Pain can be both a cause and a consequence of sleep deficiency.1 That is the whole problem in one line.
Poor sleep makes pain worse. Pain breaks up sleep. Dealing with that cycle is seen as key to good pain care and to patients’ overall health.2 Treat the pain and ignore the sleep, and half the loop keeps running.
Why this is more than common sense
Sleep and pain feed each other in both directions. That matters for each patient’s care. It also matters for preventing chronic pain and for public health.1 It is not just that hurting keeps you awake and being tired makes you cranky about it.
Researchers have proposed many specific ways that poor sleep turns pain up or down. They include the opioid, monoaminergic, orexinergic, immune, melatonin and endocannabinoid systems. They also include the hypothalamic-pituitary-adrenal axis (the body’s stress hormone system), and adenosine and nitric oxide signaling.1
Stop on one item in that list: the endogenous opioid system (the body’s own built-in painkillers). If poor sleep affects the body’s own pain-control machinery, a patient who slept poorly does not start from the same baseline as one who slept well. That is a statement about the body, not about willpower.
Medication can sit on both sides of the loop
The same review looks at drugs that disturb sleep and whether they turn pain up.1 This is an uncomfortable point, but it matters. A drug taken to reduce pain that also damages the structure of sleep may work against itself over time.
That is not a reason to stop anything on your own. It is a reason to bring up sleep by name when your drugs are reviewed. That is part of how opioid stewardship is approached here.
Sleep before surgery, pain after it
Sleep also appears to come before pain that has not happened yet. A systematic review and meta-analysis of adults looked at sleep problems and sleep disorders checked before surgery. They were significantly related to chronic pain after surgery. The effect size was small: r = 0.13 (95% CI 0.06–0.20). The authors rated their confidence in the evidence as low, because of risk of bias and mixed results across studies.3
They concluded that sleep problems before surgery should be checked to find patients at risk.3 Small effect, low certainty, but cheap to ask about. More on that in pain that persists after surgery.
What to do with this
In practice, sleep belongs on the problem list, not buried in the social history. If you are being checked for chronic pain and nobody has asked how you sleep, bring it up yourself.
Behavioral treatments for sleep and for pain overlap a great deal. We do that work in-house through counseling for chronic pain and, when mood and trauma are part of it, anxiety, PTSD and chronic pain. The other half is reducing the peripheral pain generator (the source of the pain out in the body) so that nights are bearable. The options are on the pain treatments page, and lifestyle medicine covers the metabolic side.
Frequently asked questions
Does pain cause bad sleep, or does bad sleep cause pain?
Both. Pain can be a cause and a result of poor sleep. The link runs both ways. That is why treating only one side tends to disappoint. See the range of pain treatments.
How could sleep loss physically make pain worse?
Proposed ways include effects on the opioid, monoaminergic, orexinergic, immune, melatonin and endocannabinoid systems. They also include the HPA axis (the stress hormone system), and adenosine and nitric oxide signaling. The body’s own pain-control systems are among those named. See counseling for chronic pain.
Could my pain medication be hurting my sleep?
It is a known concern. Drugs that disturb sleep have been studied for whether they turn pain up. Do not change any prescription on your own. Raise it at your review. How we handle drug burden is described under opioid stewardship.
Should I mention sleep before an operation?
Yes. Sleep problems before surgery have been significantly associated with chronic pain after surgery. The authors advise checking sleep to find patients at risk. The effect is small, and the certainty of the evidence is low. See pain that persists after surgery.
Is treating sleep going to fix my pain?
Not on its own, and nobody should promise that. It removes one thing that is making the problem louder. The source of the pain still needs treatment too. Arrange an evaluation through the appointment request form.
To discuss pain and sleep together, request an appointment, call (314) 481-5000, or text (314) 886-5902.
Sources
- Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2019;45(1):205–216. doi:10.1038/s41386-019-0439-z. Retrieved via PubMed. DOI
- Seiger AN, Penzel T, Fietze I. Chronic pain management and sleep disorders. Cell Reports Medicine. 2024;5(10):101761. doi:10.1016/j.xcrm.2024.101761. Retrieved via PubMed. DOI
- Varallo G, Giusti EM, Manna C, Castelnuovo G, Pizza F, Franceschini C, Plazzi G. Sleep disturbances and sleep disorders as risk factors for chronic postsurgical pain: A systematic review and meta-analysis. Sleep Medicine Reviews. 2022;63:101630. doi:10.1016/j.smrv.2022.101630. Retrieved via PubMed. DOI
Dr. Gurpreet Singh Padda, MD, MBA, MHP
