Marc Darrow, MD, JD.
Many people with chronic joint pain do not sleep well. Whether it is their sleep position that causes their knees, hips, shoulders and back to hurt or the advanced degenerative condition of their joints that are always inflamed and painful, the simple fact for many is they have a hard time sleeping. Doctors are beginning to understand that lack of sleep causes chronic pain and chronic pain causes lack of sleep, so a cycle has developed. For many, who have difficulty braking the sleep-pain cycle, their doctors may offer medications for either the pain or the sleep. Now there is a lot of research that opioid medications can make the situation of sleep and pain worse in the long run. This is suggested in a December 2022 paper (1) which cited that “a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during opioid use disorder recovery. . . Sleep disturbance is common and often severe in persons with opioid use disorder, especially during opioid withdrawal, but also in persons on opioid maintenance therapies.” Further, sleep disturbances are “associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving.”
Sleep, opioids and hip replacement. A cause of prolonged pain after hip replacement
An August 2021 study (2) followed the path suggested by other researchers in looking at whether sleep disturbance aggravated acute postoperative pain. In this study they looked at people who had a recent hip replacement surgery. The study authors wrote: “Poor sleep quality and impaired sleep continuity are associated with heightened pain sensitivity, but previous (research) has not evaluated whether preoperative sleep problems impact long-term postoperative pain outcomes. Here, we show that sleep difficulties prior to total hip arthroplasty adversely predict postoperative pain control 6 months after surgery. Given sleep difficulties robustly predict pain outcomes, targeting and improving sleep may have salutary effects on postoperative pain reports and management.”
Opioid addiction and sleep problems leading to problems of chronic hip pain
A February 2022 study (3) paints an overall picture of the problems of sleep in people who abuse opioids. The authors here write: “Individuals with opioid use disorder may experience worsening sleep quality over time, and a subset of individuals may have sleep disturbances that precede opioid use and do not resolve following abstinence. (Even when they give up opioids, the people still have sleep disturbance). Participants in this study reported that their sleep quality declined over their lifespan. Opioid use disorder treatment providers should routinely screen for co-occurring sleep disturbance and chronic pain. Interventions that treat co-occurring opioid use disorder, sleep disturbance, and chronic pain are needed.”
Nightmares and drug induced dreams cause chronic pain
The medical research is filled with studies that find certain medications can cause nightmares. The impact of these nightmares is discussed in an August 2021 paper (4) that suggests:
“Drug-related dreams are commonly reported by individuals in treatment for substance use disorders, which may be distressing. Existing evidence suggests that dream recollection may be influenced by clinically relevant phenomena, such as opioid use and withdrawal, general sleep disturbance, affective symptoms, and chronic pain. . . Individuals who recollected a past-week drug-related dream were more likely to report other recent sleep disturbances, including poorer sleep quality, greater insomnia symptoms, and a higher risk for sleep apnea. Post-dream craving and distress were both associated with greater insomnia symptoms, poor sleep hygiene behaviors, and greater anxiety symptoms. Individuals who had ever experienced a drug-related dream (recently, or in their lifetime) were more likely to report a history of severe withdrawal, overdose, and intravenous opioid use.”
Here the situation in some is that the nightmares cause poorer recovery, sleep apnea, and worsening insomnia.
Sleep disturbance is common and often severe in persons with opioid use disorder, especially during opioid withdrawal, but also in persons on opioid maintenance therapies.
A June 2021 paper (5) reports on the problems of sleep and addiction. The authors write: “Sleep health is an important factor across several physical and mental health disorders, and a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during opioid use disorder recovery. Sleep disturbance is common and often severe in persons with opioid use disorder , especially during opioid withdrawal, but also in persons on opioid maintenance therapies. There is ample evidence that sleep disturbances including reduced total sleep time, disrupted sleep continuity, and poor sleep quality often accompany negative opioid use disorder treatment outcomes. Sleep disturbances are bidirectionally associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving. . . the direct impact of sleep improvement in opioid use disorder patients is largely unknown, yet mechanistic and clinical research suggests that therapeutic interventions that target sleep are a promising avenue to improve opioid use disorder treatment.
Hip surgery, opioids and sleep disturbance linked
As discussed earlier in this article there are many papers that link opioid use, opioid addiction, chronic joint pain and sleep disorders. Doctors are routinely advised to watch for signs before surgery that may indicate someone will have a more difficult recovery. Even then, those signs are not obvious. A July 2019 study (6) made the connection in the difficulties of understanding sleep and opioid problems after hip surgery: The paper suggests: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present after surgery, which were significantly associated with chronic opioid use and greater total and hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may be important, but an even higher rate of sleep disorders may be developed after surgery, and continued screening after surgery may have greater clinical merit.
A paper from January 2022 (7) tested the use of melatonin for 6 weeks after hip replacement or knee replacement to see if that helped with sleep. The paper’s authors noted: “Sleep disturbance is a common concern among patients who have undergone total joint arthroplasty (replacement). Poor sleep during the postoperative period affect quality of life directly and may influence pain recovery after joint replacement.”
In this study, 118 patients undergoing hip or knee replacement were randomized to melatonin (6 mg) or placebo for 42 days after surgery. Patients in both groups showed lower sleep quality, at both 2 and 6 weeks postoperatively compared with that at baseline. The use of melatonin did not demonstrate any notable effect on sleep quality.
Hip osteoarthritis and cognitive decline
A May 2022 study tested 148 patients with hip osteoarthritis for cognitive decline possible caused by chronic pain. The doctors of this research wrote: (8) ” Patients with osteoarthritis of the hip showed decreased performance in specific neuropsychological tests. Performance in verbal and visual short-term and long-term memory and selective attention tests was significantly poorer compared to healthy controls.” The doctors concluded: “chronic pain secondary to end-stage hip osteoarthritis is associated with selective cognitive impairment. Future studies are required to investigate the effect of total hip arthroplasty on cognitive performance.”
Do feelings of being unwell impact recovery from hip replacement surgery?
The use of opioids and lack of sleep can make a patient certainly feel unwell. An April 2022 paper (9) examined the cognitive and emotional aspect of hip replacement recovery. Dividing post-recovery patients into groups based on cognitive and emotional assessment, the researchers sought to predict who would have a more successful hip replacement recovery.
Looking at patients three and six months after surgery, the researchers assessed the patients “illness perception.” Using a questionnaire the researchers identify patients for illness perception by scoring the severity of symptoms associated with their hip pain, hip replacement and general well-being, what they believed are the causes of these symptoms, the perceived duration of the symptoms related to their hip problems, their ability to recover from their hip issues. What they found among the patients were the emergence of two different types of patient identity:
- Before the hip replacement procedure:
- Type 1: The patient’s had long duration of problems which lead to many consequences, low personal and treatment control (they did not feel that could play a role in managing their hip pain), and low coherence (lack of consistency in managing their pain);
- Type 2: The patient had a lesser “identity” of being a hip replacement patient, they suffered from shorter duration of symptoms, had an idea that their management of their own condition resulted in lower consequence, and high personal and treatment control. They had better functionality and lower pain and stiffness three months after surgery compared to the type 1 patient.
Many people we have seen over the years suffered from many of the problems related joint pain, sleep and opioid issues. Use the forms below to contact us and have us assess your possible patient candidacy.
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Other articles on these topics:
1 Huhn AS, Finan PH. Sleep disturbance as a therapeutic target to improve opioid use disorder treatment. Experimental and clinical psychopharmacology. 2022 Dec;30(6):1024.
2 Bjurström MF, Irwin MR, Bodelsson M, Smith MT, Mattsson‐Carlgren N. Preoperative sleep quality and adverse pain outcomes after total hip arthroplasty. European Journal of Pain. 2021 Mar 8.
3 Ellis JD, Mayo JL, Gamaldo CE, Finan PH, Huhn AS. Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder. Journal of Clinical Sleep Medicine. 2021 Sep 28:jcsm-9676.
4 Ellis JD, Mayo JL, Finan PH, Gamaldo CE, Huhn AS. Clinical correlates of drug‐related dreams in opioid use disorder. The American Journal on Addictions. 2021 Aug 29.
5 Huhn AS, Finan PH. Sleep disturbance as a therapeutic target to improve opioid use disorder treatment. Experimental and Clinical Psychopharmacology. 2021 Jun 10.
6 Rhon DI, Snodgrass SJ, Cleland JA, Cook CE. Comorbid insomnia and sleep apnea are associated with greater downstream health care utilization and chronic opioid use after arthroscopic hip surgery. Pain Physician. 2019;22(4):E351.
7 Clarkson SJ, Yayac MF, Rondon AJ, Smith BM, Purtill JJ. Melatonin does not improve sleep quality in a randomized placebo-controlled trial after primary total joint arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2022 Jan 15;30(2):e287-94.
8 Kazim MA, Strahl A, Moritz S, Arlt S, Niemeier A. Chronic pain in osteoarthritis of the hip is associated with selective cognitive impairment. Archives of Orthopaedic and Trauma Surgery. 2022 May 5:1-9.
9 Balck F, Jeszenszky C, Günther KP, Kirschner S, Linke M. The impact of illness perception on functionality, pain, stiffness, and activity of daily living after total hip replacement surgery. Journal of Psychosomatic Research. 2022 Apr 1;155:110749.