Falling Through the Cracks in Pain Management
Pain and Opioids
Chronic pain is debilitating, and it can cause patients to “fall through the cracks”. Health care institutions struggle to find ways to create “nets” and catch these patients. Pain medications include opioids which are used to treat chronic pain. Opioids often fail to treat the patient’s primary medical condition. As time goes by, patients tend to be unsatisfied with the results.
Also, there is a good chance that some of these types of pain medications will be abused. In fact, pain medicines such as opioids are part of the United States opioid crisis. According to the Centers for Disease Control (CDC), every day, more than 115 people in the United States die after overdosing on opioids. (CDC/NCHS, 2017) The opioids include prescription drugs, including fentanyl, and synthetic street drugs such as heroin.
It is estimated that the total economic burden of prescription opioid misuse in the United States is $78.5 billion a year which includes the costs in health care, lost productivity, addiction therapy, and criminal justice involvement. (Florence, Zhou, Lou, & Xu, 2013)
Pain and Mindfulness Meditation
To overcome pain, another task which demands higher controlled attention must be pitted against it.
Other forms of therapies were introduced to manage chronic pain.
One such therapy is known as mindfulness meditation. Mindfulness meditation is: “the intentional self-regulation of attention from moment to moment”. (Goleman & Schwartz, 1876) This method has been used for quite some time. A study done in mindfulness meditation by Dr. Kabat-Zinn has reported that 65% of patients have exhibited a reduction of pain by more than 33% and about 50% of patients have reported a reduction of pain by 50% over a 10-week period of therapy. (Kabat-Zinn, 1982)
Some studies performed in mindfulness meditation have reported patients with strong feelings of anger towards their pain condition while others report some anxiety while undergoing mindfulness therapy. la Cour and Petersen point out that meditation therapy requires a learning curve for the patient to access the more important personal “inner space”. (la Cour & Petersen, 2015) This can be an exciting learning experience of discovery for some patients while other patients may see this as a constant battle that in itself can be a painful experience.
The next question to consider therefore is to find out which patients benefits the most from mindfulness meditation and which are not, and then find out what other therapies we can use in these patients.
Enter Virtual Reality: Pain and Attention
Recall a recent injury. Ever wonder why after a trauma or injury has occurred, there seems to be a delay in which actual pain is produced? Pain has to first gain access to consciousness and demands central attentional resources by interrupting all other current brain processes such as worry, fear, or desire. It does so easily because of its noxious nature. (Eccleston, 1995) Pain, therefore, can be considered as a controlled task. To overcome pain, another task which demands higher controlled attention must be pitted against it.
The characteristics of pain such as intensity, quality, and/or pattern affect the probability of capturing attention. In chronic pain, for example, the characteristics of the pain and its intensity are important for pain processing. This may explain the reason why there are “good” days and “bad” days for patients with sciatica, multiple sclerosis, and other causes of chronic pain. Persistent pains with unpredictable sensory qualities that fluctuate in intensities are more likely to be processed. (Eccleston, 1995)
Finding the perfect distractor with the ability to interrupt persistent pain stimulus processing is key to coping. Virtual reality (VR) systems offer computer-generated sensory inputs that involve sight, sound, and touch. These inputs make it essentially difficult for the brain to ignore especially if the VR program is immersive. Immersive VR is an experience that gives a perfect illusion to the patient that is in the virtual world. The strength of the illusion of the presence of the virtual world reflects the amount of attention drawn into the virtual environment. (Hoffman, Doctor, Patterson, Carrougher, & Furness III, 2000)
Virtual reality may not replace the conventional pain management anytime soon. Once the patient comes out of VR, they will soon feel pain once more. Pharmacologic therapy remains the mainstay of pain management. But the problem of using pharmacologic treatment for pain remains a challenge. Undermedication is a problem of pain management failure. But higher doses of opioids poses a serious risk such as respiratory failure and encephalopathy. Therefore, the application of pain relief using VR may be for the use of procedural pain management such as minor surgical procedures, wound cleaning and debridement, and escharotomy in burn victims.
CDC/NCHS. (2017). National Vital Statistics System, Mortality. (US Department of Health and Human Services, CDC) Retrieved May 21, 2018, from CDC Wonder, Atlanta GA: https://wonder.cdc.gov/
Eccleston, C. (1995). Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain. Behav Res Ther, 33(4), 391-405. doi:10.1016/0005-7967(94)00057-Q
Florence, C., Zhou, C., Lou, F., & Xu, L. (2013). The economic burden of prescription opioid overdose, abuse, and dependence in the United States. Med Care, 54(10), 901-906. doi:10.1097/MLR.0000000000000625
Goleman, D., & Schwartz, G. (1876). Meditation as an intervention in stress activity. J Consult Clin Psychol, 44, 456-466. doi:10.1037/0022-006X.44.3.456
Hoffman, H. G., Doctor, J. N., Patterson, D. R., Carrougher, G. J., & Furness III, T. A. (2000, March 1). Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain, 85(1-2), 305-309. doi:10.1016/S0304-3959(99)00275-4
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psych, 4, 33-47. doi:10.1016/0163-8343(82)90026-3
la Cour, P., & Petersen, M. (2015, April 2). Effects of mindfulness meditation on chronic pain: a randomized control trial. Pain Medicine, 16(4), 641-652. doi:10.1111/pme.12605