Not every form of pain relief comes in a bottle.
Though virtual reality (VR) is often associated with the next generation of games and films, it stands to make a huge impact in the field of pain management and in the fight against widespread opioid addiction.
Doctors widely prescribe opioids as painkillers. Common opioids include morphine, codeine, fentanyl, and oxycontin, as well as the illegal drug heroin. They are highly addictive, and their increased usage and abuse in recent years have prompted many to declare an “opioid epidemic.” Indeed, the opioid crisis has inflicted a devastating toll on individuals, families, and communities. According to the Centers for Disease Control and Prevention (CDC), an average of 115 Americans die every day from an opioid overdose (roughly 42,000 people per year), and that figure continues to rise.
The medical community must seek proactive ways of attacking the problem at its source through developing alternative ways of treating pain.
Many of the proposed solutions to the opioid epidemic are reactive – they respond to the problem through a series of interventions, such as greater community engagement and more effective treatments for addiction. While these strategies are undeniably valuable and sorely needed, the medical community must also seek proactive ways of attacking the problem at its source through developing alternative ways of treating pain.
This article explores virtual reality therapy as a key emerging form of pain management. Though in its infancy, virtual reality has the potential to supplement – or perhaps replace – conventional forms of pain mitigation, such as opioids. Not only does VR therapy allow patients to avoid the addictive, and potentially lethal, side-effects of opioids, but it can actually prove a more effective treatment option in cases of both acute and chronic pain.
VR Therapy in Theory and Practice
The idea of virtual reality therapy dates back to at least 1993 when Albert “Skip” Rizzo, Director for Medical Virtual Reality at the University of Southern California’s Institute for Creative Technologies, proposed VR as a treatment for post-traumatic stress disorder (PTSD). In 1996, David Patterson and Hunter Hoffman, researchers at the University of Washington’s Human Interface Technology Lab, developed a method for using immersive virtual environments to combat cases of extreme pain.
As headsets become both more advanced and more affordable, clinicians will have greater ability to put their VR ideas into practice at scale.
Though the 1990s was a period of creativity and progress for VR therapy’s theoretical underpinnings, VR technology was not yet advanced enough for researchers to translate ideas into practice. As a 2014 article in Scientific American points out, “a lack of practical hardware” stood – and continues to stand – as a particularly significant obstacle to scaling virtual reality solutions in medicine. Companies like Facebook and HTC are poised to change this, however, as they pour tens of billions of dollars into commercializing virtual reality and their respective VR headsets, Oculus Rift and Vive. As headsets become both more advanced and more affordable, clinicians will have greater ability to put their VR ideas into practice at scale.
Studies Have Shown that VR Therapy Works
In the past 20 years, numerous studies have shown that virtual reality applications can serve as effective analgesic tools.
Hoffman and Patterson conducted a study in 2000, for example, measuring the impact VR could have on burn patients as they underwent treatment. They based their experiment on the fact that for these patients, “opioid analgesics alone are often inadequate” due to how extreme a patient’s pain is during treatment. Opioids, Hoffman and Patterson argued, must be supplemented in such cases of acute pain. In each trial – one involving a 16-year-old male with a “deep flash burn on his right leg” and another involving a 17-year-old male with one third of of his body covered in deep burns – virtual reality dramatically reduced the pain experienced and anxiety levels during treatment.
Several subsequent studies have lent further credence to these results. In one such study, Patterson tested the use of VR in hypnosis on 13 different patients. Results showed that VR therapy, combined with audio hypnosis, reduced pain by 22 percent more than just one form of treatment did alone.
In a recent systematic review of prior studies examining the effectiveness of VR in pain management for burn victims, researchers found that VR therapy had a positive impact in eight of nine cases.
While the success of prior studies does not definitively prove the efficacy of VR therapy as a full-fledged replacement for opioids, it seems clear that VR should be considered a promising supplement.
As Hoffman and Patterson noted in 2000, traditional medications are often inadequate for people experiencing extreme pain. Opioids too often lead to addiction and abuse. While the success of prior studies does not definitively prove the efficacy of VR therapy as a full-fledged replacement for opioids, it seems clear that VR should be considered a promising supplement. And in light of the opioid epidemic’s severity, the medical community must continue to investigate whether VR therapy may one day serve as a viable replacement.
SnowWorld: Treating Acute Pain Through Distraction
What does VR therapy look like?
Though technology had not fully caught up to their ideas in 1996, Patterson and Hoffman put theory into practice in 2000 with the development of the application SnowWorld. As Hoffman says, part of the extreme pain burn patients experience during treatment is psychological and stems from the feeling of reliving trauma. SnowWorld was designed to immerse burn victims in an environment that explicitly contrasts fire, heat, and the experience of getting burned. In distracting patients through the virtual world, Hoffman says, VR applications like SnowWorld can significantly reduce pain.
When burn patients use SnowWorld, they see a 360-degree view of a landscape covered entirely in snow, ice, and water. Floating down a canyon, they shoot snowballs at penguins and snowmen perched along snowy ridges. Paul Simon’s song “You Can Call Me Al” plays in the background. Surrounded on all sides by images connoting coolness, users turn their minds away from their burns and, Hoffman says, experience up to 50 percent less pain during treatment than they otherwise would.
“When a patient is going through a painful procedure, and they find themselves immersed in the virtual world – SnowWorld – there’s just less attention to focus on their pain.”
“The logic behind VR analgesia is that pain requires attention,” Hoffman said at the 2017 World VR Forum. VR therapy, Hoffman and Patterson contend, is similar in principle to the mechanism explaining why patients feel (or at least remember) little pain while under the influence of anesthesia. As Patterson says, “When a patient is going through a painful procedure, and they find themselves immersed in the virtual world – SnowWorld – there’s just less attention to focus on their pain.”
SnowWorld has served as a welcome refuge for hundreds of burn patients. One such patient, Edgar Hernandez – a 16-year-old profiled in 2010 by Al Jazeera who has burns on 80 percent of his body – says that SnowWorld takes his mind off of the pain he feels during physical therapy.
“I feel less pain when I play the game, less pain than before,” Hernandez says. “I feel like I’m in a place where there’s snow, another world.”
SnowWorld has had a similar impact on First Lieutenant Samuel Brown, who experienced significant burns after his Humvee was attacked in Afghanistan. In a 2008 profile by ScienCentral News, Brown said that SnowWorld distracts him from his injuries. “I spent some time growing up in Colorado skiing, and … [SnowWorld] brings back some of those memories,” Brown said.
Brown’s doctors have also observed tangible improvements in his rehabilitation through using SnowWorld. “What we saw was marked improvement in the range of motion we were able to achieve, and most importantly, an increased level of comfort,” said Dr. Christopher Maani, an anesthesiologist at the U.S. Army Institute of Surgical Research.
SnowWorld has had a positive impact on hundreds, but it has not yet been widely adopted nationwide. Cost has stood as one obstacle, with the original computer system and customized VR headset powering SnowWorld priced at $90,000, as detailed in a recent article published by Quartz (today, an Oculus Rift headset costs roughly $400, but such a headset might not be usable during a burn patient’s physical therapy, which involves water and therefore required Hoffman and Patterson to design a customized, water-resistant system).
For Hoffman, scaling SnowWorld is one of his most important goals. “What I have cut out for me for the rest of my life is to transition [SnowWorld] from a research tool to clinical practice where it’s just used as standard care,” Hoffman said in the Al Jazeera story.
With VR technology’s increasing cost-effectiveness, Hoffman’s goal may be within reach.
Cool!: VR Therapy for Chronic Pain
Over the past two decades, substantial research has gone into proving the efficacy of VR applications like SnowWorld in treating acute pain. Yet relatively little research has investigated whether such applications might have a similar effect on chronic pain, which affects over 100 million Americans and drives the majority of prescription opioid consumption.
“VR games are going to upend this paradigm and unleash the power of play to make us healthier.”
Howard Rose, CEO of VR company Firsthand Technology and Dr. Ted Jones, a clinical pain psychologist at the Behavioral Medicine Institute, have taken some initial steps into this field. Rose founded Firsthand, and later launched DeepStream VR, an effort dedicated to developing VR healthcare applications, after working with Hunter Hoffman and David Patterson at the Human Interface Technology Lab. To tackle the problem of chronic pain, Firsthand developed the application Cool!, a game similar in many respects to SnowWorld. Patients who use Cool! walk through a range of environments in the natural world, from a forest to a snowy canyon, and shoot bubbles at various creatures along the way.
As he implied in a 2014 talk for TEDMED, Rose believes that VR applications will enable healthcare, and healing, to shift toward a more patient-centric model.
“The doctor-centered paradigm of healthcare under-utilizes our innate human power to recover on our own or to prevent illness in the first place,” Rose said. “VR games are going to upend this paradigm and unleash the power of play to make us healthier.”
In a recent interview, Rose said that he believes conventional painkillers are, in many ways, “underperforming what we want them to do.” With regard to the relationship between opioids and VR, Rose says that VR can act as a viable supplement to traditional medications. Jones has gone a step further, however, to say that VR can, in some cases, actually replace traditional painkillers. “Sometimes pills are needed, but other times, you really need other alternatives. People can tolerate a lot more pain when they’re distracted,” Jones says.
Initial studies have supported Jones’ claim. A 2016 study examining Cool!’s effect on chronic pain, discussed in a recent Toptal Insights article, found that the application reduced pain by 60 percent – twice the percentage, noted in a recent article published by TNW, that morphine users generally report. Further, 100 percent of the study’s 30 participants “reported a decrease in pain … between pre-session pain and during-session pain.”
Big Pharma and VR
The opioid epidemic continues to wreak havoc both financially and in terms of human life. On a fundamental level, this public health crisis exists because opioids are the most widely-produced and disseminated form of pain management. But as the crisis grows, calls for alternative forms of pain management will grow louder.
While the pharmaceutical companies producing opioid painkillers might naturally view such alternatives as a competitive threat, they should instead take the initiative to help develop, and therefore profit from, these new forms of pain management.
Major pharmaceutical companies have already started using VR in medical research. Pfizer, for example, uses VR to “visualize and virtually explore the human body at the molecular level” and analyze data. Novartis similarly uses VR to aid in drug design and discovery, as researchers can physically “walk around” a given protein to better understand how it might interact with a given drug.
Such VR applications are fueling drug development and innovation, but pharma companies may also do well to view – and invest – in VR as not just a tool for discovering new treatments, but an important new treatment in itself.
With billions of dollars in their research and development budgets, large pharmaceutical companies could propel VR therapy to new heights and spur widespread clinical adoption.