Getting Eight to Nine Hours of Sleep a Night - The Foundation of Pain Relief

By Jacob Teitelbaum MD

To eliminate muscle and many other sources of pain, it is critical to get 8-9 hours of solid, deep sleep each night on a regular basis. Disordered sleep is, in my opinion, a major underlying process that perpetuates pain.

Inadequate sleep can occur for a number of reasons. Many Americans simply do not make enough time. A hundred years ago, the average American was getting nine hours of sleep a night. That means as many people were getting 10 hours a night as were getting eight. Anthropologists tell us that 5000 years ago, the average night sleep was 11-12 hours a night. When the sun went down, it was dark, boring, and dangerous outside, so people went to bed. When the sun came up they woke up. The average time from sunset to sunrise is 12 hours. The use of candles initially shortened our sleep time. Then light bulbs were developed followed by radio, TV, computers, etc. We are now down to an average of six and a half to seven hours of sleep a night, and this is simply not adequate to allow proper tissue repair.

Other people get inadequate sleep because of poor sleep hygiene - often occurring because the pain keeps you awake. In fibromyalgia, however, most people have insomnia because the sleep center (called the hypothalamus) is suppressed by the illness.

Sleep has a distinct architecture with five key stages. Stages 1 and 2 sleep are fairly light, while stages 3 and 4 (or delta wave) sleep are the deeper stages of sleep. My experience, and that of many other clinicians, suggests that what are inadequate in fibromyalgia and likely in many pain patients are stages 3 and 4 of sleep. These are the stages were you produce growth hormone, which results in tissue repair and healing. Unfortunately, most sleeping pills in common use keep people in stage 2 sleep, which can actually make their problem worse. The good news is that there are number of exceptions.

Several studies have shown that if you wake up people whenever they go into deep sleep, or even shake them lightly, so that they go from deep sleep into light sleep, they will develop pain within one to two weeks and often within one night.

In fact, inadequate sleep has repeatedly been shown to contribute to pain. In one study of fibromyalgia patients, it was found that increased pain sensitivity is associated with greater sleep disturbance. Another study of female office employees in one large company showed that women who have a lot of muscle pain have insufficient sleep. Another study by Dr. Moldofsky, a respected researcher on sleep in fibromyalgia, found that things that disrupted deep sleep resulted in waking feeling unrefreshed, widespread muscle pain, tenderness, and fatigue in normal healthy people. He concluded that "there is a reciprocal relationship between sleep quality and pain." In another study of 105 fibromyalgia patients, it was also found that sleep quality was important in mediating pain and fatigue.

We find that when our patients gets eight to nine hours of solid sleep regularly each night for six to nine months their pain and, interestingly, their inability to fall asleep both resolve. They are then able to markedly reduce the amount of sleep and pain medication that they need. It is because of this that breaking the cycle of poor sleep and maintaining quality sleep for at least six to nine months are critical to breaking the cycle of pain. This was demonstrated in our placebo-controlled study "Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia - a Placebo-controlled Study," which showed 91% improvement rate in fibromyalgia when sleep, hormonal problems, infections, and nutritional deficiencies were properly treated (see www.vitality101.com for the full study text). Eight hours of solid sleep each night, without waking or hangover, is the goal and, hard as this may be to believe, it is very attainable using the suggestions that I will give you.

But how can I get eight hours of deep sleep each night if I have insomnia?

In general, I think it is a good idea to begin with natural remedies and then adding prescription therapies if the natural approaches are not adequate. This will make a big difference in making your pain go away, and you can usually come off the prescriptions about six months after you are feeling better.

Natural Sleep Remedies

Most of the natural sleep remedies discussed here are not sedating, yet they help you fall asleep and stay in deep sleep. Some are available in combination formulas as well. I recommend the following natural sleep aids:

Begin with :
- A -- Wild lettuce extract 28 mg -- one of the most powerful sleep herbals available
- Jamaican Dogwood Extract 12 Mg -- this both help sleep and is a muscle relaxant
- Hops extract 30 mg
- Passionflower extract 90 mg -- this helps both sleep and anxietyValerian extract 200 milligrams
- Theanine 50 milligrams (from green tea) -- this helps both sleep and immune function.

All six of these herbs are contained in the "Revitalizing Sleep Formula" by Enzymatic Therapy. Take 1-4 capsules at bedtime if you have trouble staying asleep or 30 - 90 minutes before bedtime if you have trouble falling asleep. You'll see the effect of a given dose on sleep the first night that you take it. It can also be taken during the day for pain and anxiety. If you're still not getting eight to nine hours of sleep a night, add in the natural remedies below.

Magnesium, 75 to 150 milligrams, and calcium, 600 milligrams at bedtime, also helps sleep.
Hydroxy L-tryptophan (5-HTP). Take 200 to 400 milligrams at night. When used for six weeks, a 300- to 400-milligram dose has been shown to decrease fibromyalgia pain and often helps people to lose weight The one caution I would note is that if you are taking other treatments that increase serotonin (these include antidepressants like Prozac, St. John's wort, Ultram, Desyrel, and the like), it is reasonable to limit the 5-HTP to 200 milligrams at night. It takes six to 12 weeks to see the full effect of 5 HTP, and it is more expensive than the other remedies. Nonetheless, it may well be worthwhile in chronic pain.
Melatonin. 1/2 milligram.

Sleep Medications

Although I much prefer natural remedies to prescription medications, the sleep disorder in most fibromyalgia patients is too severe to be dealt with by natural remedies alone. However, even if you are someone who also needs prescription sleep aids, adding natural remedies can be very helpful and usually decreases the amount of medication that you will need, resulting in fewer side effects. In addition, once you come off the sleep medications (usually after 9 to 18 months, although they can be used indefinitely, if needed) you may find that all you require are the natural remedies.

Whatever treatments you use, though, it is important that they not only increase the duration of sleep but also maintain or improve the deep stages (stages 3 and 4) of sleep. Unfortunately, most sleeping pills in common use (for example, Dalmane, Halcion, and Valium) actually worsen the quality of sleep by increasing the amount of light stage (especially stage 2) sleep and decreasing the deep stages of sleep even further. You want to be certain that the treatments and medications you use leave you feeling better the next day, not worse.

There are several approaches to using sleep treatments in pain patients. Some doctors prefer to use a single medication or treatment and push it up to its maximum level. If that works, great; if not, they stop it and switch to another medication. Other doctors prefer to use low doses of many different treatments together until the patient is getting good, solid sleep regularly. I strongly prefer the latter approach. Most of a medication's benefits occur at low doses and most of the side effects at high doses. In addition, if you combine low doses of a few different sleep aids, each of them will be cleared out of your body by morning - so you won't be hung over. Meanwhile, the effective blood levels that you have during the middle of the night from each treatment are additive, and will keep you asleep for eight to nine hours of solid sleep each night without waking or hangover. (You'll notice that I keep repeating this phrase!)

Getting Started

My treatment checklist contains many effective natural and prescription sleep recommendations as well as detailed directions for how to use them (see www.vitality101.com). My preference is to start with the sleep herbal plus Ambien. I then add Desyrel and/or Klonopin to this and go from there.

Once you have tried a low dose of a single treatment, increase the dosage each night until you either get eight to nine hours of solid sleep without waking or hangover, you get side effects (for example, next-day sedation), or until you are at the maximum dose on the checklist. Use the lowest dose that gives you the most benefit.

It is not uncommon to see your sleep worsen again during periods of increased stress - whether physical or emotional - and the flaring of your pain/illness. During these times, increase the treatments as needed to maintain eight to nine hours of solid sleep without waking or hangover. I find that patients do not have a problem with continually having to escalate the dose, so don't worry about increasing the treatments during periods of stress or flaring of your illness.

The best way to need less medication in the long run is to use as much as it takes to get eight to nine hours of solid sleep each night without waking or hangover for six to 18 months. When you are sleeping well and feeling better for six months, you can then decrease the treatments as long as you continue to get eight to nine hours of solid sleep each night without waking or hangover. If you need to take some of the sleep treatments long-term, that is also okay.

For all of the medications listed below, most of the side effects that you may notice will occur the first day that you take the medication. In addition, regardless of the package insert saying to only use Ambien for a maximum of 1 month, both research studies and the experience of many clinicians show that it can be used safely long-term.

Which prescription medications should I use?

Although I prescribe medications in different orders for different people, depending on the cause of their pain, the most common order I use is that below.

Zolpidem (Ambien)

I like Ambien because it is short-acting (that is, less likely to leave you hung over) and less likely to cause side effects than many other medications. Because it is short-acting, it may not keep you asleep all the way through the night, but will likely give you four to six hours of good, solid sleep as a foundation. The normal dosage is one-half to one 10-milligram tablet, taken at bedtime. If you wake up in the middle of the night you can take an extra one-half to one tablet (leave it by your bedside with a glass of water), and any sedation is usually gone by the time you are ready to wake up in the morning. One-half tablet is usually enough for the middle of the night. If you find that taking an additional dose in the middle of the night leaves you hung over, use Sonata (see below) when you wake instead.

Although Ambien is only FDA "recommended" to be used for less than a month, a two-year study of 4000 patients with chronic insomnia showed that people were able to use it long term whenever they needed it - without developing any significant problems.

Desyrel (Trazodone)

50 mg ½-6 tabs at night. Although technically considered an antidepressant, I find it works poorly for this, but wonderfully for sleep and anxiety.

Clonazepam (Klonopin)

Although in the Valium family, and therefore potentially addictive, Klonopin can be very helpful for people with pain and is excellent for patients with restless leg syndrome. The main side effect is next-day sedation, which is fairly common. If this occurs, take a lower dose or take it several hours before bedtime.

Cyclobenzaprine (Flexeril)

This is a muscle relaxant. It can be a very helpful medication for many people, especially if the pain is severe. The usual dose is one-half to one 10-milligram tablet at bedtime, but some people need to take two tablets at bedtime. The main side effects are sedation and dry mouth and eyes.

Carisprodol (Soma).

This is predominantly a muscle relaxant and I would use this earlier in treatment if you are being kept awake by severe pain. The usual dose is one-half to two 350-milligram tablets at bedtime. Soma is potentially addictive, although I have never seen this in patients who are only using one to two tablets at bedtime (as opposed to people taking it four times a day for pain). The main side effect is sedation.

Neurontin (gabapentin) 300 milligrams (it comes in 100 -- 800 mg doses).

Taking one to three capsules at bedtime can markedly help with both sleep and pain in many patients. Its main problem is next day sedation, which often wears off with time.

Zanaflex (Tizanidine) 4 mg tabs

One-half to two tablets at bedtime can be very helpful for both pain and sleep. It rarely causes nightmares. If this occurs repeatedly, stop the Zanaflex.

Gabitril

2 mg twice a day and increase by a maximum 4 mgs daily each week to maximum of 24 mg a day. It helps both pain and deep sleep. The average optimally effective of dose of the Gabitril is 16 mg a day (Range 10-24 mg a day). Gabitril decreased pain by approximately 30% and decreased sleep problems by approximately 40%. Another benefit is that the amount of time spent in deep, restorative sleep is increased.

Zaleplon (Sonata)

10-milligram tablets. Sonata generally wears off within three to four hours, so it is best used in the middle of the night (for example, at 4:00 a.m. ) if you wake up and need something to help you fall back to sleep, or if you have trouble falling asleep but not staying asleep.

Amitriptyline (Elavil)

Although Elavil can be very helpful, it has significant side effects and has therefore is often one of the last treatments I try.

Alprazolam (Xanax).

This is a short-acting cousin of Valium that gives a good three to five hours of sleep with less hangover in the morning. I was pleasantly surprised to find that it improves sleep quality, because it is a cousin to Valium, which usually seems to worsen this in most people. It is very good for anxiety as well, and tends to be very well tolerated. It can be addictive, however. The usual dosage is one-half to four 0.5-milligram tablets at bedtime or during the night.

Xyrem (GHB)

An excellent (and possibly the best) sleep medication for pain and fibromyalgia. Because the DEA claimed (many suspect mistakenly) that it was being used as a date rape drug, it has gone from being inexpensive and over-the-counter to being tightly regulated and costing approximately $500 a month. If all else fails, this often works very well. It comes as a liquid that can dissolve your enamel and damage your teeth, so be sure to rinse your mouth well and swallow after taking the liquid to prevent this. Your physician will need to fill out special forms to get Xyrem for you

In addition to the prescription medications above, the serotonin-raising antidepressants known as SSRIs can help improve sleep, in addition to having many other benefits in treating pain - even if there is no depression present. These medications include fluoxetine (Prozac), paroxetine ( Paxil), and sertraline ( Zoloft).

By using a combination of the treatment discussed above, almost all people, even those with fibromyalgia, can get eight to nine hours of solid sleep a night without waking or hangover. It can take a lot of trial and error to find out exactly what is best for you, but it is worth being persistent! Our research has proven that most people with fibromyalgia can be pain-free. Getting at least eight hours of sleep a night is a critical step in this process - and you can get eight hours of sleep a night!

Important Points

Getting eight to nine hours of solid, deep sleep a night without waking or hangover is critical to getting well.
Natural remedies can be very helpful for sleep, and may be safer than medications. Revitalizing Sleep Formula is excellent. Consider adding calcium, magnesium, 5 HTP, and/or melatonin as needed at bedtime.
Ambien, Klonopin, Soma, Flexeril, Zanaflex, Gabitril, and Neurontin are excellent prescription sleep medications for patients with fibromyalgia. Most regular sleeping pills make you worse by keeping you in light sleep.
Take whatever combination of these natural and prescription sleep aids you need to get eight to nine hours of sleep a night. When you're feeling better for six months you can start to lower the dose as able - as long as you continue to get eight hours of sleep a night. Anytime your sleep starts to get worse, resume sleep treatments until the insomnia passes.

The medical director of the Annapolis Center for Effective CFS/Fibromyalgia Therapies in Annapolis, Maryland, Jacob Teitelbaum, M.D., is the senior author of the landmark study "Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia - a Placebo-controlled Study." He also wrote the best-selling book From Fatigued to Fantastic! , Three Steps to Happiness! Healing through Joy , and Pain Free 1-2-3 : A Proven Program to Get YOU Pain Free!

This article was reprinted with the permission of the National Fibromyalgia Association.