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Miranda Felde, MHA, CPHRM, Vice President,

Patient Safety and Risk Management, The Doctors Company

In 2016, science teacher Bob Jester fell off a roof, broke 19 bones, and underwent surgery for his badly broken back. Doctors prescribed Oxycodone, an opioid, during Jester's extended recovery. Jester worried that he would become dependent on opioids, so he jumped at the chance to try Virtual Reality (VR) as an alternative to opioids when an acquaintance told him about a company that was using VR for pain management. When he started using a mobile headset connected to a smart phone that plays VR apps, Jester found his pain lessened and the effect lasted for several hours each time. About a year after his accident, Jester was able to wean himself off opioids.[1]

Could other patients with severe acute and/or chronic pain experience the same results?

The State of the Opioid Crisis

The number of opioid prescriptions written annually in the U.S. roughly equals the number of adults in the country.[2] And sometimes opioids, though intended to help patients, cause harm: The opioid epidemic claims the lives of 115 people every day.[3]

While the financial costs of the opioid epidemic can be tallied--In 2016, the opioid epidemic's toll hit $95 billion, with healthcare costs concentrated in emergency room visits, hospital admissions, ambulance use, and Naloxone use[4]--the personal costs to those who have lost loved ones are uncountable. The epidemic's impact is far-reaching and has emotional, physical, and financial implications for our entire society.

Exploring VR for Pain Management

Many physicians are exploring VR technologies as an alternative to prescriptions.[5] The Gate Control Theory of pain, proposed by Melzack and Wall, suggests that a person may interpret pain stimuli differently depending upon mental/emotional factors such as attention paid to the pain, emotions associated with the pain, and past experience of the pain.[6] VR addresses both attention paid to pain and the patient's emotional state: The immersive distraction of VR can help a patient mentally transport to another space, such as an underwater seascape, which may also positively affect the patient's emotional state.

In 1996, the Harborview Burn Center in Seattle, Washington, successfully piloted the use of VR for burn patients with severe acute pain. Since then, more providers have found VR can provide relief for patients experiencing acute pain, such as the type Jester experienced following surgery.[7]

Recent studies have explored whether VR can relieve chronic pain. One small, but promising, study of patients with neuropathic pain found that patients experienced a 69 percent reduction in pain during each session and a 53 percent pain reduction immediately after each session.[8]

Getting Started with VR

To explore VR as an alternative therapy, first consider the distinctions between two key terms:

• Virtual Reality (VR): Provides an immersive experience via a computer-generated 3D environment for the user to explore. The user may be able to move objects or otherwise change the environment.
• Augmented Reality (AR): Adds sounds, videos, and/or graphics to an existing environment, such as an outdoor planetarium where AR viewing glasses show constellations highlighted in the sky.[9]

Then, evaluate VR interfaces that are relevant for patients managing pain, such as:

• Head-mounted display (HMD): Like a heavy-duty pair of goggles plus headphones. Completely surrounds the user's visual field for an immersive experience.
• Treadmills and haptic gloves: Allow the user to physically move around in the virtual environment, and to physically move objects within that environment.

And weigh the value of interfaces that are more relevant for physician use, such as:

• Smart glasses: May look more like regular eyeglasses or more like safety glasses. May display information or help the physician capture information for the electronic health record (EHR).
• Desktop VR or Window on a World (WOW): Uses a desktop or laptop computer to run simulation programs, including those for training.

Mitigating VR Patient Safety Risks

While therapeutic VR for pain management shows promise, there are patient safety risks. They include:

• Falls: Patients wearing a full-surround headset cannot see their real-world environment and may walk into or trip over objects. Even patients in bed can knock things over while waving their arms around. Create a safe physical environment for VR use.
• Motion sickness: Many people experience some combination of eye strain, headaches, and/or nausea.[10] Patients who are ordinarily prone to any of these symptoms may not be good VR candidates.
• Psychological effects: The brain can store VR experiences as memories in almost the same way it stores physical experiences. Young children, especially, may confuse VR experiences with real experiences, especially when remembering them later. "If you were to do this in the real world, how would it affect you? That's the way to think about virtual reality," says Jeremy Bailenson, director of Stanford's Virtual Human Interaction Lab.[11]
• The unknown: VR technology is still in its infancy, and therefore, little is known about the long-term consequences of VR use.

The Future of VR for Pain Management

Some physicians imagine a future of tetherless headsets that allow patients in pain the freedom to escape reality and transport to another emotional space. To reap the potential benefits of VR while mitigating its risks, clinicians could start with a two-part approach: identifying patients with specific clinical indications that would benefit from the use of VR and assessing patients for potential risk factors. Successful implementation of VR for pain management depends on wisely deciding which patients are VR candidates--and which are not.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

[1] Schroeder K. After accident leaves him paralyzed, retired teacher Bob Jester battles his chronic pain with virtual reality. Riverhead Local. October 4, 2017. https://riverheadlocal.com/2017/10/04/accident-leaves-paralyzed-retired-teacher-bob-jester-battles-chronic-pain-virtual-reality/. Accessed June 25, 2018.

[2] Marcus H. Prescribing opioids safely. The Doctor's Advocate 2017; 2nd quarter. https://www.thedoctors.com/the-doctors-advocate/second-quarter-2017/prescribing-opioids-safely/. Accessed June 25, 2018.

[3] Understanding the epidemic. Centers for Disease Control and Prevention Website. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed June 25, 2018.

[4] Castellucci M. Economic burden of opioid epidemic hit $95 billion in 2016. Modern Healthcare. http://www.modernhealthcare.com/article/20171116/NEWS/171119908. Accessed June 25, 2018.

[5] Barad J. New realities in medicine--exploring the virtual and augmented horizon. Panel presented at: A4M MMI World Congress. December 14-16, 2017; Las Vegas, NV.

[6] Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Management. 2011 Mar; 1(2): 147-157.

[7] Loguidice CT. Virtual reality for pain management: A weapon against the opioid epidemic? Clinical Pain Advisor, September 5, 2017. https://www.clinicalpainadvisor.com/painweek-2017/chronic-pain-management-with-virtual-reality/article/684461/. Accessed June 19, 2018.

[8] Loguidice CT. Virtual reality for pain management: A weapon against the opioid epidemic? Clinical Pain Advisor, September 5, 2017. https://www.clinicalpainadvisor.com/painweek-2017/chronic-pain-management-with-virtual-reality/article/684461/. Accessed June 19, 2018.

[9] Palladino T. National Geographic's open-air planetarium displays augmented reality constellations through Aryzon viewers. Next Reality, June 21, 2018. https://next.reality.news/news/national-geographics-open-air-planetarium-displays-augmented-reality-constellations-through-aryzon-viewers-0185390/. Accessed June 25, 2018.

[10] LaMotte, S. The very real health dangers of virtual reality. CNN Website, December 13, 2017. https://www.cnn.com/2017/12/13/health/virtual-reality-vr-dangers-safety/index.html. Accessed June 25, 2018.

[11] LaMotte, S. The very real health dangers of virtual reality. CNN Website, December 13, 2017. https://www.cnn.com/2017/12/13/health/virtual-reality-vr-dangers-safety/index.html. Accessed June 25, 2018.