NSAID or *NSYNC? Music as an Analgesic

July 23, 2023

By Mikaela Belsky

Peer Reviewed

As I walked out of Bellevue, I plugged in my headphones and clicked shuffle. Minutes later, I passed a friend who was confused as to “why” I was in “such a fantastic mood?I proceeded to tell him about my day: one round of CPR, two confirmed metastatic cancer cases, three young patients informed of life-shortening diagnoses, and four patients spiking fevers despite weeks of antibiotics. I genuinely had no idea why I was in such a fantastic mood, except maybe that I just paused Bye Bye Bye by *NSYNC on my phone. If one mediocre yet nostalgic song could transform my mood in three minutes, could music have the same effect on my patients? Unlike me, my patients were in pain and needed various analgesics to make it comfortably through the day. Might music decrease their pain?

With the modern shift away from a strictly biomedical model of pain prevention, music analgesia has increased in popularity. The US officially recognized music therapy as an adjuvant therapy in the 1940s, but music therapy was proposed by the ancient Greek philosopher Pythagoras and likely existed long before his time.1 In 1920, Dr. Esther Gatewood described what is now known as the “iso-principle” of mood change: the simultaneous entrance of two separate sensory stimuli, neutralizing each other and allowing only the more persistent stimulus into consciousness.2 Thus, playing a meaningful song can allow awareness to depart from reality; the neurologic and psychological impulse towards nostalgia and emotion would trump or at least mask unpleasant, contradictory sensations of pain.

Soon after, music was experimentally shown to improve muscle tone, digestion, cardiac output, respiratory rate, pulse, and blood pressure.2 Research progressed to identify three possible and likely interrelated mechanisms.3 First, limbic system stimulation activates endorphin release and parasympathetic nerves, allowing for relaxation and pleasure. Second, music sends impulses through ascending brainstem projections, regulating the central nervous system and commanding psychological interpretations of stimuli.3 Lastly, periodic physiological movements like breathing and heartbeat may respond specifically to transmitted musical information; rhythm, melody, strength, and speed can all be communicated through a song.3 Experts are still determining the details, mainly because music and pain interpretations are highly individual.4

A meta-analysis of 97 trials across a wide range of diagnoses, settings, ages, types of pain, and intensity levels consistently found that music significantly decreases pain. Music also decreased emotional pain-related distress, anesthetic use, opioid and non-opioid painkiller intake, heart and respiratory rate, and blood pressure.5 Music improves surgical pain outcomes, especially when played during postoperative or regional anesthesia phases.6-9 It even reduces opioid requirements after abdominal, orthopedic, and cardiothoracic surgeries, decreasing pain intensity during labor and postpartum.10-12 As for cancer-related pain, a 2022 systematic review reported significance in 92% of studies evaluating pain modulation in cancer patients receiving music therapy.13

Despite these encouraging results, there may be differences depending on the method of administration. Music medicine (MM) is “pre-recorded music listening experiences administered by medical personnel,” while music therapy (MT) is a tailored, progressive experience relying upon a relationship between client and therapist.5,14 Both can improve pain perception, although music therapy may have a more clinically meaningful effect in reducing acute, procedural, chronic, and cancer-related pain. In contrast, music medicine may lead to a greater reduction in biomedical analgesic use.5

As for songs that are most beneficial for the patient in pain, preferred personal music has been shown both qualitatively and quantitatively to enhance the analgesic effect of music.15 It does not matter whether one prefers Fleetwood Mac, Bach’s Concerto for Two Violins, Kendrick Lamar, Wicked, or Twinkle Twinkle Little Star; the songs simply must be loved by the listener. Loved songs are tied to salient memories of people, places, and moments and allow for a shifting of focus from pain. The goal is for music to progress from acting as a pain distractor to becoming the center of attention. Pain is then a nagging afterthought–the distractor of music rather than an overbearing experiential focus, just as Dr. Gatewood postulated. A musical stimulus that is meaningful to the listener takes on the power to distract, neutralize, or even mask pain entirely.

Why do we not see physicians prescribing music as they would a drug? Research long ago established a place for music within pain management, and an entire journal is dedicated to MT–The Journal of Music Therapy. Perhaps the helpfulness of personally meaningful songs poses a drawback; patients may object to listening to their favorite songs at times of great pain, hoping to avoid negative future associations. As such, research should continue regarding acute and procedural pain and the role that music can play in abatement. Additionally, music appears to vary in pain management effectiveness and transience in different individuals.16,17 Although age-stratified evidence shows the greatest benefit in children, other epidemiologic factors remain unclear.5

Further investigation into self-directed listening is also necessary. Like many forms of medical treatment, there should be guidelines regarding the use of music beyond MT and MM, specialized alternative pain care, or the watchful eye of experts. With this next step, high-risk patients would continue to benefit from professional MT and MM. For others, there is no reason that music could not be prescribed like a drug, by doctors of all specialties, for chronic pain, post-operative pain, prophylaxis, and more.

Overall, in both inpatient and outpatient settings, and now even telemedicine, music can be an accessible complementary approach to biomedicine.18 It is cheap, with few if any side effects, and widely enjoyed. We may never fully understand the science behind music’s analgesic effects, and we may never find a metric that accurately quantifies the complicated, individual, subjective experience that is pain. Yet, what harm is there in centering our patients’ complex, personal, subjective experiences and encouraging them to hum along?

Mikaela Belsky is a 2nd year medical student at NYU Grossman School of Medicine

Peer reviewed by Michael Tanner, MD, associate editor, Clinical Correlations

Image courtesy of Wikimedia Commons, source: https://commons.wikimedia.org/w/index.php?search=nsync&title=Special:MediaSearch&go=Go&type=image


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