Opioids Haven't Solved Chronic Pain. Maybe Virtual Reality Can
When someone walks or rolls into the emergency department at Cedars-Sinai hospital in Los Angeles with food stuck in their throat, the ER staff calls someone like Brennan Spiegel. As a gastroenterologist, food-pulling-out is something he’s uniquely equipped to do. So when he got the call one day to see a young man admitted with something caught in his esophagus, he was already mentally preparing for a trip to the operating room. But when he arrived, there was something off about the way the patient was beating his chest with his fist. “This guy’s not choking,” Spiegel thought, “he’s having a panic attack.”
So rather than calling for a gurney and an OR transfer, Spiegel reached for a pair of virtual reality goggles, pulled them over the patient’s eyes, and dialed up a scene of a beach in Hawaii. Within a few seconds the patient stopped struggling. A few minutes later he had stopped moving entirely—not even when prodded. Slightly alarmed, Spiegel began to peel the goggles off the patient’s face. Tears came pouring out. “I’ve been thinking about my whole life in there,” the patient said. “I feel like it’s spinning out of control.”
A short while later, the patient was discharged to psychiatric care. There had never been any food in his throat. The mind can play tricks like that. Luckily, VR can play tricks right back.
Cedars-Sinai is one of an increasing number of hospitals testing how virtual reality could improve patient outcomes. Spiegel is one of the clinical researchers leading that charge. He’s focusing his efforts on something much more universal than the occasional psychosomatic suffocation: pain. Over the past few years he’s conducted clinical trials that show a pair of 3-D goggles can reduce the experience of pain—all kinds, from joint injuries to cancer—by a quarter.
Now, he’s testing the technology for treating chronic pain—the kind that afflicts more than 25 million Americans. All too often, addictive painkillers are the only treatment option for those patients. And with opioids claiming the lives of nearly 100 people every day, doctors are scrambling to find non-addictive alternatives. Virtual reality might soon be one of them, if the science can show it really works.
Scientists started probing the power of VR to ease suffering more than 20 years ago. VR pioneer Hunter Hoffman, a researcher at the University of Washington in Seattle, launched the first pain studies in the early 2000s, using an eight-pound helmet hooked up to a computer the size of a small refrigerator.
Back then, the $90,000 unit transported burn wound patients into a frosty 3-D video game called SnowWorld, designed in cool blues and whites. Burn patients, Hoffman explains, often relive the trauma of their fiery encounters while their wounds are being cleaned. When Hoffman’s patients spent that time in SnowWorld, they reported feeling half as much pain as when they endured the procedure stuck in the reality of the hospital room. What’s more, when he tested SnowWorld on subjects who volunteered to endure a hot poke in the foot, they felt less pain too.
“Acute pain is a perfect match for VR,” says Hoffman. “You only need it for 20 minutes and it has drastic effects.” Chronic pain is a different, more challenging problem. Still, he thinks VR has the potential to enhance many treatments that already work. “If you say, ‘go home and meditate,’ not many patients will follow through,” Hoffman says. “But if you give them a VR system and say ‘go into this ancient world and meditate with monks,’ they’re more likely to actually do it.” VR is just a delivery method: What matters most is what the patients see and experience on the other side of the headset.
So as the cost of the technology has dropped, companies have popped up to build those experiences. One of those is AppliedVR, located just a 15 minute drive from Cedars-Sinai, on Beverly Hills’ Avenue of the Stars. It’s been building out a collection of 3-D content designed to combat pain, like a VR version of Netflix.
“We’re trying to figure out how to prescribe the right experience to the right person based on their needs and their interests,” says President Josh Sackman. So far his team has designed two dozen worlds, each one falling into one of four categories: distraction, relaxation, escape, and education. “But the end goal is to teach skills using technology, not to depend on it for the relief itself.”
The first experience they built was something called Bear Blast. It’s a cartoonish castle-scape where you go around shooting red teddy bears with balls from a cannon you aim with your head. The more bears you knock over, the more points you get. This is the game Spiegel gave to patients in a recent clinical trial. Out of 100 people who self-reported persistent, daily pain, half got an $800 kit with a Samsung headset and a Galaxy phone loaded with Bear Blast. The other half got to watch 2-D relaxation videos of lakes and babbling brooks. While they experienced a small bit of relief, the VR group reported feeling 25 percent less pain than when they started.
Bear Blast works—at least in theory—by distracting your brain. By grabbing all of its attention, the game closes down pathways that would transfer pain signals from your peripheral nervous system. The more immersed you are, the less pain you feel.
So how do you design for that? It’s one part game design playbook, one part trial and error. AppliedVR’s first attempt was actually a total flop. They started out fashioning a sort of candy-colored Disneyland ride, where you careen through a fantasy world knocking over things as you go. But they quickly discovered it was too freeform. People needed more direction. Hence, bowling over cute, fuzzy teddy bears. That works really well for acute pain. But the same principles apply for content that’s meant to deliver more long-lasting effects.
In a more recent trial at Cedars, Spiegel gave his patients more than just Bear Blast. They could choose a variety of experiences, like swimming with dolphins or flying over the fjords of Iceland in a helicopter, or just sitting on a beach and thinking about life. A voice in your ear might talk you through a breathing exercise, or ask you to contemplate the people and things that bring you joy. Mindfulness, meditation, and cognitive behavioral therapy are well-established pain management techniques, but most doctors don’t offer them to patients because they’re worried no one will buy in. The promise of a pill is a lot more tangible.
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“We know that positive thinking can actually work on a molecular level, by stopping ions from jumping the gate and causing pain signals to reach the brain,” says William Clark Becker, an internist at the Yale School of Medicine, where he researches pain management and addiction. He is not involved in any of AppliedVR's trials. “You can’t transplant people’s nerves. You can’t undo the process, but you can dampen the heightened pain signals that are getting up to the brain. And positive-thinking people are also better equipped to withstand the vagaries of everyday life.”
He’s found that his patients actually respond really well to mindfulness and CBT, and delivering those treatments in immersive VR is a tantalizing idea. But he says the important thing is making sure the evidence is there to show it’s an effective way to reach patients. Doctors like Spiegel are developing a stronger and stronger case that it is. In his next study, he's working with a major insurance company to evaluate whether or not virtual reality can reduce the number of opioids taken by people who've been recently injured on the job.
He imagines a world in the not too distant future where people coming out of surgeries or recovering from an accident walk out of the hospital with a set of VR goggles instead of a painkiller prescription. Because as Americans learned last week when President Trump declared the opioid crisis a public health emergency, if “we get people before they start, they don’t have to go through the problems of what people are going through.” Easier said than done. But maybe easier to do with virtual reality.