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Sunday, 17 April 2011

Pain Control, Hypnosis, and Medical Ethics


Two years ago I wrote about self-directed hypnosis as a effective and ethically admirable clinical intervention. A recent New York times article - "Using Hypnosis to Gain More Control Over Your Illness" - got me back into the literature on hypnosis for pain control. Since I last dipped into it there have been impressive findings about the impact of hypnosis on procedures associated with pain and anxiety. Here are a few examples:

  • A Cochrane review confirmed that women taught self-hypnosis used less pain medication during labor and were more satisfied with their pain management experience than women receiving standard care.

  • A study conducted at Mt. Sinai in New York showed that hypnosis combined with cognitive behavioral therapy reduced the amount of fatigue experienced by women undergoing radiotherapy for breast cancer.

  • 236 women undergoing large core needle breast biopsy were randomized to standard treatment, structured empathy, and self hypnosis. Pain and anxiety were significantly less with hypnosis, resulting in a shortening of procedure time (39 minutes compared to 46 minutes). The savings from a shortened procedure offset the incremental cost of hypnosis.

  • For children undergoing a voiding cystourethrogram, a decidedly unpleasant radiological study that requires insertion of a catheter through the urethra and fluoroscopic visualization of the bladder while the child urinates. (Just thinking about the procedure gives me anxiety.) In a randomized study, children from 4 - 15 who, along with their parents, received a one hour training session in self-hypnosis, reported significantly less pain and anxiety during the procedure and showed fewer outward signs of distress, leading to a 14 minute shortening of procedure time and reduced cost.

If a new drug - I'll call it hypnotyx - was shown to have comparable effects to self-hypnosis, we would see rapid wide dissemination, a likely cost of several hundred dollars a pop, and, ultimately, hundreds of millions of dollars in sales. Parents would demand hypnotyx for their children. Adults undergoing biopsies would insist on receiving it. But self-hypnosis, a low technology, "alternative" treatment, without a glitzy name, vigorous advertising, or significant profit opportunity, has relatively few fans.

This embrace of "pharmacophilia" is a sad reflection on our national medical culture. We physicians can't simply blame the low uptake for an "alternative" treatment like self-hypnosis on our patients. If we expressed comparable enthusiasm and belief in hypnosis that would occur for hypnotyx our patients would move in the same direction. Advertising has a huge impact, but so does our offhand comments, tone of voice, facial expression, and other components of communication.

If I were again involved in managing a group practice - something I've been out of for 25 years - I'd make a systematic effort to bring techniques like self-hypnosis into areas of the practice like those the studies focused on. It's well and good for individual physicians to incorporate "alternative" methods into their standard practice, but that won't go far in changing our medical culture.

The focus of my work is on ethics, but I cringe when I'm introduced as an "ethicist." The term connotes expertise in an arcane domain, when the fact is that articulating and promoting values is a universal responsibility. With regard to promoting self-hypnosis as an effective, low risk/low cost approach to reducing pain and anxiety, the true ethics leaders will be those who succeed in implementing the robust research findings that are readily available in the literature!

(Dear friends - I've been in Hawaii for two excellent weeks of holiday and then in DC for a meeting - that accounts for the two week hiatus in posting.)


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