**7.6 Opioids analgesics**

*Updates in Sleep Neurology and Obstructive Sleep Apnea*

sleep hygiene, relaxing training, and cognitive therapy.

sleepy and get out of bed if not asleep after 20 min [73].

or less efficacy depending of personality and circumstances [76].

disorders. Therefore, it could be used in several domains [78–80].

**7.3 Cognitive behavioral therapy for pain (CBT-P)**

patients, there are only few studies addressing this.

**7.5 Pharmacological therapy**

devices [75].

the bedtime [77].

**7.2 Cognitive behavior therapy for insomnia (CBT-I)/disturbed sleep**

Regarding sleep, cognitive behavior therapy for insomnia (CBT-I) proved to be superior to pharmacotherapy in several outcome studies [71, 72]. CBT-I consists of psychoeducation about sleep and insomnia, stimulus control, sleep restriction,

*Stimulus control techniques* pretend to associate bed with a rapid sleep onset by teaching the patient to avoid habits other than sex and sleep in bed. Naps should also be avoided and regular sleep-wake schedules must be encouraged. Another important aspect is that the patient should learn only to go to bed when feeling

*Sleep restriction* pretends to limit the amount of time spent in bed in relation to the actual time asleep. In the first days, this will lead to a mild sleep deprivation which soon will increase the sleep drive and afterwards to a more consolidated sleep with better rest and efficiency. When the patient improves, time in bed will increase again [74]. *Sleep hygiene* contributes to more adequate behaviors near bedtime as avoiding caffeine or tobacco, intense exercise, or too much light, noise, and use of electronic

Relaxation training will reduce cognitive and physical tension prior to bedtime. Techniques like hypnosis, meditation, and guided imagery can be used with more

*Cognitive therapy* will help patient to have real beliefs regarding sleep and to adopt attitudes that will favor sleep. For instance, many patients lie in bed and think they will not sleep the whole night, making them worried about this. This technique also pretends to eliminate excessive rumination and negative thoughts, mainly in

*Cognitive behavioral therapy* is also available for other sleep disturbances such as sleep apnea, narcolepsy, sleep-wake circadian mismatch, and several pediatric

Several psychological- and behavioral-related options showed to be effective for chronic pain, including CBT-P, acceptance and commitment, mindfulness, progressive muscle relaxation training, motivational interviewing, and goal setting to behavioral activation. CBT-P is effective in a manner that its principles are associated to identify and approach those negative or dysfunctional thoughts and behaviors that usually worsen patient's adjustment to chronic mechanisms of pain. It was shown to effectively reduce patient distress in patients with pain-associated conditions. Although it is expected that CBT-P also has impact on sleep in those

**7.4 Combined cognitive behavioral therapy directed to both sleep and pain**

A synergistic (CBT-I + CBT-P) approach was associated with significant greater improvements either in pain and sleep when compared with each isolated strategy. Fatigue, depression, and overall improvement in quality of live with less pain interference were observed in patients treated with this combination [81].

Reciprocal interaction between pain and sleep disturbance makes it important to concurrently address and treat both conditions in order to succeed. In some

**98**

Opioids may improve subjective sleep quality in some patients with chronic pain, but can also interfere with sleep in others, mainly if they have sleep related breathing disorders which may be aggravated by this class of analgesic drugs. Other well-known potential adverse effects are hyperalgesia, tolerance, and dependence. That is the reason to support the recommendation *against* the use of opioids for insomnia, although it could be effective in highly selected pain patients [82].
