【原】就诊于三级医院疼痛专科的疼痛患者的睡眠问题：疼痛相关焦虑、药物使用、自我报告疾病和睡眠障碍性疾病的作用（九）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Miettinen T, Sverloff J, Lappalainen OP, Linton SJ, Sipilä K, Kalso E. Sleep problems in pain patients entering tertiary pain care: the role of pain-related anxiety, medication use, self-reported diseases, and sleep disorders. Pain. 2022 ;163(7):e812-e820.本次学习由阎芳副主任医师主讲。

4.2. Self-reported diseases and restless legs

In a multicountry study, Koyanagi et al. showed a linear dose-dependent correlation between the number of chronic conditions (angina pectoris, arthritis, asthma, chronic lung disease, depression, diabetes, hypertension, obesity, and stroke) and sleep problems. When observed separately, angina (OR 1.75-2.78), arthritis (OR 1.39-2.46), and depression (OR 1.75-5.12) were the conditions most often associated with sleep problems. Here as well, as expected, those pain patients with sleep problems more frequently reported health conditions (angina pectoris, asthma, and depression) than those sleeping normally. In particular, the difference in asthma reports in the groups (1.7% vs 19.6% in the sleep problems group) is noteworthy. Luyster et al. showed that insomnia was common (37%) among those with asthma and it was also associated with worse asthma control. Asthma can lead to sleep disturbance via several physiological mechanisms, such as increase in bronchial hyperresponsiveness. Furthermore, asthma and OSA are mutually associated. However, Brumpton et al. showed that insomnia tripled the risk of developing asthma over an 11-year follow-up period.

4.2. 自报疾病和不宁腿综合征

在一项多国研究中，Koyanagi等人发现，患慢性病（心绞痛、关节炎、哮喘、慢性肺病、抑郁症、糖尿病、高血压、肥胖和中风）的种类数与睡眠问题之间呈剂量依赖性线性相关。单独来看，心绞痛（OR 1.75-2.78）、关节炎（OR 1.39-2.46）和抑郁症（OR 1.75-5.12）是最常与睡眠问题相关的疾病。在本研究中同样，正如预期的那样，有睡眠问题的疼痛患者报告的健康状况（心绞痛、哮喘和抑郁症）比睡眠正常的患者更多。尤其值得注意的是，两组哮喘报告的差异（1.7%对睡眠问题组19.6%）较大。Luyster等人表明，失眠在哮喘患者中很常见（37%），同时，失眠也导致哮喘控制不佳。哮喘可通过多种生理机制导致睡眠障碍，如支气管高反应性增加。此外，哮喘和OSA是相互关联的。然而，Brumpton等人在11年的随访中发现，失眠使患哮喘的风险增加了三倍。

Chronic pain, depression, and sleep problems are already known to have bidirectional relationships; so, it was therefore not unexpected that so many (31.6%) among those with sleep problems suffered physician-diagnosed depression in the past year. However, this finding underlines the fact that, along with pain and anxiety, depression is frequently involved in the sleep problems of pain patients. It seems that sleep problems are an independent risk factor for the development of depression, possibly through, for example, increase in inflammatory substances, decrease in monoamines (such as serotonin, noradrenalin, and dopamine), or alterations in circadian rhythm processes. These same factors are also of interest for chronic pain development.

众所周知，慢性疼痛、抑郁和睡眠问题具有双向关系；因此，在过去的一年中，有如此多（31.6%）的睡眠问题患者被医生诊断为抑郁症，这并不意外。然而，这一发现强调了一个事实，即除了疼痛和焦虑，抑郁症经常与疼痛患者的睡眠问题有关。睡眠问题似乎是抑郁症发生的一个独立危险因素，可能通过炎症物质增加、单胺类（如血清素、去甲肾上腺素和多巴胺）的减少或昼夜分泌节律过程的改变来实现。这些因素对慢性疼痛的发展也很有意义。

Back pain, joint diseases, and RA have previously been shown to be associated with increased sleep problems, and here too, back pain and joint diseases were more common in those with sleep problems. However, surprisingly, arthritis was more common among those sleeping normally than those with sleep problems. In the sample, arthritis was rarely the main cause for pain, but a co-occurring disease, the symptoms of which are today usually well controlled pharmacologically.

背痛、关节疾病和类风湿性关节炎之前已被证明与睡眠问题加重有关，本研究亦发现，背痛和关节疾病在睡眠问题患者中更常见。然而，令人惊讶的是，关节炎在睡眠正常的人中比睡眠问题人群中更常见。在本研究的所有病人中，关节炎很少是疼痛的主要原因，一般与其它疾病同时存在，且关节炎所导致的症状目前通常可以用药物得到很好的控制。

The prevalence of RLS in those having sleep problems, 33.2%, was nearly three-fold of that in those sleeping normally, and markedly higher than estimates of 5% to 10% in the general population. Factors suggested to cause or to be associated with RLS include genetic predisposition, brain iron deficiency, and alterations in dopaminergic metabolism or circuitry. Dopaminergic mechanisms may link RLS and widespread pain. Also, sleep problems in RLS are associated with anxiety and depression, and therefore, as in pain, the latter may be contributing factors in sleep problems. The prevalence of OSA in those with sleep problems was twice that of those sleeping normally, but the difference was not statistically significant.

在有睡眠问题的人群中，RLS的患病率为33.2%，几乎是正常睡眠人群的三倍，明显高于一般人群的5%-10%。可能导致或与RLS相关的因素包括遗传易感性、大脑中铁缺乏和多巴胺能代谢或回路的改变。多巴胺能机制可能介导了RLS导致的广泛疼痛。此外，RLS患者的睡眠问题与焦虑和抑郁有关，因此，与疼痛一样，后者可能是睡眠问题的促成因素。睡眠问题患者OSA的患病率是正常睡眠者的两倍，但差异无统计学意义。

4.3. Use of medications

Not surprisingly, pain and sleep medication utilization was significantly higher in the sleep problems group. However, some of the medications used can be considered problematic for sleep, such as the most commonly used benzodiazepine derivatives. Their high use may be partly attributable to the underlying problem of anxiety in these patients. Benzodiazepines affect sleep structure negatively, while one reason for continuing their use includes dependence. Also, analgesics have both beneficial and detrimental effects on sleep, although research is limited. If medications affect sleep, this may complicate efforts to alleviate the comorbidity of pain and sleep problems. Therefore, nonpharmacological methods to improve sleep would be preferable.

4.3.药物的使用

不出所料，睡眠问题组的止痛和睡眠药物使用率显著较高。然而，某些药物可能被认为对睡眠产生不良影响，例如最常用的苯二氮卓衍生物。它们的大量使用可能部分归因于这些患者的潜在焦虑问题。苯二氮卓类药物对睡眠结构有负面影响，而继续使用的一个原因包括依赖性。此外，尽管研究有限，但止痛药对睡眠既有有益的影响，也有有害的影响。如果药物影响睡眠，这可能会使解决疼痛和睡眠问题共病的努力复杂化。因此，改善睡眠的非药物方法更可取。