Understanding the science of pain with the help of virtual reality

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JUDY WOODRUFF: Now let’s turn to our series on the opioid crisis, its enormous toll in American life, and efforts to get a handle on it.

We have spent the past couple of days showing some of the devastation it has wreaked, as more and more people have become hooked.

Tonight, as part of our weekly Leading Edge science segment, Miles O’Brien explores the mechanics of pain, and some possible alternatives for coping with it.

It’s part of our ongoing focus, America Addicted.

MILES O’BRIEN: Kevin Walsh is intimately familiar with pain, excruciating pain.

KEVIN WALSH, Patient: When it very first happened, it was just so intense that I would literally — my whole body just kind of froze for a minute.

MILES O’BRIEN: He is talking about the day he got burned by hot grease in the commercial kitchen where he worked.

KEVIN WALSH: They have a pain scale of one to 10. It was like a 15.

MILES O’BRIEN: The treatment protocol for burn victims is almost as painful as the injury itself. Nurses repeatedly remove dressings and scrub the wounds. It’s called debridement.

KEVIN WALSH: Sometimes, they really get in there, and they will scrub pretty hard. And it gets — yes, it gets very, very painful.

MILES O’BRIEN: To endure it, he takes opioids, the most effective pain treatment medicine offers. But he also does something else. While the nurses do their work, he enters SnowWorld, a virtual reality video game that is simple and yet engrossing.

KEVIN WALSH: I could tell that they were peeling off a bandage, and I remember actually thinking in my head, you know, this should hurt a bit more. But I was focused on the game, because I was trying to shoot a penguin, and not really worrying so much about them taking my dressing off.

MILES O’BRIEN: Kevin Walsh was a patient at Seattle’s Harborview Hospital, run by U.W. Medicine, a pioneer in the treatment of pain.

DR. DAVID TAUBEN, UW Medicine: Virtual reality is a way of moving someone to a different place, a safe place, a place they don’t have pain.

MILES O’BRIEN: David Tauben heads the Division of Pain Medicine.

DR. DAVID TAUBEN: We underestimate the power of our brains and our minds to shape and regulate our own experiences.

MILES O’BRIEN: This is a place that was built on wrestling with pain in novel ways.

One of its founding doctors, the late John Bonica, had a previous career as professional wrestler. He earned fame, fortune and a long litany of injuries. Hobbled by arthritis, the man knew pain inside and out.

JOHN BONICA, Founder, UW Medicine: For some 45 years, I have had to wrestle the medical profession, the public, the health agencies, in order to make them aware that pain is a very important subject for studying and for education training.

MILES O’BRIEN: It was the first place to treat pain as the problem, not just a symptom of something else. The approach is multidisciplinary.

DR. DAVID TAUBEN: It includes psychologists, physical therapists, and a lot of non-drug providers, was based on eliminating the opioids and the sedatives that so many patients were put on.

MILES O’BRIEN: Opioids are similar to naturally produced chemicals that attach to nerve cells called receptors in our brains and central nervous systems.

Opioids affect our limbic brain, which manages emotions, giving us feelings of pleasure, relaxation and contentment, our brain stem, which controls unconscious activity, like breathing, coughing and pain. And they attach to receptors in the spinal cord, blocking pain messages sent back to the brain.

During the Civil War, doctors used opioids widely on soldiers to treat pain, but many started showing symptoms of addiction. This led doctors to a century of conservatism in prescribing opioids.

But then, in 1980, a letter to the editor of “The New England Journal of Medicine” turned that thinking on its head. The authors looked at 40,000 hospitalized patients. Although 12,000 of them received opioids, only four of them became addicted. Their conclusion? The development of addiction among medical patients is rare in cases where there is no history of addiction.

It was a survey of existing databases, not a rigorous peer-reviewed study, and yet it had great influence. The pendulum swung. Opioid drug prescriptions increased dramatically.

DR. DAVID TAUBEN: The pharmaceutical manufacturers were quite happy to promote these agents. They had a big incentive to minimize the associated risks.

MILES O’BRIEN: The opioid push also made it harder for patients to get reimbursement for alternatives, such as biofeedback and hypnosis, even though studies show half to three-quarters of those who undergo hypnosis have improvement in their pain.

DAVID PATTERSON, UW Medicine: How’s your pain been doing?

TIM CLARK, Patient: A little better.

DAVID PATTERSON: yes.

TIM CLARK: I have cut back on some of the opioids.

MILES O’BRIEN: Tim Clark is debilitated with intense, chronic neuropathic pain, the lasting result of contracting the Guillain-Barre virus five years ago.

DAVID PATTERSON: Describe what the neuropathic pain is like for you.

TIM CLARK: It’s usually like an electrical shock. It’s a sharp, shooting pain.

MILES O’BRIEN: He regularly sees psychologist David Patterson for hypnosis sessions like this.

DAVID PATTERSON: Now let that breath go and let your eyelids close.

Hypnosis is really a special learning state, and, again, what happens is the part of the brain, that sensory, the part of your brain that’s saying, you can’t do this, it’s not possible, turns off, and so you’re really able to get people to a different place.

Maybe you have a thought that, oh, I’m getting worse, I’m never going to get better. And what you’re going to find is that, first of all, these thoughts are ridiculous.

It’s not this type of hands-off, bring you back to the present. It’s bringing people to a similar state as when they’re meditating, but being very directive with the suggestions that you give.

MILES O’BRIEN: Tim was once extremely active, a competitive sailor with a rewarding career. His horrible pain ended all of that, and while opioids seemed like the solution for a while, they soon made matters much worse.

TIM CLARK: And so why wouldn’t I be depressed? But the opioids make it worse, and I get in a real funk. If I can cut back on them even a little bit, I seem to have a more positive attitude.

MILES O’BRIEN: He used to take three to four Dilaudid pills a day. Now it’s more like three to four a week.

This has surprised David Patterson, who once thought hypnosis helped only patients with acute pain.

DAVID PATTERSON: Now we’re finding that if you train people in hypnosis over weeks, they start changing the neurostructure of their brain. So it is actually useful for chronic pain too, but we’re just beginning to understand that better.

MILES O’BRIEN: Pain is essential for survival. It is nature’s alarm bell, a way of protecting us from further harm. But no one really knows why pain persists long after the body has healed.

DR. DAVID TAUBEN: Acute pain is a nice warning that you need to make a change in what you’re doing. It feels like it’s wrong. You respond as if it’s wrong, but that signal continues. And that becomes overwhelming for many people.

Chronic pain is a stuck alarm.

MILES O’BRIEN: I know this all too well. I deal with chronic pain that seems to emanate from a place that doesn’t exist: my amputated left arm. It’s called phantom Pain.

HUNTER HOFFMAN, UW Medicine: So, the brain is expecting there to be a hand, and it’s filling in the blanks.

MILES O’BRIEN: Hunter Hoffman is director of the Virtual Reality Research Center and the creator of SnowWorld. He says phantom pain is called top-down, meaning it’s in the head.

HUNTER HOFFMAN: Your phantom limb is an excellent example of your brain’s expectations and predictions, even in the absence of a physical limb there.

MILES O’BRIEN: Chronic pain is usually top-down.

Hoffman designed SnowWorld with bottom up, acute pain sufferers like Kevin Walsh in mind. To demonstrate it, he inflicted some pain on me.

HUNTER HOFFMAN: There are people that actually make pain inducers.

MILES O’BRIEN: With a thermal stimulator, an adjustable heater.

HUNTER HOFFMAN: One more, or you want to go up a half-a-degree? You can go up a half-degree if you don’t want to go…

MILES O’BRIEN: Let’s do a full degree and see how that feels.

HUNTER HOFFMAN: Is that comfortable? I can adjust it.

MILES O’BRIEN: Oh, yes, it’s pretty good.

HUNTER HOFFMAN: All right. And here, we will put on your earphones.

MILES O’BRIEN: While I was intent on hurling snowballs at penguins, I didn’t feel the heat at all. And, on top of that, I didn’t feel any phantom pain. It apparently addresses pain both coming and going from the brain. This got Hunter’s attention.

HUNTER HOFFMAN: Well, what we showed was, it helped reduce your chronic pain.

MILES O’BRIEN: Right.

HUNTER HOFFMAN: That was actually, I think, the first demonstration of that.

MILES O’BRIEN: Yes?

HUNTER HOFFMAN: That was the first…

MILES O’BRIEN: Really?

HUNTER HOFFMAN: … first demonstration.

MILES O’BRIEN: We just did bleeding-edge science, huh?

HUNTER HOFFMAN: Exactly.

MILES O’BRIEN: Pain needs an audience, and the better we get at focusing on other things, the more we can manage it, without turning to narcotic drugs.

In Seattle, I’m Miles O’Brien for the PBS NewsHour.

JUDY WOODRUFF: Tomorrow, our series continues with a look at how the opioid crisis has hurt the nation’s work force.

And online: Leaving old unused pain medication in the bathroom cupboard increases the likelihood of it being ingested by children or pets. How do you safely get rid of them?

Find a doctor’s advice, and more stories from our series, at PBS.org/NewsHour.

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