Hypnotherapy Reduces Postoperative Opioid Use

Hypnotherapy may be an effective way to reduce opioid use in postsurgical settings, new research shows.

In a study of patients undergoing total knee arthroplasty (TKA), those undergoing hypnosis before surgery used fewer opioids postoperatively than their counterparts who did not undergo psychosis, even though pain, length of hospital stay, and complications were similar between the two patient groups.

Results of the randomized controlled study showed patients who receive hypnosis experienced a 24% reduction in postop opioid use vs the non-hypnosis group.

“I’m hoping this intervention gets attention from surgeons and internists, and anesthesiologists as well, as being a viable option for surgical patients [to reduce opioid use],” study investigator Jessie Kittle, MD, Stanford School of Medicine, Stanford, California, told Medscape Medical News.

The findings were presented at the virtual American Academy of Pain Medicine (AAPM) 2021 Annual Meeting.

An Underutilized Therapy?

“I picked a job right out of residency as a surgical pain management hospitalist and would see many people who come in for orthopedic surgery, and it occurred to me that a good 50% of my day was treating opioid-related complications after surgery,” said Kittle.

Dr Jessie Kittle

“I was getting consults for low blood pressure, vomiting, constipation that was turning into bowel obstructions, and yet people were also in horrible pain all the time. It occurred to me that there must be other tools that we can use besides opioids,” Kittle said.

She began to delve into the literature on treating pain after orthopedic surgery and was surprised to find a wealth of literature on the use of hypnosis for procedural pain and reducing opioid use.

“I couldn’t believe that I had not heard about this before in medical school or otherwise,” she said.

Not everybody is hypnotizable, Kittle said. About 75% of the population can be hypnotized, and this ability remains stable for each person throughout their life span.

“We can test this with functional MRI. If we put people who are not hypnotizable under a memory condition, a hypnosis condition, and a resting state, where they are not thinking about anything, nothing happens. But when you try to hypnotize people who are highly hypnotizable, you see a huge change in the connections between certain parts of the brain,” she explained.

Although not everyone is hypnotizable, there could be added benefits from a placebo effect.

“If you take a very highly-motivated person, and they really want hypnosis to work and they really trust the doctor, and they believe this good result is going to happen, they may get a benefit, but yes, there will be some people for whom this won’t work,” Kittle said.

The study was conducted at Stanford from October 2017 to December 2019 and included 64 patients undergoing TKA who were randomized to receive hypnosis (n = 31; median age 71 years; 65% female) or no hypnosis (controls, n = 33; median age, 66 years; 51% female).

Patients randomized in the hypnosis group received a 10-minute hypnosis session between 1 week and 1 day prior to surgery. They also had access to a recording of the session.

“The recording was basically the hypnosis session they had with me. They could call the phone number and hear it any time, and at the end, they could leave me their name and birth date. That is how I tracked how often they listened to the recording,” Kittle explained.

“The script covers body relaxation and includes direct visualization about where the location of pain is in the body, what it looks, and feels like, to imagine what it would be if it were a shape, and then imagine the shape changing its characteristics to make it more comfortable, and eventually ask it to move completely out of the body.

“We also talk about how it is natural to feel nervous before surgery [and] to give them positive reinforcement about all of the normal feelings people have about surgery, and after surgery to imagine yourself enjoying your best physical function and recovery,” she said.

Results showed a 24% reduction in postoperative opioid use in the hypnosis group vs the non-hypnosis group. The mean (SD) postoperative opioid use was 2.9 (2.0) opioid oral morphine milligram equivalents per hour (MME/hr) in the hypnosis group, and 3.8 (3.1) in the control group (P = .2007).

In addition, of the patients in the study who were on opioids before surgery, those in the hypnosis group (n = 9) reduced their postoperative opioid consumption by 55% compared with those in the control group (n = 8). The mean (SD) postoperative opioid use was 3.4 (2.3) MME/hr in the hypnosis group, and 7.5 (3.1) MME/hr in the control group (P = .0082).

Patient satisfaction with hypnosis was high with 72% of participants in this group reporting pain relief and 93% reported they would use it again.

Clinicians who would like to learn more about hypnosis can get more information from the American Society of Clinical Hypnosis or the Society for Clinical and Experimental Hypnosis, Kittle said.

Growing Awareness

Commenting on the findings for Medscape Medical News, Ann E. Hansen, DVM, MD, associate chief of staff for primary care, VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas, said she agrees medical education should include hypnotherapy.

“Primary care providers and hospitalists should familiarize themselves with the validated hypnotic susceptibility scales, and with the simple Spiegel eye roll test, which tests for hypnotizability,” said Hansen, who was not involved in the study.

“It’s a new field [and] there’s not enough data yet. Hypnosis is not mainstream, so any contribution to increase awareness is good, because it is potentially a very effective modality,” she said.

Hansen is a proponent of the Spiegel eye roll test, discovered by Dr Herbert Spiegel in 1972.

“The dyed-in-the-wool people say that test is not validated, and the more extensive screens are validated, but I have used it on a number of occasions clinically because it just takes a few seconds. The old-timers relied on it. My father, who was a physician born in 1905, believed in that test,” she said.

Hansen’s father, Hans Kraus, was a pain specialist who has been credited as being the father of sports medicine in the US. He was an associate professor of clinical physical medicine and rehabilitation at the New York University School of Medicine who became one of President John F. Kennedy’s doctors after he successfully treated the president for his back problems.

His obituary in The New York Times lists an impressive array of celebrity patients, including Kennedy, Katherine Hepburn, Eleanor Roosevelt, Arthur Godfrey, Yul Brynner, Rita Hayworth, Angela Lansbury, Oleg Cassini, Paulette Goddard, Robert F. Kennedy, and the skier Billy Kidd, who credited Dr Kraus’ treatments with making it possible for him to win an Olympic gold medal. 

“My father believed in hypnosis as a modality that could help selected patients,” Hansen explained, “and he did a little bit himself, but would send most of his patients to psychiatrists or other professionals. 

“He would use the eye roll test sometimes to determine if someone was hypnotizable and a good candidate for pursuing hypnosis as part of their treatment plan, to manage their pain and anxiety,” Hansen said.

“We are dealing with pain, and there is the mental component. In the brain, the pathways for pain, depression, anxiety, all of those overlap. Fifty years ago, people knew that intuitively and now they’ve proven it in the laboratory,” she added.

Kittle and Hansen have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2021 Annual Meeting: Poster Educational Session 1. Presented April 23, 2021.

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