Pain, Insomnia, and Diabetes

Studies show that sleep problems contribute to Type 2 diabetes. But diabetes seems to increase pain sensitivity, and pain makes it harder to sleep. What a vicious cycle! What is the pain/sleep/diabetes connection, and what can we do about it?


I’ve written several times about diabetes and sleep, and also diabetes and pain. But this week I read an article that links all three problems. In the drug information journal MPR (Monthly Prescribing Reference), Debra Hughes, MS, discusses these issues with Victor Rosenfeld, MD, Medical Director of the Sleep Center at the SouthCoast Medical Group, Savannah, Georgia.

“Sleep and diabetes go hand-in-hand,” writes Hughes. “Diabetes can cause sleep loss, and poor sleep can increase the risk for or worsen diabetes. Tired people eat more sugary foods for energy. Sleep deprivation has been linked with prediabetes.

Dr. Rosenfeld says the path from poor sleep to diabetes sometimes leads through weight gain. “Weight gain worsens sleep, which worsens weight and diabetic control, which worsens sleep – and so on.”

In some cases, this vicious cycle involves obstructive sleep apnea (OSA). A 2009 article in Diabetes Care reported that 86% of obese people with Type 2 diabetes had sleep apnea.

According to Dr. Rosenfeld, another study found that 97% of those who were both obese and had diabetes suffered from OSA. With or without obesity, OSA is associated with insulin resistance. This could be due to the stress hormones stimulated by low oxygen levels during sleep.

Use of continuous positive airway pressure (CPAP) may improve insulin sensitivity. But even without OSA, poor sleep is associated with insulin resistance and diabetes. And then diabetes itself interferes with sleep. Some of this interference is through pain.

Diabetes can hurt, as many readers told me here. A main source of diabetes pain is peripheral neuropathy, or PN. There seem to be many causes of PN. Nerves or blood vessels may be damaged by high glucose, but injuries and various lifestyle factors can affect neuropathy. Sleeplessness is one such factor.

According to Dr. Rosenfeld, alpha-lipoic acid (100 milligrams twice daily) might help prevent progression of diabetic neuropathy. The drugs Cymbalta (duloxetine), Neurontin (gabapentin), and Lyrica (pregabalin) might help with both sleep and pain. All have side effects, however.

Pain and sleep
Surveys of people with diabetes report rates of chronic pain anywhere from 20% to over 60% – much higher than rates in the general population.

If you have chronic pain, sleep becomes much more problematic. More than half of people with chronic pain complain of poor sleep. According to Dr. Rosenfeld, the primary causes of pain-related sleep loss include back pain, headache, musculoskeletal pain, and several other types of pain.

The less sleep you get, the more sensitive to pain you are likely to be, and the more insulin resistance you are likely to have. So where do you start? With the pain, the sleep, the glucose control?

I think you can start anywhere, but there’s a lot to be said for sleeping better. Many pain specialists start treatment by trying to help people get more sleep. It’s not just the quantity of sleep that matters. There is also the quality of sleep, which specialists call “sleep architecture.”

You need to get proper amounts of REM (dreaming) and NREM (non-dreaming) sleep. Unfortunately, sleep medicines and pain medicines can disrupt sleep architecture. You might get the hours of sleep, but not the benefits. So in seeking treatment, it might take some time to find the right drugs. Or maybe no drugs would be better for some of us. Herbs or good sleep hygiene practices might help more.

If you suspect or know that you are sleeping poorly, you could be checked for OSA. You could see about more comfortable sleeping situations, like a quiet, dark room and a comfortable mattress. You could learn about sleep hygiene (winding down, a bedtime ritual, — more ideas here). Some people with diabetes have improved their sleep dramatically by taking 500–1,000 milligrams of magnesium in the evening or at bedtime

Dr. Rosenfeld says that issues such as shift work, other medicines, or too much or not enough exercise may also play a role in disturbing sleep. These issues should be addressed.

I know that basically, the people who get the worst sleep have the worst health and the most pain. So sleep is important. I’d like to learn more about it. In your experience, is there a sleep/pain connection? And do you ever notice that your blood glucose levels change depending on how well you sleep? What do you do to help you sleep?

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  • Joe

    First let me say, this is my life. Pain, fatigue, diabetes, OSA. After heart surgery to repair a defective valve I suffered chronic pain in my ribs, back and shoulders that has never subsided. After decades of sleeping great using CPAP and a good mattress, I was left unable to sleep due to pain, and developed insomnia despite near debilitating fatigue. My MD treated this with zolpidem for sleep and tramadol for pain. I can sleep soundly for 8, 10, even 12 hours, but I still wake feeling fatigued. I’ve tried several times to go off the tramadol, but to be honest it barely controls the pain when I use it. I’m nearly unable to function without it. So I don’t know if my meds are impairing my sleep, but I can’t sleep without them.

    On a slightly more organic note, my wife swears by valerian root, which she uses on the very rare occasions she has trouble sleeping. I haven’t studied it so I’m not eager to mix it with my prescription meds.

  • O.G.

    Be afraid. Be very afraid…if a physician wants you to “try” a prescription drug like the failed anti-depressant Cymbalta, now recommended for pain; or Tramadol, which supposedly does the same; or Gabapentin, also alleged to help sufferers like us.

    Those fast-running voiceovers in the commercials attempt to make dangerous drugs look benign by getting you to ignore any red flags: unconscionable at best, unethical or even criminal at worst.

    I had very bad experiences with all three of the aforementioned drugs (with Cymbalta the worst, leading me –when I was lucid again–to file a written complaint with the FDA–and I will never again accept a prescription drug without being, let’s say, seriously post-surgical.

    Are sleep, pain, and BG control in diabetes related? Anecdotally, I’d say yes: many of us experience this, so it isn’t rocket science to say so. Do the usual suggestions (drugs, the CPAP) to remedy this axis of evil help? Again anecdotally and personally, I’d register a resounding “no.”

    I plan to explore every herbal and other non-pharmaceutical and non-mechanical avenue of assistance available to me in the future. The conventional approaches led, in my case, to serious side effects, more suffering, and the pains of stopping the (ineffective anyway) prescription medications. The least harmful? The CPAP…all IT gave me was a raging headache and a rip-roaring sinus infection, and worse insomnia than I started with from trying to sleep with a machine on my head.

    The only prescription medications I’m using are my (unavoidable: I’m a LADA or “1.5” diabetic) insulin and two 250mg doses per day of Metformin. Beyond that, diet, exercise, and other lifestyle changes, plus a few vitamins and supplements, are it.

    Fellow patients, beware!

  • Terri

    I hadn’t previously considered the relationship between pain, sleep, and poor sugar readings. I have chronic pain due to hyrneated discs, bulging discs,spinal stenosis, bone spurs, and arthritis in the spine. I have had one disc removed in my neck and have a titanium plate fused with a piece of my pelvic bone. Both of my knees (3 surgeries on one), shoulders (1 surgery), and wrists (3 carpal tunnel surgeries on right wrist and 1 carpal tunnel on left) are painful as well. On top of that are the usual diabetic pain with neuropathy.

    Strangely enough, I was an insomniac prior to the chronic pain; however I’m sure that doesn’t help. I have tried over the counter meds for sleep, prescription meds, exercise, bedtime rituals, eating a bedtime snack, and not eating a bedtime snack. Ive tried white noise, no television, dark room, meditation, relaxation tapes, complete silence to soft music, reading, and temperature control. I remain on sleep meds even though I believe I’ve built up a tolerance to them.

    My diabetes has been out of control for all but one year of the thirty years since my diagnosis. It makes sense that sugar readings would be higher with someone who is in pain. Illness and stress often cause higher sugar readings. I suppose that the relationship between illness and pain would do the same. Also, being sleep deprived causes the body to be susceptible to illness. It’s an interesting connection when you think about it. So what’s the answer to break the cycle?