Abstract
DEAR SIR,
Severe chronic pain often disrupts sleep. Despite optimal pain management, a significant number of patients still have disrupted sleep due to residual pain symptoms. We are reporting the first documented case of a patient with severe chronic pain and insomnia that responded to low-dose quetiapine.
The patient was a 34-year-old man whose problems commenced 5 years ago when he was a passenger in a vehicle that had a collision at speed. Prior to this event he reported that his sleep was generally sound. After the accident, he was medically cleared but a day later he developed lower limb paralysis that lasted for 24 h. Two days later,
he developed back pain that persisted. He did not report any nightmares or other symptoms associated with post-traumatic stress disorder.
After the accident, the patient usually went to bed at around 12 midnight. He would then be unable to fall asleep for 40-60 min. He would wake up two to three times in the middle of the night because of pain; each time, he would be awake for 2-3 h. During the periods when he was awake, he tried to ‘shut down’ his mind, relax and ‘be at ease’. Occasionally, he would get up when unable to sleep. Sometimes, he chose to do paperwork before falling asleep again. He reported frequent changes in body position when trying to fall asleep. There were no reports of brux-ism, snoring, gasping or abnormal limb movements. There was also no evidence of current mood, anxiety or psychotic disorders.
The patient described constant pain in his lower back, which he rated as 5-7 out of 10 in severity. He was commenced on pain medication (codeine 30-60 mg per day), which he found helpful. However, this was not enough to control the pain while he was sleeping. He tried acupuncture but this was only helpful briefly. He used relaxation therapy, which consisted of visualization and progressive muscle relaxation; he would do this every day for approximately 30-40 min. He also learned to do meditation for 20-30 min each morning and did this regularly for 5 months.
Apart from the chronic low back pain, there was no other medical history of note, including no substance abuse or dependence.
Management initially focused on cognitive behavioural therapy (CBT) for insomnia. However, there was no positive effect. The pharmacological pain treatment was optimized and included the use of codeine and amitriptyline. Despite these measures, he remained unable to sleep satisfactorily. He then was started on quetiapine; this was titrated up to 200 mg with good effect. He was able to sleep 6 h with short sleep latency. Furthermore, he awoke refreshed and had good function throughout the day. He ran out of medication for several weeks and then reverted back to the pattern of pain-interrupted sleep. Quetiapine was restarted with good result.
Insomnia is common and has many possible aetiological factors.[1] Secondary insomnias make up a large proportion and, of these, chronic pain is an important cause. Consequences of insomnia includes distress and impairment in social and/or occupational functioning. It has been shown that CBT is the preferred treatment for chronic insomnia.1–4 However, insomnia secondary to chronic pain can be extremely difficult to treat; a core aim of treatment is to achieve control of the pain syndrome. Quetiapine has a number of theoretical benefits for sleep. It is known to be sedating and reports show that it does not adversely affect sleep architecture.[5] To our knowledge, the present case report is the first description in the literature showing quetiapine successfully used for insomnia secondary to refractory chronic pain.