Alternatives to Opioids for Chronic Pain
The United States is currently wading through an opioid epidemic. The CDC reports that 75% of drug overdoses involve opioids, and the number of deaths has increased over 6 times between 1999 and 2021 (CDC, 2023). The overdose rate increased by 30% during COVID-19, from 2019 to 2020 (mostly fentanyl), and those who have substance abuse disorders had a higher risk for poor COVID-19 outcomes (NIDA, 2023). Chronic pain is reported to have a yearly economic cost of over 600 billion dollars in the United States and affects more than 100 million Americans. Opioids are a poor choice for chronic pain. As nurses, we see the outcomes of substance misuse, but we also see a need to offer other evidence-based ways to help manage pain for our patients. Numerous other effective, evidence-based modalities can give patients tools to better manage their pain and have an increased quality of life. In the dynamic realm of healthcare, nurses continually seek innovative approaches to ease the suffering of their patients. The patient needs an array of options, and a combination of any of the options may work best.
Types of Pain
Pain is classified as acute pain (sudden onset and lasts for a limited amount of time) or chronic pain (long-lasting and often resistant to medical treatment). There are more classifications, such as neuropathic pain, nociceptive pain, and radicular pain, and these are also often chronic. These subtypes are often chronic and may be intermittent or constant. Some examples of chronic pain are arthritis, fibromyalgia, or back injuries. In truth, pain is subjective. It is what the patient tells you it is. What helps one patient may not help another.
Guided Imagery
Guided imagery, also known as mental imagery in nursing care, is a therapeutic technique that involves using a nurse's guidance or recorded audio to help patients create and focus on mental images for specific therapeutic goals. It is a form of mind-body therapy that aims to harness the power of the mind to improve the patient's overall well-being and is used in mindfulness meditation to calm the mind. Nurses can help patients focus their attention on positive and calming mental images, diverting their minds away from pain sensations. This distraction can reduce the perception of pain and provide a sense of relief and comfort. The calmness empowers patients to play an active role in their pain management, fostering a sense of control and self-efficacy. The five types of guided imagery in nursing care not only complements traditional pain management methods but also supports holistic and patient-centered approaches to healthcare.
Sensory-focused imagery encourages patients to vividly imagine soothing sensations, such as warmth, coolness, or gentle touch. Nature imagery, including picturing serene landscapes or tranquil natural settings, can promote relaxation and distract patients from their pain. It has the power to transport patients to a calmer mental space. Healing imagery involves patients envisioning their bodies healing and regenerating. This idea can boost their confidence in the body's ability to recover and reduce anxiety related to pain. Positive affirmations, where patients repeat uplifting and empowering statements, can foster a more positive mindset and enhance their ability to cope with pain, ultimately reducing its impact. Patients can use symbolic images or metaphors to represent their pain and work through it mentally, transforming the pain into something more manageable or less intimidating.
Research shows that guided imagery induces a sense of empowerment and calmness, reduces anxiety and pain, boosts endorphin production, minimizes blood loss, and diminishes the need for pain medication among patients undergoing coronary artery bypass graft procedures. Other studies have shown a significant improvement of other postoperative pain management with the use of guided imagery.
To begin implementation, explain what will be happening and ask the patient to describe a place that brings them peace. Encourage your patients to find a quiet and comfortable space to relax. Then, instruct them to close their eyes (or look down) and take slow, deep breaths. Next, guide them to imagine their serene and soothing place, such as a beach, a forest, or a meadow. Use descriptions of the scene that include all five senses, asking them to imagine what they see (the blue sky), what they feel (the gentle wind on their face), what they smell (the richness of the forest smell) or hear (the birds calling and the leaves rustling). Add more detail. It helps to be there with them in your mind, imagining what you would see, hear, smell, taste, and feel. In this tranquil mental space, they can now visualize their pain as a physical object or sensation. Have them describe it… and then work on manipulating or diminishing it. This response might involve changing the color, shape, or size of the pain or simply letting it dissipate into the surroundings. Encourage them to use all their senses to immerse themselves in this experience. One example from a patient with RSD chronic pain visualized her pain as a pokey grey monster, but she found she could visualize petting it and calming it, so it was less frightening when she was done.
Researchers have studied image guidance in various types of settings, including postoperative, PACU, ICU, emergency room settings, and, most recently, pain management in COVID-19 patients. One study suggested guided imagery as an affordable, user-friendly, and straightforward complementary medical approach for addressing anxiety and pain in COVID-19 patients; thus, guided imagery may enhance relaxation and strengthen patients' immune responses in their battle against COVID-19 (Parizad et al., 2021).
Hypnosis
The integration of hypnotherapy into clinical settings promises a new dimension in pain management. While hypnosis was endorsed by the American Medical Association in 1958, it has fallen out of practice because of the creation of pharmaceuticals. There is a paradigm shift, and more physicians are referring chronic pain to treatment with guided imagery and hypnosis. There is a growing body of evidence supporting the effectiveness of hypnotherapy as a complementary tool in our caregiving arsenal (Tinelli et al., 2022).
Hypnotherapy involves guiding patients into a state of focused attention and deep relaxation and is used to help ameliorate pain, reduce anxiety, and facilitate healing. Patients undergoing hypnotherapy have reported reduced pain perception, decreased anxiety, and a diminished need for pain medications. Hypnotherapy has demonstrated effectiveness in various conditions, including chronic pain, surgery, childbirth, and palliative care. In a broader context, hypnosis has the potential to enhance the management of pain in emergency departments, pre or post-op, and other settings.
By inducing a state of deep relaxation and heightened focus, skilled hypnotherapists guide patients into a trance-like state where they can address and reframe their perception of pain. The process often begins with guided imagery, and then the patients are guided deeper into calm. This process often leads to reduced pain intensity, decreased reliance on pain medications, and enhanced coping mechanisms. Hypnotherapy can be particularly effective in managing chronic pain conditions, such as fibromyalgia or lower back pain, by assisting patients to manage discomfort and stress more effectively. Its non-invasive nature, lack of real side effects, and the potential to empower patients in their healing process make hypnotherapy a valuable tool in pain management. As a nurse, incorporating hypnotherapy into patient care plans can provide an additional avenue to enhance their overall quality of life and comfort during their medical journey.
Patients and healthcare professionals may have reservations about the mysterious nature of hypnosis, which can lead to skepticism or misunderstandings about its principles and practices. This can be addressed through education and by fostering a sense of trust. Hypnosis should not be used as a standalone treatment for severe or acute pain, and its integration into pain management should be in conjunction with traditional medical interventions. Clear communication, informed consent, and the normalization of using hypnotherapy help its use in various settings (Tinelli et al., 2022).
Massage
Massage is a body/skin manipulation technique that has been used around the world for eons. It was referenced in Babylonia (900 BC), China (2700 BC), India (1500-120 BC), Greece by Hippocrates (460-377 BC), Rome by Plato (427-347 BC) and Socrates (470-399 BC) and in the original Olympics (776 BC) for the athletes. There are many types of massage therapy techniques. For example, Swedish or Classic massage utilizes five different stroking movements, and deep tissue massage is a technique that does not seem to have a universally agreed-upon definition. With so many massage therapy techniques, it is not unexpected that studies report a wide range of results (25% to 100%) in pain reduction, with some types more consistently 60%-71% reported reduction in pain (Miake-Lye et al., 2019; Sahraei et al., 2022).
Substance P is found in the dorsal horn of the spinal cord, and elevated levels are known to be associated with chronic pain conditions. Massage therapy has been shown to reduce the level of Substance P in the saliva (Keeratitanont et al., 2015). An increase in muscle blood volume and skin blood flow has been reported at the site of the massage, as well as a reduction in pain intensity. There is speculation that the increase in blood flow could result in decreased Substance P levels and a reduction in the waste metabolites, such as lactic acid in the area, which results in decreased pain and a return to normal peripheral function. Other studies report an increase in oxytocin and the release of endorphins and serotonin with massage therapy.
Some of the most compelling research demonstrates how brain activity, as measured by an electroencephalogram, is affected by massage therapy. Dull pain sensation travels to the brain at a rate of 0.5 to 2 miles per second and sharp or burning pain sensation travels to the brain at 5-35 miles per second. According to the Gate Control Theory, since touch sensation travels to the brain at 35-75 miles per second, the brain will focus on the touch sensation instead of the pain sensation. Gate Control Theory is well documented and researched. Gate Control Theory is often used during childbirth for labor pain. If the patient fills all their senses with pleasant stimuli (lemon drop in mouth, gentle heat on skin, calming music, pictures of loved ones or favorite places, and pleasant aromas) then the numerous sensations coming in override the pain signals.
Other persuasive research shows that massage therapy affects the autonomic nervous system. Reduction in heart rate and blood pressure was shown during massage therapy sessions. This reflects that the parasympathetic nervous system is being triggered (Miake-Lye et al., 2019). The effect of massage therapy on muscle tension is also significant. Feelings of tightness, cramping, and spasms can be addressed with massage therapy, and thereby reducing pain.
Acupuncture
Acupuncture is a Traditional Chinese Medicine (TCM) treatment that is believed to have been in use for 2,500 years. It is a system of medical treatment that incorporates diet, exercise, herbs, spirituality practices, as well as acupuncture. It usually uses 5 to 20 small stainless steel, flexible needles, 10 to 100mm in size, placed into specific points on the body. Acupuncture is based on underlying philosophical principles of Confucianism and Taoism. These principles are the belief that individual health comes from the alignment of the qi, or “vital energy,” and acupuncture encompasses yin/yang, and uses these to realign the qi, the energy flow in the body. Acupuncture has been used for decades in the United Kingdom’s (UK) National Health Service and other evidence-based countries, but the public in the United States is generally not aware of the potential benefits.
Acupuncture in the treatment of chronic pain has not been fully embraced by the US, even though it is available at many of the top academic medical centers. While it is not known how acupuncture works, there is strong evidence of its effectiveness and is recommended by the World Health Organization for more than 100 conditions. Let’s be real, we still do not know how aspirin works. One theory of acupuncture is that needle stimulation influences inflammatory markers. Another is that needle stimulation induces hormonal changes. A third postulates the pressure itself influences loose connective tissue which causes immunomodulation. Another posits that analgesia results from the release of analgesics at the spinal and supraspinal levels, such as enkephalins and endorphins. And yet another, the Neurohumoral hypothesis, which is based on more than 100 scientific papers, theorizes that, in part, the pain-relieving properties are associated with the stimulation of nerve fibers in the horn of the spinal cord, which causes a cascade of endorphins (USDHHS, 2022; Vickers et al., 2023). While there are many theories, studies using functional MRIs have shown physiologic changes in the central nervous system in patients undergoing acupuncture. Traditional Chinese Medicine talks about how it clears the flow of energy through the body.
There have been many studies and systematic reviews of the efficacy of acupuncture in chronic pain. Because acupuncture is an individualized treatment that uses different points on the body, with different manipulation manners used by practitioners, different lengths of treatment, and different patient desired responses, it is impossible to develop a standardized treatment. There is some good research to support its use. The fact that The American College of Physicians recommends acupuncture as a first-line treatment for chronic low back pain and the National Institute of Healthcare Excellence suggests the use of acupuncture for chronic headaches and migraines demonstrates more acceptance for the use of acupuncture for chronic pain.
Nursing Implications
There might be skepticism or resistance to alternative or complementary therapies in the healthcare system, which can hinder the integration of these approaches into standard pain management protocols. Proper education, rapport, and implementation are the keys to providing patients the tools to overcome the complications of chronic pain. These techniques do take a nurse’s time away from other tasks and other patients, so it may not always be possible.
Implementing many of these techniques for pain management requires training and expertise to effectively guide patients through the process. Opportunities for nurses to be certified or at least further trained in these techniques are available. It does take some practice for nurses to become skilled at these techniques, but it empowers patients to take control of their pain and reduce their reliance on medication or other pain management techniques. We must also help assess and treat the whole patient. Depression and anxiety have an influence on the intensity of pain, so by addressing depression and anxiety, pain may also be reduced.
Other pain control methods a nurse might want to offer for the patient to explore with their doctor are physical therapy and exercise, topical medications, short term use of NSAIDS, corticosteroids, nerve blocks, epidurals, spinal cord stimulation, ultrasound, TENs, traction, or cognitive behavioral therapy referral. The type of pain, duration, intensity, and the patient’s perception of the meaning of the pain are all relevant to choosing which approaches may be best, and as always, the teaching is individualized, considering costs, access, and support. We hope to encourage more nurses to join us in this exploration of the other possibilities, training, and certification, where the power of the mind converges with the art and science of nursing to provide holistic and compassionate care.
Charlotte is an outpatient clinic charge nurse at Vanderbilt University Medical Center. She has been an RN for 11 years and ten years of that has been with Vanderbilt, and is a clinical hypnotherapist.
Amber Lauer is a Medical Aesthetics Mental Health Nurse Practitioner who focuses on the whole being in all aspects of primary care. Amber is a clinical hypnotherapist.
Dr. Wilson is the Chair of Excellence and Professor at Austin Peay State University School of Nursing and was the 2017 Holistic Nurse of the Year. Debra Rose uses hypnotherapy and other modalities to help patients manage pain.