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Written by

Professor Harald Breivik Harald Breivik is emeritus professor of anaesthesiology, University of Oslo; consultant at the department of pain management and research, Oslo University Hospital, Oslo, Norway; and editor-in-chief, Scandinavian Journal of Pain

Pain and sleep disturbances

Published 14 June 2017

Pain expert Professor Harald Breivik discusses the problem of differentiating between cause and effect with pain and sleep disturbances

Co-morbid pain and sleep disturbances are common. Which is the chicken and which is the egg?

‘Sleeping with Pain is a Nightmare’ is the title of an editorial comment paper by Pekka Mäntyselkä in the Scandinavian Journal of Pain, where a number of research papers have dealt with this important and perplexing topic.1

Anyone who has suffered acute pain lasting a few days will confirm this observation. Severe pain overshadows every thought and every emotion. Finding a comfortable sleeping position is often impossible, and if one dozes off and changes body position during sleep, the pain quickly wakes one up. It is not difficult to understand that if this continues, perhaps for weeks and months, the suffering caused by the pain will be magnified by sleep deprivation.2 The chicken in this scenario must be the acute pain that causes sleep disturbances.

However, people who suffer from sleep disturbances definitely have a higher risk of developing a chronic pain condition.3 In people with a minor local pain condition, musculoskeletal pain, an arthritic joint with variable pain intensity, long periods with tolerable pain, or rare episodes of more severe pain, if sleep disturbances are also present, there is considerable risk for the pain to spread and generalise to a fibromyalgia-like pain condition, or generalise to widespread pain.1–3

Patients who suffer from chronic pain and are prescribed opioid analgesic drugs may have some relief from the intense pain, but their sleep remains disturbed. Opioids can disturb normal sleep rhythm and decrease the content of restorative sleep. The patient with abnormally long-lasting pain after surgery who is prescribed opioids, often keeps on complaining of disturbed sleep – requiring a higher dose of opioids and a sleeping pill or an anxiolytic benzodiazepine as well.4

Combining opioids for pain, hypnotics for sleep-deprivation and benzodiazepines for anxiety is a dangerous mixture. Part of the epidemic of prescription-opioid fatalities in the US (creeping closer to other countries) is this toxic mixture of potent long-acting opioids with potent anxiolytic drugs or sleeping pills.5 This is likely due to lack of knowledge of how dangerous this practice is. Therefore, an intensified education of healthcare professionals as well as the lay public should be undertaken by the relevant associations and organisations.5

Cognitive behavioural therapy (CBT) for sleep abnormalities of chronic pain patients

Prescribing hypnotics and benzodiazepines concurrently with opioids should be avoided whenever possible.5 Several studies indicate that CBT programmes focused on sleep hygiene and quality of sleep can be beneficial for patients with different types of chronic pain – from chronic osteoarthritis to fibromyalgia.2,6

  • Harald Breivik is emeritus professor of anaesthesiology, Universitetet i Oslo, Norway. He is also editor-in-chief of the Scandinavian Journal of Pain


  1. Mäntyselkä P. Scandinavian Journal of Pain 2012;3:208–209.
  2. Smith MT, Haythornthwaite JA. Sleep Medicine Review 2004;8:119–132.
  3. Nitter A, Pripp AH, et al. Scandinavian Journal of Pain 2012;3:210–217.
  4. Cheatle MD, Webster LR. Pain Medicine 2015;16 Suppl 1:S22–26.
  5. Dowell D, Haegerich TM, Chou R. The Journal of the American Medical Association 2016;315(15):1624–1645.
  6. Vitiello MV, Rybarczyk B, et al. Journal of Clinical Sleep Medicine 2009;5: 355–362.

Date of preparation: June 2017; MINT/PAEU17029