Hypnosis May Lessen Pain, Morphine Use in EP Lab

Hypnosis may have a role to play in pain management during catheter ablation for atrial flutter, a single-center randomized trial suggests.

Compared with placebo, hypnosis delivered through headphones while patients were under conscious sedation reduced both perceived pain and the need for morphine, according to lead author Rodrigue Garcia, MD (Centre Hospitalier Universitaire de Poitiers, France), and colleagues.

There were no complications in the hypnosis group and six—including four cases of severe hypotension related to morphine administration—in the placebo group, they report in a study published online August 12, 2020, ahead of print in JACC: Clinical Electrophysiology.

“Hypnosis is an effective adjunct to analgesia in reducing pain perception and may eliminate the need for intravenous opioids and their associated risks,” they write.

Anne Curtis, MD (University at Buffalo, NY), speaking for the American College of Cardiology, said there aren’t really any drawbacks to using hypnosis for this purpose. “There’s not going to be any side effects to it or downsides that I can see and there’s an upside in decreasing the amount of pain medications that are needed and patients’ perception of anxiety and pain,” she commented. “So I do think there are benefits if either the providers or the nurses or both are interested in doing that.”

But Curtis was skeptical about the broader applicability of the findings. “Honestly, I probably wouldn’t institute it if I was in the lab,” she said. “It’s an interesting technique that I don’t think is going to go a whole lot farther than what they were doing.”

The PAINLESS Study

Atrial flutter ablation is typically performed under conscious sedation using IV opioids like morphine with or without benzodiazepines, which itself carries a risk of adverse events. “Opiate use is associated with a risk for respiratory depression, hypotension, and, in rare circumstances, mortality,” Garcia and colleagues note.

Hypnosis offers a possible solution. “Hypnosedation uses hypnosis combined with locoregional anesthesia and small doses of intravenous analgesic agents,” the researchers explain. “It has recently been reported to be more efficacious than conventional analgesia during electrophysiological procedures in case reports, case series, and prospective nonrandomized studies.”

Do I think it’s going to be widely accepted? Honestly, probably not. Anne Curtis

The PAINLESS study was designed to provide more robust data. At their center, the researchers randomized 113 patients with typical atrial flutter (mean age 70; 21% women) to hypnosis or placebo during the ablation procedure. All patients were treated with a standard-of-care analgesia protocol that included IV administration of 1 mg of morphine whenever patients either scored their pain level as 5 or greater on an 11-point scale or requested it.

Hypnosis was delivered through headphones by practitioners trained by the French Hypnosis Association. In the placebo group, patients heard non-hypnotic relaxation suggestions and white noise through the headphones.

The primary outcome was the patients’ assessment of pain using a 10-point visual analog scale 45 minutes after the procedure—this was significantly lower in the hypnosis group (4.0 vs 5.5; P < 0.001).

Pain perception assessed every 5 minutes during the procedure with a numeric rating scale was consistently lower in the hypnosis group, and both operator and patient evaluations of sedation were better.

Patients who received hypnosis were less likely to require morphine (61% vs 93%), and among those who did receive the opioid, the total dose was lower in the hypnosis arm (1.3 vs 3.6 mg; P < 0.001 for both).

Easy Implementation

Curtis said, “the more you give pain medicine, the more people can have problems like respiratory suppression, so if you don’t have to use it, I think that’s good.” But the difference between groups in the overall morphine dose is not that great, she added. “In most patients, it probably wouldn’t make a difference whether you used a couple [milligrams of morphine] or not, but in some patients it might.”

Pointing to one potential limitation of the approach evaluated in the PAINLESS study, Curtis said adding hypnosis to the procedure could potentially add cost if a separate hypnotist needs to be involved.

The investigators, however, said hypnosis can be easily implemented in the electrophysiology (EP) lab, noting that at their center, two nurses have been trained to deliver it and the approach has been expanded to other procedures.

“If the nurse can also provide that hypnosis then I think there’s no added cost to that, plus you get some benefit out of it,” Curtis commented. “What that means then is that you have to have some enthusiasm by the nurses who are in charge there to want to do something like that. Do I think it’s going to be widely accepted? Honestly, probably not. It’s a small difference and it just adds some extra things to the procedure.”

Hypnosis also probably wouldn’t work for more complex EP procedures, she said, noting that atrial flutter ablation follows a standard approach and doesn’t take that long. Other procedures, like complex ablations for A-fib, are much longer and often require general anesthesia, which would complicate delivery of hypnosis.

“Where it might have the most use,” Curtis suggested, “could be [for] elderly patients or anybody in whom you think there’d be a particular sensitivity to the drugs that are used to relieve pain.”

Garcia et al acknowledge that there’s more work to be done: “Additional randomized trials are needed to determine whether pre-selection of patients receptive to hypnosis prior to ablation is a relevant strategy in the setting of standard-of-care implementation and to determine whether hypnosis is effective for other ablation procedures, such as atrial fibrillation ablation.”