America has a drug problem, an ongoing opiate habit we just can't shake. Now, to exorcise this demon, researchers are attempting to use virtual reality to treat pain—in hopes that the technique will prove as effective as it is outlandish.
Maureen Simmonds, a professor of physical therapy at the University of Texas' Health Science Center, told me a story that encapsulates the depth of our opiate dependency. Simmonds once attended a workshop at the International Association for the Study of Pain that was described as focusing on the problems of opioids. She was excited that someone was critiquing how commonplace opiate prescription had become. Instead, the presenter spent the duration describing drugs to manage the side effects of opiate prescription. Simmonds was horrified, and rightly so. That's like a presenter describing marijuana's dangers by identifying the best drinks to cure cottonmouth and the top snacks to sate the munchies—only far more deadly.
In 2014 alone, 47,000 people died from overdoses. But, while DARE classes across America warn about the dangers of alcohol, marijuana, heroin, and cocaine, the deadliest killer lies in plain sight: prescription painkillers. Opioid medication accounted for nearly 19,000 deaths—more than heroin and cocaine combined. While pharmaceutical companies make excellent patsies for the crisis—and certainly shoulder some blame—the opioid abuse epidemic also has deep roots in our cultural relationship with pain.
"What we found was that VR reduces pain as much as a moderate dose of hydromorphone."
It's perhaps unsurprising that pain is among the primary reasons people see a doctor. Daily aches and discomfort create nagging reminders that are, at best, annoying, and at worst can be debilitating. Yet, despite the frequency of patients seeking medical assistance for pain, healthcare providers have been notoriously ineffective at treating it. Dr. Joji Suzuki, Director of the Division of Addiction Psychiatry at Brigham and Women's Hospital, points to a combination of practitioners' good intentions, and a scarcity of effective treatment options, as one of the primary drivers behind the opioid crisis. "In the '80s and...early '90s there was a big push to do a better job of treating pain," Suzuki said. "You had to ask every patient what their pain severity was." However, "if you ask about pain, you have to do something about it."
With few alternative treatments available, that "something" too often meant the reflexive prescription of opioids. It didn't help that, at the time, Purdue Pharmaceuticals aggressively marketed OxyContin as a non-habit forming form of oxycodone, giving doctors an easy "fix" for patients' pain. "The combination of not being trained well at managing pain, [being] encouraged to do more of it, and now having all these powerful opioids available," Suzuki concluded, created the fertile ground for our nation's pain-pill problem.
Now we find ourselves in the throes of a deadly epidemic and, while doctors have begun prescribing opiates more sparingly, we still don't have many more tools for effective pain treatment than we had in the '80s. A new hope may be on the horizon, though, in an unlikely guise: virtual reality.
My first exposure to VR use came when I took a position as a scientific consultant and research analyst for CognifiSense, a company developing commercial applications for therapeutic VR technology. In this position I was tasked with reading the available research regarding virtual reality's medical uses. I was initially skeptical about this novel approach to analgesics, but the emerging scientific discussion convinced me VR's potential is more genuine than gimmick.
Though VR may seem more at home in the realm of science fiction than medical science, Dr. Hunter Hoffman and Dr. David Patterson have been working for 20 years to develop VR systems designed to reduce pain. Hoffman, the Director of the University of Washington's VR research center, and Patterson, a UW School of Medicine professor of psychology, initially designed VR systems to supplement the use of opiates in burn patients undergoing dressing changes. The pain produced by these procedures is so intense that typically even significant doses of opioids don't produce sufficient analgesia. "What we found was that VR reduces pain as much as a moderate dose of hydromorphone," Hoffman said. And in an fMRI study, they found "VR [combined with opiates] worked better than either alone."
VR pain relief may sound complex and futuristic, but the underlying mechanism isn't much more sophisticated than the actions of a mother making silly faces at her son while he's vaccinated. "Pain requires conscious attention," Hoffman said. "Virtual reality uses up a lot of attentional resources [so] the brain has less attention available to process incoming pain signals." Hoffman and Patterson have provided convincing evidence of their treatment's effect by using FMRI to analyze neural patterns, which show less pain related brain activity for patients receiving VR.
Although VR is typically used in addition to treatment with opiates, there's reason to believe using VR for acute procedural pain may reduce patients' risk for subsequent opiate abuse. One of the problems with opiate treatment, Hoffman said, is that "pain meds become less effective after you use them a few times, patients habituate. Day after day you might have to increase the dose to get the same amount of pain reduction," adding to the risk of patients subsequently developing opiate dependencies upon discharge. If clinicians use VR as an adjunct therapy, Hoffman suggests, patients may receive "satisfactory pain reduction…[and] you might not have to increase the dose."
While using VR to alleviate acute pain may mitigate some patients' risk for opioid dependency, Dr. Simmonds suggests that people suffering from chronic pain represent the majority of patients who develop opiate addictions. For the average chronic pain patient, Simmonds says, the risk of opiate addiction "is quite real, and quite problematic, especially if…[drugs are] prescribed for longer than the short-term." Dr. Suzuki agrees, noting that "for acute pain issues there's a discrete period of time when the opioids are needed and when you look at studies, those patients don't tend to end up staying on [opioids]." This stands in stark contrast, he laments, to the common practice of prescribing, "escalating doses of opioids chronically for chronic pain conditions."
If VR treatment is to make any inroads towards curbing opiate abuse, it will need to effectively treat chronic pain. Unfortunately, this presents a greater obstacle because chronic pain is, by nature, more complex than its acute cousin. Indeed, Simmonds notes, "chronic pain is now known to be not just a symptom of an illness or injury, [but] it actually is the pathology. You get changes in the nervous system that actually persist," oftentimes for the rest of a patients' life. For these patients, she explains, "you manage [pain], you don't cure it." And while there is an abundance of evidence pointing to VR's effectiveness in managing acute pain, evidence of its potential to treat chronic pain is sparser. "It has a lot of potential," says Simmonds, but "what's missing is really good longitudinal studies," to show effectiveness over time.
There are, however, promising signs. Hoffman noted that, unlike opiate treatment, "we've done studies where we use VR for 10 days and there was no decline in analgesia with multiple uses." Still, chronic pain treatments are better framed in terms of years, not days, and the opioid crisis itself presents the perfect example of the danger in projecting long-term efficacy from short-term results. Moreover, even if VR distraction continues to deliver relief, its effects are limited to the time in which the patient dons the headset. For this reason, David Patterson notes that the best way to decrease chronic pain is often to increase activity. Therefore, he said, the goal of VR therapy for chronic pain "is not necessarily to reduce pain," but rather to promote mobility.
It may sound counterintuitive, but Simmonds agrees that one of the challenges many patients face is a psychological aversion to movement they fear will be painful. Initially after an injury, you have to move slower in order to spare your body the force that accompanies sudden movements. In order to recover, she says, it is vital to return to normal movement patterns, "but some patients that are fearful don't recalibrate, they don't check to see if they are able to speed up."
Simmonds is hopeful that, for these patients, VR can provide relief that goes beyond simple distraction. By manipulating what a patient sees through a VR headset, she says, "you can manipulate how fast people [move]." So, for example, in some studies her team will put subjects in a VR experience where they walk down a hallway or country road. Then, the team manipulates the digital scenery to go by more slowly than it would otherwise at their present walking speed. "What happens with patients," she said, "is that as the optic flow gets slower, they speed up." By manipulating their perception, she is able to make patients walk more quickly than they might otherwise. In other studies, Simmonds manipulates the VR program's background music; patients tend to speed up as the tempo increases. In place of music, sometimes the participant hears footsteps, most will walk faster if the auditory footsteps increase in speed. This variable approach allows her to make minor alterations and tailor a VR program to maximize a particular patient's rate of motion during mobility exercises.
These techniques may do less than opioids to dull pain in the immediate short term but can potentially improve patients functioning over time. Simmonds describes a self-reinforcing cycle: "If you make people feel better, they will do better, and if they do better they will feel better." On top of these benefits, treating chronic pain with VR in place of opioids, or alongside a much decreased dose, could circumvent the pitfalls that lead to addiction. While there's little evidence that opiates produce long term benefits for chronic pain sufferers, their repeated use presents a clear and present danger. "The opioid is a huge reward in terms of brain stimulation," says Patterson, "if people are rewarded when they receive pain, by receiving those euphoric agents, it builds up chronic pain."
"There's a recognition that pharmacological solutions have severe limitations."
Though the science is continuing to develop, the recent explosion in the availability and sophistication of VR technology—and drastic drop in price—means that VR apps designed to treat pain will soon be a commercial reality. Tassilo Baeuerle, Founder and CEO of CognifiSense, is one such entrepreneur with designs on taking analgesic VR mainstream.
"There's a recognition that pharmacological solutions have severe limitations," Baeuerle observes, and "we're going to pursue both medical applications and commercial approaches." Some of Baeuerle's plans will have to go through healthcare regulatory processes. Others, though, will be marketed as simply entertainment and support, and could hit shelves—or app stores—in the near future. "I think the commercial reality is now," says Baeuerle, "there are a number of companies on the stage who are starting to market [VR for pain], and it will be available this year or early next year."
While virtual reality's true potential for treating pain is still to be discovered, Baeuerle is right about one thing: "These kinds of solutions are coming into the market at the right time." The magnitude of the present opioid crisis reveals a country in dire need of effective pain treatments that don't engender opiates' risk for abuse, addiction, and death. VR research may still be in development, but recent exponential progress in VR technology suggest virtual treatments designed to manage pain may be just around the corner.