Pain Management: Beyond Pharmacology to Acupuncture and Hypnosis
from – the journal of the american medical asociation – http://jama.ama-assn.org
by – Jane E. Loitman MD
Pain and its complications are common problems for physicians, clinicians, and patients. Of the 17 million new cases of cancer reported worldwide each year, 56% of patients indicated having moderate to severe pain 50% of the time, 81% had greater than 2 complaints of pain, and 34% had greater than 3 complaints of pain.1 Many patients, hopeful of a cure or palliation of their pain, turn to alternative practitioners.2 From 30% to 70% of patients use alternative or complementary therapies, and while 57% of physicians report a willingness to refer patients for complementary therapies, only 28% of physicians had actually done so.3-6
In its definition of pain, the International Association for the Study of Pain includes actual or potential tissue damage as well as the emotional experience of pain. Understanding the multifaceted experience of pain becomes important in treatment. To mitigate their suffering, patients may turn to complementary and alternative therapies to reduce feelings of stress, anxiety, nervousness, agitation, despondency, lack of motivation, lack of enjoyment, and lethargy.
During medical education, physicians generally are taught that the tools of their trade include pharmacotherapy, surgery, psychotherapy, and physical therapy. Yet other modalities exist for alleviating pain, and physicians can better participate in pain management by learning about the efficacy of complementary therapies and when and where to apply them (Table 1).
The Allopathic Physician’s Approach
In the standard approach to disease the physician must understand the neurophysiology and neuroanatomy of pain. A vocabulary of descriptors must be part of the physician’s armamentarium. A working knowledge of the syndromes associated with various presentations of pain is essential when the physician is obtaining the patient’s history, collecting data, and performing the physical examination. Additional factors help determine what, if any, complementary treatments might help the patient in a given setting when synthesizing an assessment. Those with acute pain need disease treatment and enough symptom relief to tolerate the workup and therapy. Those with malignant or chronic nonmalignant pain need symptom relief that allows optimal physical and mental function and, if death is unavoidable, allows the patient to die relatively free of pain.
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Acupuncture, which originated in China during the Xia dynasty (2140-1711 BC), is based on the concept that the continuous flow of chi, “life energy,” is vital to one’s health. Acupuncture treatments aim to improve health by inserting hair-thin needles into specific points on the body that are thought to enhance the flow of chi.
In the United States acupuncture gained public attention in 1971, when a well-known columnist, James Reston, underwent an emergency appendectomy in Beijing and described acupuncture’s effectiveness in alleviating severe pain.7 In 1986, the NIH Consensus Development Conference on the Integrated Approach to the Management of Pain identified acupuncture as an effective tool for many types of pain and other symptoms.8 These days, Americans make up to 12 million visits to acupuncturists per year.9 Allopathic physicians perform or refer to acupuncture primarily in cases of pain and substance abuse, and most research on acupuncture has focused on these treatments.
Stimulating particular points using needles, pressure, heat, or electric waves causes the measurable release of endorphins into the blood.10 The activation of small myelinated nerve fibers sends impulses into the spinal cord, midbrain, pituitary, and hypothalamus. Various endorphins block incoming pain information through the release of serotonin, norepinephrine, and possibly GABA.10 Studies11–12 demonstrate that acupuncture is especially, though not exclusively, effective with myofascial pain and trigger points.
During acupuncture, patients should not feel pain from the therapy itself. The frequency of treatment will vary according to the particular condition. Treatments last from 5 to 30 minutes, and from 1 to 20 needles may be used. Although some patients experience immediate pain improvement, others require at least 3 treatments. Risks associated with this treatment include fainting, bruising, pain, infection, or injury to underlying tissue, but these reactions are rare. Acupuncture is contraindicated in the treatment of malignancy, mechanical obstruction, fulminant infection, hemorrhagic diseases, or conditions that require surgical repair.
Hypnosis, a therapy used in pain management since the mid-1800s,13 is based on conscious relaxation in association with patient-designed suggestions and exercises. Hypnosis assists patients in obtaining deep levels of relaxation, which often leads to more peaceful sleep, increased energy, and a diminished experience of pain.
In the initial consultation, the patient discusses specific problems and begins to develop trust and a rapport with the hypnotherapist. The prerequisites for treatment are the capacity for a degree of concentration, imagination, and a willingness to participate fully. The patient remains in control of the process throughout the session, which reduces any risk for adverse reactions.
The hypnosis session can be directed toward the patient’s emotional and physical stress either separately or simultaneously. Through deep breathing techniques, the patient is guided physically and cognitively into the relaxation of each part of the body. In a deeply relaxed state the subconscious mind is open to receiving the beneficial suggestions constructed by the patient and therapist beforehand. The hypnotherapist suggests changes in the behaviors, thoughts, and feelings of the patient. The patient, in hypnosis, will accept only those suggestions that are relevant to his or her needs. By maintaining awareness throughout the session, the patient is later able to reinforce the hypnotic experience independently.
A conducive setting for hypnosis includes a quiet space, muted lights, a comfortable chair, and uninterrupted time. Although the absence of environmental distractions is preferable, hypnosis can provide positive results in almost any setting. A session usually lasts between 20 and 60 minutes. Patients have reported feelings of heightened emotional well-being, deep relaxation, and reduction of physical pain. A greater number of sessions generally leads to greater improvement.
Research has not yet been able to delineate the mechanism underlying hypnosis’ effect, but it appears to be more effective than placebo.14-15 Studies have shown that those with the greatest capacity to relax respond best.16
Acupuncture and hypnosis can benefit some patients with pain; patients with myofascial pain or headache respond well to acupuncture, and highly anxious patients who want to actively participate in and control their care respond well to hypnosis. The clinician should realize that while not every therapeutic modality will work on everyone, there are options, including pharmacotherapy, physical therapy, and complementary therapies. Given the multitude of complementary therapies available and the incomplete understanding of their mechanisms and efficacy, clinicians unfamiliar with them might want to familiarize themselves with the services available in their communities. If the physician considers acupuncture, hypnotherapy, and other complementary therapies as adjuvants to nonsteroidal anti-inflammatory drugs and opioids for the treatment of pain, he or she may find patients more grateful and the practice of medicine more interesting.