Optimizing Control of Pain from Severe Burns: A Literature Review

American Journal of Clinical Hypnosis,  Jul 2004  by Patterson, David R,  Hoffman, Hunter G,  Weichman, Shelley A,  Jensen, Mark P,  Sharar, Sam R

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The importance of assessing and treating pain was made salient recently when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2000) declared that pain should be regarded as the fifth vital sign. Yet, the literature suggests that problems with undertreatment of pain have only improved modestly. In the 1970s and 1980s, scathing editorials were published by such journals as the Lancet and New England Journal of Medicine chastising physicians for undertreating this problem (Angell, 1982; Freed, 1976), and this was supported by a number of studies (Anand & Hickey, 1987; Eland & Anderson, 1977; Perry, Heidrich, & Ramos, 1981). Melzack (1990) argued in a Scientific American review that the problem persisted, in spite of unwarranted fears about addiction to morphine when used for pain control, and cited compelling evidence for this, such as children frequently receiving major surgery, including limb amputation, with no medication for relief of their postoperative pain.

More recent writings suggest that undertreatment of pain is still a significant problem in a variety of clinical settings (Breitbart et al., 1996; Carr & Thomas, 1997; Ducharme, 2000; Engel, Kartin, & Jensen, 2002; Katz, 2002), including the extremes of age (Banos, Ruiz, & Guardiola, 2001 ; Feldt & Oh, 2000) and patients with cancer (Frank-Stromborg & Christensen, 2001). The persistence of inadequate treatment is the result of educational factors (e.g., subtherapeutic dosing, lack of documentation of analgesic effect) as well as psychological factors; e.g., pain is subjective, regarded as a "symptom" and not a "disease," and often cannot be targeted by "magic bullets" (Ducharme, 2000; Jacob & Puntillo, 2000; Resnik, Rehm, & Minard, 2001). Although increased attention to pain assessment and pain management has occurred in recent years, observations that inadequate acute pain management contributes to poor functional outcomes in settings such as burns (Ptacek, Patterson, Montgomery, Ordonez, & Heimbach, 1995) and orthopedic trauma (Feldt & Oh, 2000) adds further motivation for designing effective pain therapy. As a result successful treatment of acute pain may pay long-term dividends in other aspects of medical care and outcome.

A salient point of this literature has often been that pain is undertreated through pharmacological means. Opioid analgesics (e.g., morphine/codeine-based drugs) are irrationally withheld from patients. Although undertreatment of pain does occur, and has been a frequent argument in our own writings (Patterson, Doctor, & Sharar, 1999; Patterson & Sharar, 2001), we contend that attention to nonpharmacological alternatives to opioid analgesics for pain control is even more wanting. Few controlled studies on treating acute pain with psychological techniques have been published. Opioid analgesics are indicated for use in a variety of acute pain settings and should be the cornerstone of treatment for the severe pain that accompanies burn injuries (Patterson & Sharar, 2001). However, pharmacologies do not control all pain in all patients (Carrougher & Patterson, 2002; Choiniere, Grenier, & Paquette, 1992; Perry et al., 1981). Further, such drugs do have side effects that can cause complications including nausea, constipation, sedation, itchiness, urinary retention, cognitive impairment, hallucinations, and respiratory depression (Brown, Albrecht, Pettit, McFadden, & Schermer, 2000; Cherny et al., 2001). Further, the use of doseopioids (as often occurs with burn patients) can unduly delay hospital discharge and thus prolong hospital stays, an increasingly pertinent issue in a society conscious of health care costs. Lang et al. (2000) recently demonstrated that hypnosis can decrease both operating room time and the use of expensive sedating/analgesic drugs. Thus, it is essential that more research be performed on psychologically based analgesic techniques, for they can augment pharmacologie analgesia and potentially diminish, or in some cases even eliminate, the need for opioid analgesics.

We contend that our proposed studies offer some innovative, powerful and exciting adjunctive nonpharmacologic approaches to burn pain. To lay a foundation for our proposed studies we will discuss 1) the nature of burn pain and conventional treatments; 2) virtual reality (VR) and distraction; 3) hypnosis; 4) interfacing VR and hypnosis; and 5) psychological and physical outcome of burn injuries.

Burn pain is an extremely unpleasant form of suffering, and can be difficult to treat. It is well known that a burn injury results in one of the most intense types of nociception imaginable (i.e., nociception = afferent neural signaling that forms the basis of pain). However, the pain that accompanies the treatment of a burn injury creates the true challenge, for typical burn care involves a series of aggressive procedures that stimulate nociceptive afferent fibers on a daily basis for days, weeks, or months after the initial injury. In conventional care, a burn injury is assessed as to its depth and treated accordingly. Shallow burns are allowed to heal on their own, and full-thickness thermal injuries typically are excised and covered with a skin graft (Tompkins et al., 1986). In many burn centers, patients with burns of indeterminate depth undergo a series of wound debridements and dressing changes on a daily basis. The pain of a burn patient can be anticipated and treated, to a large degree, based on the phase of care in which he or she is involved. Burn pain is divided into three distinct types (excluding postoperative pain), depending on the clinical setting in which it occurs. "Background pain" is present continuously from the time of the injury until wound healing is complete, and can vary in severity. Wound cleaning, limb mobility exercises, therapeutic skin stretching, and other medical procedures result in "procedural pain," which is of high intensity, but limited duration. When pain control interventions fail, patients experience "breakthrough pain." Each of these three types of burn-related pain has specific treatment strategies associated with them.