Reducing Pain and Morphine through hypnotherapy

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Atrial flutter (AFL) ablation patients reported less pain and required less morphine with hypnotism during the procedure, a small randomized trial found.

Conducted through headphones by an experienced practitioner, hypnosis was associated with consistently lower pain perception throughout the ablation procedure compared with a placebo that consisted of listening to non-hypnotic relaxation suggestions and white noise, according to the PAINLESS group led by Rodrigue Garcia, MD, MSc, of Centre Hospitalier Universitaire de Poitiers, France.

With hypnosis, the mean pain score was 4.0 on a 10-point visual analog scale, which was significantly better than the average of 5.5 in the placebo group (P<0.001), the investigators reported in their study published online in JACC: Clinical Electrophysiology.

Hypnosis patients also rated their sedation better and took less morphine (average dose 1.3 vs 3.6 mg, P<0.001).

Accordingly, this group had no complications, whereas 11% of the placebo group had opioid-related complications — namely respiratory depression and symptomatic hypotension.

“This is of particular importance for elderly patients with major comorbidities undergoing ablation, who are at increased risk for complications from opioids,” Garcia’s group said. “Nevertheless, this difference in opioid-related adverse events should be confirmed in larger studies.”

“Hypnosedation uses hypnosis combined with locoregional anesthesia and small doses of IV analgesic agents. It has recently been reported to be more efficacious than conventional analgesia during electrophysiological procedures in case reports, case series, and prospective nonrandomized studies,” the authors noted.

Despite the scientific rigor and positive findings of the current study, hypnosis is not likely to find a place in the electrophysiology lab, commented Hugh Calkins, MD, of the Johns Hopkins Hospital in Baltimore. “Pain control is not a burning issue. There may be other conditions where [hypnosis] may be of value, but I doubt it will move the needle forward,” he told MedPage Today.

AFL ablation itself takes “very little sedation” and is a quick procedure. To save a little painkiller, one would be bringing in a hypnotist, which presents logistical challenges such as hiring, training, and billing, according to Calkins.

The French group suggested that “hypnosis can be easily implemented in the electrophysiology laboratory” and noted that two of its nurses were able to deliver this therapy after each taking a 7-day training course.

The PAINLESS trial had been conducted at a single center in 2017-2019.

Investigators randomized 113 patients (mean age 70 years, 21% women) to hypnosis or placebo. On top of the assigned treatment, all patients were allowed to get 1 mg of IV morphine in case of moderate-or-worse pain or upon request.

No study participant had undergone prior electrophysiological procedures. There were no significant baseline differences between arms.

AFL ablation took over half an hour on average. There was no difference in procedural success between hypnosis and placebo groups.

Major limitations of the randomized trial included its single-center nature and reliance on patients’ subjective pain assessment.

“Hypnosis is an effective adjunct to analgesia in reducing pain perception and may eliminate the need for IV opioids and their associated risks,” Garcia