Running header: OPIOIDS VERUS HYPNOSIS

Opioids versus Hypnosis for Pain Control in Advanced Disease Cheryl A. Shapiro Ferris State University

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE Abstract Opioids have been used for pain for years. However, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependence, or abuse. The review summarizes existing evidence regarding the efficacy, safety, and abuse of opioids as treatment for chronic non-cancer pain. Even though evidence is limited, multiple sources have concluded that chronic opioid therapy can be effective for carefully selected and monitored patients with chronic non-cancer pain. This paper also reviews trials of hypnosis for the treatment of chronic pain. The findings indicate that hypnosis interventions consistently produce significant decreases in pain.

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE Opioids Versus Hypnosis for Pain Control in Advanced Disease Advanced disease usually comes with a great deal of pain. Even if the diagnosis is terminal, patients should have a quality of life with a bearable amount of pain without side effects that are counterproductive. Opioid therapy is the standard for relieving pain, but how well does it work when the pain continues for months and years? If opioids are not the full answer then what might help? Therefore the question of hypnosis is a great one because the power of the mind is an amazing thing. As nurses we answer questions, educate, and spend time with these people who are looking for help and suggestions. It is not uncommon for a patient to say, “no one ever told me that.” We need to be there with real solutions for people in chronic pain. Pain Pain is something everyone is familiar with. We know that it is a warning system to let us know soemthing is wrong and we should do somthing about it. The simpleist example is removing one’s hand from a hot source. When nerve endings sense damage, pain is transmitted through the body by the nervous system to the brain. When these pathways are damaged, this is also interpreted as pain (Association of Cancer Online Resources, 2002). The common definition in modern medicine is that pain is whatever the person says it is.. But what about chronic pain that is part of an advanced and potentially incurable disease? Chronic pain does not look like acute pain. One suffering from chronic pain is acustome to it and may not show any observable signs like guarding, sweating or elavated blood pressure (Finn, R. 2005). Chronic pain is unnecessary, it can delay healing; lengthen hospitalization and decreases participation in rehabilitation and general activity (Valente, S. 2006). A Descriptive Summary of Opioid Use for Pain Control Opioid Basics

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE An opioid is a chemical that works by binding to opioid receptors, which are found mainly in the central nervous system and the gastrointestinal tract. The analgesic effects of opioids are due to decreased perception of pain, decreased reaction to pain as well as increased pain tolerance. The main side effects are euphoria, respiratory depression, constipation, and sedation. Opioid toxicity may show up with nightmares or myoclonus (Hewitt, Jordan, 2004) Physical dependence is likely with prolonged use (Grover, C. 2007). However, somatic and visceral pain responds well to opioids (Wachter, K. 2004). The World Health Organization (WHO) recommends starting with NSAIDS before moving up their scale to opioids, and then starting with the milder ones such as hydrocodone. In addition, suppressing pain around the clock is imperative. They estimate that this plan of administering the right drug in the right dose is 80%-90% effective (World Health Organization, 1996). The types of common, natural opioids are morphine and codeine. There are also semisynthetic opioids created from the natural opioids, such as hydromorphone, hydrocodone, oxycodone, and oxymorphone. Finally there are fully synthetic opioids: such as fentanyl, methadone, and tramadol (Grover, C. 2007). Opioids come in different forms such as oral, intravenous, intramuscular, sublingual, intradermal patches and rectal suppositories. The choice of route to use depends on the individual’s needs, and the type of opioid. Evidence With all the information we have about opioids, there is very little literature about its effectiveness in treating non-cancerous chronic pain. Long term use is well known for abuse and side effects. This is in the midst of huge increases of sales. In the ten years from 1997-2007, hydrocodone rose by 280%, methodone by 1,293% and oxycodone by 866% (Manchikanti, L.

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE 2011). At the same time we have an outcry of undertreated pain. There are not many who would argue against the fact that opioid use poses a danger with increased emergency visits and death. Opioid deaths are now larger than motor vehicle accidents (Manchikanti, L. 2011). Proven scientific evidence for the effectiveness and safety of opioids in chronic pain has not been established. The basis of opioid use is their unique analgesic efficacy. In recent years, multiple reviews have been published to evaluate the effectiveness of opioid therapy for chronic pain. However, very few of them evaluated long-term opioid therapy. A comparative efficacy and safety review of long-acting oral opioids for chronic noncancer pain which included literature published through October 2002 was completed. They concluded that there was insufficient evidence to prove that different long-acting opioids are safe or effective (Chou, R. 2003). An article in the Journal Pain Symptom Management (2008) reviewed 26 studies with 27 treatment groups that had 4,893 participants. They concluded that many patients discontinue long-term opioid therapy, especially oral opioids, due to side effects or insufficient pain relief (Noble, et al. 2008). However, they also concluded that weak evidence implies that patients who maintain opioid use long-term experience clinically significant pain relief (Noble, et al. 2008). A review by Andrea Trescot MD (2008) looked at available evidence for long-term opioid therapy in treating chronic non-cancer pain. They concluded that there is weak evidence for morphine and transdermal fentanyl and limited evidence for all other opioids including oxycodone and hydrocodone (Trescot, A. 2008). A systematic review of randomized trials of opioid management for chronic non-cancer pain with at least 12 weeks of follow-up was completed. Based on the review of only 20 participants, they concluded that the indicated level of evidence was only fair for tramadol in

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE managing osteoarthritis (Manchikanti, L. 2011). However, for all opioids for all other conditions, the evidence was poor based on either weak positive, indeterminate, or negative evidence (Manchikanti, L. 2011). A Descriptive Summary of Hypnosis for Pain Control It is no secret that pain is not usually controlled with opioids. However, pharmacological management is not the only way to manage pain. Indeed, pain is a multifaceted experience that is made up of physical and psychological factors and therefore can be improved with complementary treatments. A type of complementary therapy for pain is hypnosis. It is a trance state where one is open to suggestions and relaxation. The person can be relatively unaware of, but not completely blind to, his or her surroundings (Valente, S. 2006). Hypnosis can enhance self care because it gives then some control of self care. Indeed it is said that all hypnosis is really self-hypnosis because it requires the co-operation of the person being hypnotized. The only requirement seems to be that the person must be able to concentrate. It typically starts with relaxation and then refocusing (Valente, S. 2006). Evidence with Burn Pain Although this is a study involving acute pain, it is included as study evidence for hypnosis in general. In Switzerland a study was completed comparing pain in burn victims using hypnosis compared with historical pain relieving methods. The statistics showed significant improvement in pain control and a decrease in narcotic use. Over a course of time, 23 patients were treated in the ICU with hypnosis and narcotics. 23 others were in a matched control group that was treated with standard treatment. Different opioids were converted into morphine equivalents using a computerized conversion comparison. Pain was rated using the Visual Analog Scale (VAS) which uses a 10-cm device to assess the level of pain which presents as

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OPIOIDS VERUS HYPNOSIS FOR PAIN CONTROL IN ADVANCED DISEASE ruler from 0-10. This had already been shown to be a useful instrument measuring in pain in burn patients. In addition vital signs were taken before and after painful procedures (Berger, M. 2009). Hypnosis was proposed to patients as soon as possible. A learning time was given until patients could achieve a trance level. This was done under a nurse with three years of training with a psychiatrist. Hypnosis was started on a median of 9 days after injury. Intensity and noxious stimuli are reduced by suggestion during the hypnotic state (Berger, et al. 2009). The mean VAS daily score was significantly reduced in the intervention group from 1.4 to 0.9 points (p < 0.0001). Individual items changed as well. Anxiety was significantly reduced from 3.2 to 1.2 points (p < 0.0001), depression feeling was reduced from 1.8 to 1.0 points (p = 0.014), well-being (best = 0) was improved from 3.7 to 1.2 points (p < 0.0001) (Berger, et al. 2009). Evidence with Cancer Pain Fifty-four women with breast cancer were randomly assigned to standard care, group therapy or group therapy with hypnosis training. Both groups reported less pain then those in the control group. In addition, those receiving hypnosis reported significantly (p