Sleep disturbance is an important clinical complaint for individuals with nonmalignant pain conditions. This review is a broad introduction to the literature on sleep disturbance and chronic pain conditions. The article critically reviews studies of sleep disturbance in musculoskeletal pain, arthritis, headache, and fibromyalgia. Current neurobiological hypotheses regarding the pathogenesis of sleep disturbance and chronic pain, common comorbid disorders, and pharmacologic and non-pharmacologic treatments for sleep disturbance are reviewed.

These data suggest that physical functioning, duration of pain, and age may be more important than pain intensity and depressed mood in contributing to decreased overall sleep quality and sleep latency. The contribution of physical functioning was particularly strong and should be included in subsequent studies of sleep, pain, and mood. The SF-36 should be compared to pain-specific quality-of-life measures to further evaluate the usefulness of this instrument with outpatients with chronic nonmalignant pain conditions.

The addition of transdermal fentanyl to a treatment regimen containing no opiates or small amounts of opiates for patients with chronic nonmalignant pain did not negatively affect their driving performances, reaction times, cognition, or balance. Future studies in this area are needed to guide treatment decisions.

Epidural morphine injection followed by a steroid has been reported to be effective for the post-laminectomy pain ('failed back') syndrome. This double-blind, parallel study was undertaken to evaluate that mode of therapy. Twenty-two patients who had undergone at least one prior laminectomy, who were still symptomatic, were randomized to receive 50 mg of lidocaine epidurally with: (a) 75 mg triamcinolone diacetate (TR); or (b) 8 mg of preservative-free morphine (MP); or (c) both (TR and MP), at 1 month intervals for 3 consecutive months. The spinal interspace identified with the patients' pain complaint was the site of injection. For each treatment, patients were admitted to the Clinical Research Center for 24 h and their condition continuously monitored with a pulse oximeter and apnea monitor. Five to 7 patients in each group had pain relief for less than 1 month. No patient given morphine had pain relief for more than 1 month. Life-threatening ventilatory depression occurred in the group given triamcinolone and morphine. The use of morphine alone or combined with slow release triamcinolone does not appear to be appropriate for the treatment of the post-laminectomy pain syndrome.

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