This story is part of Pain in America, a nine-part series looking at some of the underlying causes of the opioid addiction crisis and how we treat pain.
When Shelley-Ann Anderson, 43, has an episode of acute pain from sickle cell disease, a constant stabbing-like sensation creeps along her spine and legs. That pain can spread to any part of her body, from her shoulders all the way to her fingertips and toes. It can come out of the blue and persist for weeks. It leaves her exhausted, but she can’t sit still.
Sometimes she can manage the pain with relaxation techniques, massage, over-the-counter anti-inflammatories, heating pads and warm baths. “None of us want to go to the hospital,” she said. “We do what we can to not go there.”
But if these methods don’t help, patients like Anderson may end up visiting the emergency room for fluids and stronger medication, such as opioids.
Sickle cell patients who come to St. Jude Children’s Research Hospital in Memphis, Tennessee, have a new option for pain relief — virtual reality. The hospital, in conjunction with the Methodist Comprehensive Sickle Cell Center, is carrying out a clinical trial on 76 participants to study the effectiveness of VR as a pain management strategy for sickle cell patients ages 6 to 25. (The partnership allows researchers to look at a broader age range, as St. Jude treats pediatric patients through age 18 and Methodist treats adults of any age.)
“Pain is one of the most common causes of ER visits for sickle cell patients and it also debilitates them emotionally and functionally,” said Dr. Latika Puri, an assistant faculty member in the department of hematology at St. Jude Children’s Research Hospital. “So that’s been a big motive in thinking about medications other than opioids.”
‘Psychological Analgesia’
Half the patients in the St. Jude trial are receiving VR therapy along with the hospital’s standard pain management treatment, while the others get the standard pain management treatment.
Patients getting VR therapy are equipped with a headset that transports them to an underwater world, where they’re immersed among sea turtles, orca whales and other marine life while listening to a relaxing soundtrack. The headsets were made by KindVR, a company that develops custom VR therapies designed to lower patient pain and stress in medical settings.
The VR experience itself lasts 15 minutes, and patients’ pain scores are measured 30 and 60 minutes after the experience begins. Patients who are 7 and younger report their pain using the FACES scale, a set of illustrations showing various facial expressions to represent pain level. Patients older than 7 rank their pain on a scale of 0-10.
Puri said the researchers running the three-year trial, which began in February 2018, can see that VR has helped patients in a number of ways.
One benefit is a decrease in pain-related anxiety. Some patients worry about how long their pain may last or if it will keep them away from school. Immersing themselves in a virtual environment can briefly shut out those concerns. Virtual reality, Puri said, “gives them a pause, a minute to just sort of reset their minds and calm them down to deal with their pain a little better.”
Distraction is another way VR is helping patients. When someone is in pain, Puri explained, the brain focuses on perceiving that pain. VR can redirect a person’s attention elsewhere. “The pain energy is actually being distributed and being shifted away from the perception of pain,” she said.
Anderson ― who has not participated in the trial ― said she can see how this could be effective, noting that she and others with sickle cell disease often use their phones or television as a distraction. “It’s because we’re trying to be taken away from the pain that we’re experiencing,” she said.
An influential idea about pain, gate-control theory, suggests that thoughts and emotions play a role in how we interpret pain and that our perception of pain can be changed or inhibited when the brain’s attention is diverted elsewhere.
“In the right mental state of mind, if you feel calm and relaxed and happy, we don’t really have time for pain and don’t need the pain,” said Dr. Brennan Spiegel, the director of health services research at Los Angeles-based Cedars-Sinai Health System, which has been home to extensive research on and use of medical VR.
VR can also alter someone’s perception of time, which can make an uncomfortable medical procedure feel shorter, for example.
“When the prefrontal cortex is occupied by VR, it does weird things to time,” Spiegel said.
Earlier studies have also found that VR can be an effective method of pain management. In one study from the University of Michigan, women who used VR during the first stage of labor experienced significantly lower pain and anxiety scores. A few studies among burn victims show that VR during physical therapy can reduce pain scores and the amount of time spent thinking about pain. A recent study at Cedars-Sinai found that patients hospitalized for gastrointestinal, psychiatric, orthopedic and other conditions who used VR reported less pain than a control group.
Patient satisfaction surveys at St. Jude have been positive, and some people with sickle cell disease have even requested VR for pain management at home, Puri told HuffPost. That’s not an option while the trial is ongoing, as they can only participate in the VR experience in the hospital one time, but the hope is that VR may become more widely available and expand to other settings, such as MRI scans and chemotherapy sessions.
“I think it has great potential as a powerful non-pharmacological adjunct to medical therapy,” Puri said. “Some studies actually describe it as ‘psychological analgesia,’ which I think it is.”
An Alternative To Opioids
A secondary objective of the St. Jude study is to determine if opioid consumption decreases among the patients who receive VR therapy. Puri believes that VR, when combined with other pain therapies, has the potential to reduce opioid use, but said further research is needed.
Researchers at Cedars-Sinai are carrying out a 16-month study on whether VR therapy affects opioid use among employees receiving workers’ compensation. Travelers Insurance, the largest provider of workers’ compensation insurance in the U.S., is one of the study’s funders, along with Samsung Electronics.
Travelers is interested, of course, because it wants fewer of its beneficiaries to end up relying on opioids after a work injury. “They’re looking for non-opioid approaches to bend the prescribing curve a little bit,” Spiegel said.
The Food and Drug Administration is interested in therapeutic VR, too, and is hosting a public workshop on it next month. The agency has also given the evolving therapy a formal name: medical extended reality, or MXR.
“The fact that the FDA is paying attention and has named this field is pretty important,” Spiegel said, adding that he recently spoke with the American Medical Association to talk about getting VR for pain management included in the codes used to bill insurance companies.
For now, clinicians can sometimes bill for VR under existing codes for exposure therapy or cognitive behavioral therapy.
“Today we’re talking about it for pain management, but that applies to every single specialty of medicine,” Spiegel said.