Annually, over 50 million surgical procedures take place in the United States. With the incidence of new persistent opioid use following surgical procedures estimated to exceed 6% 1, this contributes to an estimated 2 million Americans becoming persistent opioid users following initial postoperative exposure. Drug overdose is the leading cause of accidental death in the United States in recent years 2. In light of recent evidence suggesting that opioids are not as necessary in general anesthesia as previously thought 31 and the current opioid shortage, there is now an opportunity to curb the opioid crisis. Postoperative opioid use can be minimized in several ways, such as using co-analgesics (e.g. non-steroidal anti-inflammatory drugs); however, these yield a number of negative side effects. As such, non-drug-based postoperative pain management solutions are an important area of research, including in the form of audio therapy.
Evidence has pointed to rather high frequencies of wakefulness without explicit memory during general anesthesia 4. Therefore, certain research teams have sought to harness the intact perception of words and sounds by testing the use of taped therapeutic suggestions delivered during general anesthesia.
One 2001 double-blind randomized study found that audio therapy in the form of positive intraoperative suggestions had no beneficial effects on pain management, as it did not reduce postoperative pain or nausea scores. Consistently, neither the consumption of morphine or anti-emetics was reduced 5.
In contrast, however, another 2001 double-blind study found that intraoperative music and music in combination with therapeutic suggestions may benefit postoperative recovery following hysterectomy 6. A 2008 meta-analysis probing the effect of hypnosis on stress management related to medical procedures found that therapeutic suggestions are more effective when delivered at least partially prior to the medical procedure rather than solely during the procedure 7. Effects varied widely based on method of hypnosis delivery and age, with children responding better than adults. Thereafter, a 2016 meta-analysis of 32 randomized controlled trials on the efficacy of therapeutic suggestions under general anaesthesia, while finding no effect on pain intensity or mental distress, did find small but statistically significant positive effects on postoperative drug use and recovery 8.
Most recently, a 2020 blinded randomized controlled study sought to assess the effect of audio therapy played to patients through earphones during surgery on postoperative pain management and opioid use. Results revealed that such therapeutic suggestions during general anesthesia could provide a safe, cheap, clinically amenable, non-drug-based method of reducing postoperative pain and opioid use, alongside its potential for more generalized use 9. However, in light of these results, given that patients do sometimes have a degree of intraoperative awareness, surgical teams should remain aware of any background noise or negative conversations during surgery that may have opposite effects.
Therapeutic suggestions during anesthesia warrant further assessment, specifically in the context of more invasive and painful surgical procedures, and according to research protocols that standardize the applied suggestions and anesthetic regimen. In addition, audio therapy programs would likely need to be carefully developed to specifically target an individual’s background, age, and preferences.
Overall, intraoperative audio therapy is emerging as a potential supplemental method of managing postoperative patient pain and has important social implications with regard to curbing opioid misuse and addiction.
References
1. Brummett, C. M. et al. New persistent opioid use after minor and major surgical procedures in us adults. JAMA Surg. 152, 170504 (2017). doi:10.1001/jamasurg.2017.0504
2. Jones, G. H., Bruera, E., Abdi, S. & Kantarjian, H. M. The opioid epidemic in the United States—Overview, origins, and potential solutions. Cancer (2018). doi:10.1002/cncr.31713
3. Egan, T. D. Are opioids indispensable for general anaesthesia? Br. J. Anaesth. 122, e127–e135 (2019). doi:10.1016/j.bja.2019.02.018
4. Levinson, B. W. States of awareness during general anaesthesia: Preliminary communication. Br. J. Anaesth. (1965). doi:10.1093/bja/37.7.544
5. Dawson, P. R., Van Hamel, C., Wilkinson, D., Warwick, P. & O’Connor, M. Patient-controlled analgesia and intra-operative suggestion. Anaesthesia (2001). doi:10.1046/j.1365-2044.2001.01763-5.x
6. Nilsson, U., Rawal, N., Uneståhl, L. E., Zetterberg, C. & Unosson, M. Improved recovery after music and therapeutic suggestions during general anaesthesia: A double-blind randomised controlled trial. Acta Anaesthesiol. Scand. (2001). doi:10.1034/j.1399-6576.2001.045007812.x
7. Schnur, J. B., Kafer, I., Marcus, C. & Montgomery, G. H. Hypnosis to manage distress related to medical procedures: A meta-analysis. Contemp. Hypn. (2008). doi:10.1002/ch.364
8. Rosendahl, J., Koranyi, S., Jacob, D., Zech, N. & Hansen, E. Efficacy of therapeutic suggestions under general anesthesia: A systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. (2016). doi:10.1186/s12871-016-0292-0
9. Nowak, H. et al. Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: Multicentre randomised controlled trial. BMJ (2020). doi:10.1136/bmj.m4284