PAIN MANAGEMENT & VIRTUAL REALITY Naileshni Singh, MD Director of Education Associate Professor University of California, Davis 11/4/17 DISCLOSURES No relevant financial disclosures Discussion of off label uses of devices (Virtual Reality) Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards. OBJECTIVES Learn about the association between mental health (MH) and chronic pain. Understand the unique role that opioids play in those with MH issues and pain. Learn about non-medication based treatments such as interventional therapies. Discuss applications of virtual reality in MH treatment and pain management. 1
MENTAL HEALTH AND PAIN Depression (60.8% and 33.8% for severe depression, Rayner 2016) Anxiety (35%, McWilliams 2003) Substance use/substance use disorder Opioid use disorder (61.8% had pain prior to OUD, Hser 2017) Alcohol use (13%, Saunders 2012) Sedative/hypnotic use (39%, Saunders 2012 ) Personality disorder (51-59%, Fishbain 1986 and Polatin 1993) PTSD (10-50%, Sharp and Harvey 2001 and Brennstuhl 2015) Somatic symptom disorder (Katz 2015) Panic disorders (7.3-36.5%, Castro 2009) Chronic Pain and Depression: Sorting Out Types of Mood Disorders Michael R. Clark Practical Pain Management and McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106(1-2):127-133. RISK FACTORS FOR CHRONIC PAIN Mental health diagnosis High levels of self-reported pain Certain surgeries Sleep Disorder Poor coping skills Pain catastrophizing, pain related anxiety and fear of pain, helplessness (Keefe 2004) Hx. of trauma or childhood abuse experiences (Leisner 2014 and Brennstuhl 2015) 2
SUICIDE AND CHRONIC PAIN Risk is at least doubled in those with chronic pain and mental health disorders Prevalence of suicide attempts between 5-14% Prevalence of suicidal ideation 20% Risk factors: Type, intensity, duration of pain Insomnia Helplessness, hopelessness Desire to escape from pain Pain catastrophizing and avoidance Lack of pain coping skills Psychol Med. 2006 May;36(5):575-86. Epub 2006 Jan 18.Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Tang NK, Crane C. OBJECTIVES Learn about the association between mental health (MH) and chronic pain. Understand the unique role that opioids play in those with MH issues and pain. Learn about non-medication based treatments such as interventional therapies. Discuss applications of virtual reality in MH treatment and pain management. MENTAL HEALTH, PAIN AND OPIOIDS 2015: 91.8 million US adults (37.8%) on opioid medications (US population in 2015= 321 million) 12.5% misuse opioids while 16.7% reported a prescription opioid use disorder Ann Intern Med. 2017 Sep 5;167(5):293-301. Epub 2017 Aug 1.Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. 3
RISK FACTORS Misuse and abuse more common in: Uninsured Unemployed Low income Poor health More ER utilization Major depression Suicidal ideation Anxiety (50% screen + for opioid misuse) Adult Users of Nonmedical Prescription Opioids Are More Likely Than Nonusers To Consider Suicide Both persistent and former users reported suicidal ideation at significantly higher rates than individuals who had never used a nonprescribed opioid medication. National Institute on Drug Abuse, Thoughts of Suicide May Persist Among Nonmedical Prescription Opiate Users, March 4 th, 2013. OVERDOSE AND PAIN Retrospective cohort review of those with mental health diagnosis and non-cancer opioid use (2009-2012) Overdose rate of 0.67% Higher for those with depression/benzo use, >100 mg oral morphine equivalents 20% less risk of overdose for patients on long term antidepressants J Gen Intern Med. 2015 Aug;30(8):1081-96. Epub 2015 Feb 4.Drug Overdose in a Retrospective Cohort with Non-Cancer Pain Treated with Opioids, Antidepressants, and/or Sedative-Hypnotics: Interactions with Mental Health Disorders. Turner BJ, Liang Y. 4
WHY? WHY? Hypogonadism predisposes to depression (Wainwright, 2011). Long term and high opioid opioids hypogonadism depression and other mood changes. Treatment options: Discontinue or decrease opioids Supplement testosterone Opioid induced hyperalgesia OBJECTIVES Learn about the association between mental health (MH) and chronic pain. Understand the unique role that opioids play in those with MH issues and pain. Learn about non-medication based treatments such as interventional therapies. Discuss applications of virtual reality in MH treatment and pain management. 5
PSYCHOLOGICAL THERAPIES FOR PAIN CBT- first line for back pain, headache, arthritis and fibromyalgia Biofeedback- chronic MSK pain, arthritis, and headache Effective as some medications More effective when combined with medications PSYCHOLOGICAL THERAPIES FOR PAIN Mindfulness- greater acceptance of pain, improved QOL/less disability, pain catastrophizing, disability, fatigue, anxiety, feeling in control, self-efficacy Effective for headaches MBSR Mindfulness based CBT Brief mindfulness PSYCHOLOGICAL THERAPIES FOR PAIN Factors associated with success Self efficacy Pain coping strategies Readiness to change Acceptance Early intervention Telephone and internet based Caregiver assisted Exposure based protocol J Pain. 2004 May;5(4):195-211.Psychological aspects of persistent pain: current state of the science. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. 6
Neuraxial injections Sympathetic blocks Joint injections Lidocaine or Ketamine IV Capsaicin patch Implanted therapies Virtual reality INTERVENTIONAL THERAPIES FOR PAIN Anxiety or anxious symptoms Depression Mania Homicidal ideation Treatment: Family/psychological support Anti-psychotic/mood stabilizer STEROIDS FOR PAIN OBJECTIVES Learn about the association between mental health (MH) and chronic pain. Understand the unique role that opioids play in those with MH issues and pain. Learn about non-medication based treatments such as interventional therapies. Discuss applications of virtual reality in MH treatment and pain management. 7
VIRTUAL REALITY FOR PAIN Definition (dictionary): the computer-generated simulation of a three-dimensional image or environment that can be interacted with in a seemingly real or physical way by a person using special electronic equipment Full immersion- all the senses Augmented reality- most of the senses Interact with virtual objects-video game aspect Head and gaze tracking system Block users view of outside world Formatted to limit motion sickness Varied offerings Relatively inexpensive Modified headsets-mri, water resistant Promotes self efficacy VIRTUAL REALITY SnowWorld 8
MECHANISMS Decreases activity in the anterior cingulate cortex, insula, thalamus, and primary and secondary somatosensory cortex (SS1 and SS2). CNS Spectr. 2006 Jan;11(1):45-51.Using FMRI to study the neural correlates of virtual reality analgesia. Hoffman HG1, Richards TL, Bills AR, Van Oostrom T, Magula J, Seibel EJ, Sharar SR. MECHANISMS Gate Control Theory Attention Theory-limited capacity for attention Multiple Resources Theory-sensory systems function independently Intercortical modulation- between signaling pathways of pain matrix through all senses and attention, emotion, memory Why is VR more effective than video gaming, TV distraction, audio only distraction? Procedure related pain/distraction Adjunct to psychological therapy Education USES FOR VIRTUAL REALITY 9
PROCEDURE RELATED PAIN Burn units for wound changes 35-50% reduction in pain in adult burn patients (Hoffman 2011) Opioids + VR improved pain more than opioids alone (Hoffman 2007) in healthy volunteers exposed to experimental thermal pain PROCEDURE RELATED PAIN 54 pediatric burn patients reported 27-44% decrease in pain during physical therapy sessions with an increase in fun. Pharmacological therapy, No VR Burns. 2011 Feb;37(1):61-8. Epub 2010 Aug 7. A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns. Schmitt YS, Hoffman HG, Blough DK, Patterson DR, Jensen MP, Soltani M, Carrougher GJ, Nakamura D, Sharar SR. Pharmacological therapy + VR VR FOR TRIGGER POINT INJECTIONS OUTCOMES- pain relief, impression of change, anxiety Surprisingly pleasant Not much anxiety and stress Now I need to take a vacation Can I keep this on 10
VR FOR CHRONIC PAIN VR for chronic pain patients N= 30 patients 100% reported pain reduction 33% decrease in pain post-session 66% decrease in pain intra-session PLoS One. 2016 Dec 20;11(12):e0167523. ecollection 2016.The Impact of Virtual Reality on Chronic Pain. Jones T, Moore T2, Choo J. Phobia treatments Social phobia Arachnophobia Agoraphobia PTSD Aviophobia Public Speaking Meditation VR FOR PSYCHOLOGICAL TREATMENTS J Behav Ther Exp Psychiatry. 2008 Sep;39(3):250-61. Epub 2007 Jul 25.Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis. Parsons TD, Rizzo AA. COMPLICATIONS & ISSUES Side effects are low Headaches Nausea Dizziness Motion sickness Adjuvants to medications Re-experiencing of trauma? Too advanced for older generations? 11
CONCLUSIONS Mental health disorders are associated with pain, opioid use, misuse, and abuse. Treating mental heath disorders may need multimodal approach. Virtual reality is an effective and emerging tool for treating mental health disorders, acute pain, and chronic pain. THANK YOU! Questions? 12