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The opioid crisis: Psychiatrists are well equipped to intervene


 

The U.S. opioid crisis and ongoing epidemic of chronic pain are inextricably intertwined, and psychiatrists are increasingly being called upon to intervene.

In a June 2016 blog post penned in the wake of new Centers for Disease Control and Prevention prescribing guidelines calling for a move away from opioids as the first-line treatment for many types of chronic noncancer pain, National Institute on Drug Abuse (NIDA) Director Nora D. Volkow, MD, decried the absence of psychiatrists on the front lines.

“Thus far, psychiatrists have not taken an active role in addressing the problem of chronic pain, but they have an important role to play here, for multiple reasons,” she wrote.

Chronic pain is closely linked to multiple psychiatric problems, she explained.

Dr. Nora D. Volkow, director, National Institute on Drug Abuse

Dr. Nora D. Volkow

“For example, with chronic pain comes a high risk for suicide and depression. Pain also impacts sleep, which independently can be a factor in mental (as well as physical) health. And these psychiatric conditions bear on the effectiveness of adjunctive pain therapies such as exercise and medication, which may be difficult to implement when a person is also suffering from depression,” she said.

Furthermore, extensive evidence supports the use of some nonpharmacologic psychiatric therapies, she noted.

Indeed, there are numerous approaches, which have been shown to be effective or are showing promise in trials, that psychiatrists can take to intervene in the crisis and to help individual patients control pain and reduce the need for opioid medication. One that is underused and undervalued despite decades of research demonstrating its effectiveness, and which, according to David Spiegel, MD, has the potential to help at least two-thirds of affected adults, is hypnosis.

Power of hypnosis

“The brain has a whole lot to do with pain perception, and there’s a lot you can do to control it,” said Dr. Spiegel, the Jack, Samuel, and Lulu Willson Professor in Medicine in the department of psychiatry and behavioral sciences at Stanford (Calif.) University and a member of the Institute of Medicine.

And despite what many patients and physicians believe, it’s simply not true that if you’re not using a drug, you can’t actually control pain, he added.

Dr. David Spiegel, the Jack, Samuel, and Lulu Willson Professor in Medicine in the department of psychiatry and behavioral sciences at Stanford (Calif.) University and a member of the Institute of Medicine.

Dr. David Spiegel

In fact, techniques such as hypnosis are “powerfully effective for pain control,” he said, noting that he has conducted randomized controlled trials in both acute procedural pain and chronic cancer pain that showed substantial reductions in pain among those who were taught to use self-hypnosis.

For example, in a prospective randomized study of 241 patients undergoing percutaneous vascular and renal procedures, he and his colleagues found that self-hypnotic relaxation was superior to both intraoperative standard of care and structured attention (i.e., the “friendly nurse” group) for reducing pain and anxiety, and was better than standard of care for reducing drug use and reducing procedure time. It also improved hemodynamic stability compared with the other approaches (Lancet. 2000 Apr 29;355[9214]:1486-90).

“It works,” said Dr. Spiegel, also associate chair of the psychiatry department at Stanford.

Hypnotizability can be assessed using various validated scales; he said he can determine hypnotizability within 5 minutes, in part by giving a suggestion that the patient’s arm is getting lighter and is beginning to float. A component of involuntariness – if the patient’s arm feels like it is floating effortlessly and actually moves up in the air – indicates hypnotizability.

Most children, and about two of every three adults, can be hypnotized, he said.

Self-hypnosis, particularly in the chronic pain setting, can be life-changing, as patients can use it whenever needed once they learn how, he said, describing one young patient who had been suffering from intractable migraines and associated vomiting for years, and had failed to respond to numerous medications. Within minutes of being taught self-hypnosis, she said her pain had decreased from 7 to 3 on a 0-10 scale, and after coming out of the hypnotic state, she described feeling as rested as if she’d been sleeping for a decade.

Her mother broke down in tears of relief, Dr. Spiegel said.

Another patient who had suffered from immobilizing back pain had a similar experience: His back pain was immediately reduced by about 60% .

“Does it always work? No, but no treatment always works, and at worst it’s harmless,” Dr. Spiegel said, adding: “I don’t get people addicted to hypnosis. It just doesn’t happen.”

So why is hypnosis still considered outside the mainstream? In part that’s the case because of its “purple cape, dangling watch” image, but there also is a conception that hypnosis takes away control. In reality, it enhances control, he said.

“I think every psychiatrist – every physician – should know hypnosis,” he said.

Many, but not all medical schools teach hypnosis, and at least two U.S. societies – the American Society of Clinical Hypnosis and the Society for Clinical and Experimental Hypnosis – conduct workshops and annual scientific meetings where those interested can learn, he noted.

“It’s not that hard to learn ... and it’s a very useful skill for a professional,” he said.

Other approaches to pain management

For the one in three adults who are not hypnotizable, Dr. Spiegel teaches distraction techniques, and sometimes recommends acupuncture, which can be helpful for some patients. Exercise and physical therapy also can be of benefit for chronic pain.

“You can have very real pain that you can learn to deal with as people did throughout history. That doesn’t mean you should suffer unnecessarily; there is a time and place for opiates and other [pharmacologic] strategies, but they should be one among an array of choices,” he said, adding that for chronic pain, opioids can be more of a problem than a solution, and learning these techniques “can really help people safely deal with pain.”

Jeffrey Borckardt, PhD, professor and director of the division of biobehavioral medicine at the Medical University of South Carolina (MUSC), Charleston, agreed that hypnosis is a well-researched and effective treatment for pain, despite being better known for weight loss and smoking cessation. Another, lesser-known treatment that has been shown to have some effect for pain is acceptance and commitment therapy, or ACT, which incorporates the practice of mindfulness.

Dr. Jeffrey Borckardt, professor and director of the division of biobehavioral medicine at the Medical University of South Carolina, Charleston.

Dr. Jeffrey Borckardt

A 2014 study (J Pain. 2014 Jan;15[1]:101-13) demonstrated a beneficial effect of ACT in nearly 50% of patients studied, and in a 2017 study (J Pain. 2017 Jun;18[6]:664-72), ACT was associated with improved function in chronic pain patients.

However, there is another well-researched – and well-known – nonpharmacologic approach to the treatment of pain: cognitive-behavioral therapy, or CBT. CBT isn’t as new and exciting as some experimental approaches that Dr. Borckardt is working with and studying, such as transcranial magnetic stimulation and transcranial direct current stimulation. But CBT is readily available and typically covered by insurance (unlike those experimental therapies), and has been shown in numerous studies to be highly effective, he said.

CBT and ‘360’ programs

CBT also was mentioned by Dr. Volkow in her June 2016 blog post. She called it “one of the most effective pain treatments,” and said that “assisting patients in learning to change their pain-related thoughts, emotions, and behaviors is going to help with their condition, regardless of other pharmacological interventions.”

Dr. Borckardt said it is particularly effective in the context of programs that provide what he called “a 360 approach.” These multifaceted treatment programs aim to help chronic pain patients taper off of opioid medications and to find other approaches to managing pain.

Only a handful of such comprehensive, intensive outpatient programs exist across the United States, but the concept is taking hold, driven in part by the opioid crisis, and more centers are opening. In fact, Dr. Borckardt is helping to develop such a program at MUSC. The program will likely be housed in the MUSC Wellness Center, and much like the Mayo Clinic’s Pain Rehabilitation Center, which opened in 1974 and was one of the first such programs in the world, the MUSC program will involve an integrated team of health care professionals that provide CBT for pain, physical therapy, occupational therapy, and other programs designed to help patients living with pain.

This is widely accepted as being the best approach for pain rehabilitation, Dr. Borckardt said.

TMS and TDCS

Dr. Borckardt also has worked with some more cutting-edge approaches to pain management. Transcranial magnetic stimulation (TMS), which is approved for the treatment of depression, also has shown promise for treating pain. TMS can target areas in the brain involved with specific functioning, such as emotional regulation. The high-frequency stimulation is believed to enhance that particular area and produce a clinical effect.

“Pain is a subjective, largely psychological experience, and it involves an emotional component,” he said, explaining that the rationale for the use of TMS for pain is that the emotional component of the pain experience can be targeted along with the sensory and cognitive aspects of the pain experience.

TMS is being used in various studies, and has been used off label for pain management, but the out-of-pocket cost is high because it is not currently approved for pain and is therefore not covered by insurance, he said.

For depression, TMS typically is used 5 days per week for 3 weeks – at a cost ranging anywhere from $100 to $500 per session. It remains unclear how many sessions would be required for pain treatment to produce a sustained effect, but it would likely be similar to the requirements for depression treatment, and may also require follow-up treatments, Dr. Borckardt said.

“We do know with reasonable confidence that it impacts pain perception and can impact sensory or emotional components of pain, depending on the part of the brain treated. But we don’t know how long we have to treat, how often, or how durable the effects are,” he said, noting that several groups are studying TMS for pain.

Notably, there is also some very preliminary evidence that TMS may be useful for treating addiction by affecting cravings for substances such as opiates, nicotine, and alcohol. If that effect is confirmed, TMS could help chronic pain patients reduce their need for higher opioid doses, thereby lowering the risk of overdose, which is an important factor in the opioid crisis; most patients who use opioids don’t become addicted, but they can be at risk for overdose because of the need for high doses to control their pain, he explained.

In one study, the use of TMS postoperatively reduced the amount of in-hospital drug use by 40%, he said, noting that the reduction could convert to a reduction in the use of pain medication after discharge as well.

A related treatment, transcranial direct current stimulation, or tDCS, involves placement of electrodes directly on the scalp to run weak electrical currents through the brain, again trying to alter areas associated with pain perception. Ongoing studies are looking at combining tDCS and CBT with the hope that the two will have synergistic effects, including one in veterans with low back pain and opioid misuse. Another small pilot study in patients with fibromyalgia recently concluded and had some promising results.

These and other nonpharmacologic approaches to pain management could play an important role in the effort to reduce opioid prescribing. Currently, about 90 Americans die each day after overdosing on opioids, according to NIDA, and the CDC estimates that prescription opioid misuse alone in the United States costs $78.5 billion per year in health care, lost productivity, addiction treatment, and criminal justice involvement.

In her plea to psychiatrists to take action to intervene, Dr. Volkow underscored the value that they bring to the table.

“It is crucial that we not lose sight of the reality and complexity of chronic pain as management of chronic noncancer pain moves toward greater caution around opioid medication. This should not be solely an issue for primary care medicine or neurology, but also for specialties such as psychiatry that have much to offer people who are suffering from complex disorders in which physical symptoms merge with psychological distress,” she wrote.

Dr. Volkow has written hundreds of peer-reviewed articles, including analyses of the opioid crisis (N Engl J Med. 2017 Jul 27;377[4]:391-4) and (Neuron. 2016 Oct 19[2]:294-7). Dr. Spiegel is coauthor of Trance and Treatment: Clinical Uses of Hypnosis (Washington: American Psychiatric Association Publishing, 2004), a textbook written to help psychiatrists and other physicians learn to use hypnosis. Dr. Borckardt receives research funding from the National Institutes of Health.

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