood, higher energy and improved psychosocial functioning (Whale & Gooberman-Hill, 2022).
A Message of Hope
The good news is that the vicious pain-sleep cycle can often be interrupted. When sleep improves, many individuals also notice meaningful relief from their chronic pain. This is not because the pain is eliminated entirely, but because its grip on daily life is loosened. Pain sensations may still be present but often feel less overwhelming. In addition, mood, energy, and capacity to partake in daily activities increase, in spite of the pain that remains. Clinical trials in people with chronic pain show that CBT-I improves insomnia symptoms and can lead to modest but meaningful improvements in pain, mood, and daily functioning (eg., Tang et al, 2010, Koffel et al., 2018).
CBT-I does not directly treat the underlying cause of pain, but by improving sleep, it can reduce pain sensitivity and improve coping. CBT-I provides practical, straightforward tools that are proven to break the vicious cycle and rebuild healthier sleep patterns. Over time, this can lead to less fatigue, better ability to cope and a greater sense of control over your life.
At Sleep Matters, our team of clinical psychologists are trained in CBT-I and are experienced in supporting people living with the overlap of chronic pain and sleep difficulties. If sleepless nights have become part of your pain experience, we invite you to get in touch. It can be a meaningful step towards better nights and more manageable days ahead.
References
Australian Institute of Health and Welfare. (2020). Chronic pain in Australia. https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf?v=20230605184320&inline=true
Fitzgerald, T., & Vietri, J. (2015). Residual Effects of Sleep Medications Are Commonly Reported and Associated with Impaired Patient-Reported Outcomes among Insomnia Patients in the United States. Sleep Disorders, 2015, 1–9. https://doi.org/10.1155/2015/607148
Klyne, D. M., Smith, S. S., & Hall, M. (2024). Should cognitive behavioral therapy for insomnia be considered for preventing and managing chronic pain? SLEEP, 47(10). https://doi.org/10.1093/sleep/zsae177
Koffel, E., Kuhn, E., Petsoulis, N., Erbes, C. R., Anders, S., Hoffman, J. E., & Polusny, M. A. (2018). A randomized controlled pilot study of cognitive behavioral therapy for insomnia in veterans with chronic pain. Journal of Clinical Sleep Medicine, 14(3), 375–383. https://doi.org/10.5664/jcsm.6988
Li, M. T., Robinson, C. L., Ruan, Q. Z., Surapaneni, S., & Southerland, W. (2022). The influence of sleep disturbance on chronic pain. Current Pain and Headache Reports, 26(10), 795–804. https://doi.org/10.1007/s11916-022-01074-2
Mathias, J., Cant, M., & Burke, A. (2018). Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-analysis. Sleep Medicine, 52, 198–210. https://doi.org/10.1016/j.sleep.2018.05.023
Seiger, A. N., Penzel, T., & Fietze, I. (2024). Chronic pain management and sleep disorders. Cell Reports Medicine, 5(10), 101761. https://doi.org/10.1016/j.xcrm.2024.101761
Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O. E., Kvale, G., Nielsen, G. H., & Nordhus, I. H. (2006). Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults. JAMA, 295(24), 2851. https://doi.org/10.1001/jama.295.24.2851
Tang, N. K. Y., & Harvey, A. G. (2010). Effects of cognitive behavioural therapy for insomnia on sleep, pain, and daily functioning in patients with chronic pain: A randomised controlled trial. Pain, 148(1), 34–41. https://doi.org/10.1016/j.pain.2009.10.020tang
Whale, K., & Gooberman‐Hill, R. (2022). The importance of sleep for people with chronic pain: Current insights and evidence. JBMR Plus, 6(7), e10658. https://doi.org/10.1002/jbm4.10658
Whibley, D., AlKandari, N., Kristensen, K., Barnish, M., Rzewuska, M., Druce, K. L., & Tang, N. K. (2019). Sleep and pain. Clinical Journal of Pain, 35(6), 544–558. https://doi.org/10.1097/ajp.0000000000000697
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