A Review of Aromatherapy in Pain Relief: The Economics of Pain

by Jane Buckle, RN, Ph.D. 

NAHA Spring Aromatherapy Journal 2001 - Vol. 11 No. 1 

The cost of US healthcare is now more than twice the developed-country average as a share of gross domestic product¹. Chronic pain costs the US economy approximately $70 billion dollars per year and affects around 80 million Americans². During the last five years there has been a staggering 2,700% increase in the numbers of social security disability awards due to chronic back pain³ and the emergence of specialized pain clinics⁴. Pain is one of the most commonly addressed symptoms in a clinical setting and is one of the main reasons why patients turn to alternative medicines⁵. 

“Chronic pain is a complex emotional, social and physical dysfunction with a myriad of symptoms ranging from anxiety, depression, irritability, insomnia to loss of appetite and immobility”⁶. Orthodox medicine tends to treat chronic pain with a mixture of opioid and non-opioid drugs. There is evidence that tricyclics or benzodiazepines (more commonly known for their anti-depressant properties) inhibit the action of nociceptor neurotransmitters. These drugs are used as analgesics (the dosage being less than that given for depression) and are particularly relevant in the treatment of neuropathic pain. 

Emergence of Aromatherapy 

Recently, aromatherapy has emerged as part of an integrated, multi-disciplinary approach to pain management. Aromatherapy is thought to enhance the parasympathetic response through the effects of touch and smell, encouraging relaxation at a deep level. Relaxation has been shown to alter perceptions of pain. Essential oils have pharmacologically active ingredients. These can have analgesic effect of their own or potentiate orthodox. Clinical trials are in the early stage but a recent review suggests aromatherapy could be an intriguing complementary therapy to consider in the management of chronic pain⁷. Several State Boards of Nursing accepted aromatherapy as part of holistic nursing care⁸. 

Definitions 

Aromatherapy is the controlled, therapeutic use of essential oils⁹. Essential oils are the volatile, organic constituents of fragrant plant matter¹⁰. When essential oils are used by nurses for therapeutic purposes, aromatherapy becomes clinical¹¹. Clinical aromatherapy is common practice amongst nurses in many parts of the world, such as the UK, Australia, South Africa, Germany and Switzerland care¹². 

The renaissance of aromatherapy occurred fifty years ago in France, but the roots of aromatherapy can be found in herbal medicine that dates back thousands of years and is still responsible for 80% of the world’s health care¹³. Many of our medicines originally came from herbs and some of those herbs were aromatic. 

In the United States aromatherapy is not yet really understood – many people thinking all that is involved is to inhale a few aromas. However, only pure essential oils are used in aromatherapy and they are frequently applied topically. Clinical aromatherapy requires clinical training. Take lavender for example. There are three different species of lavender: one is a sedative, one is a stimulant and the other can be neurotoxic in large doses but is effective against pseudomonas¹⁴. Lavandula angustifolia (true lavender) has a calming effect comparable to valium¹⁵. It can also enhance the effect of hypnotics¹⁶. Lavender also has cytophylactic properties and can be applied topically to enhance healing of burns and wounds¹⁷. 

Essential oils are the steam distillates of aromatic plants and should be 100% pure. However, many are adulterated, extended, diluted or synthetic. Using essential oils that are not pure may have a negative effect – for example causing an allergic reaction. Essential oils are highly concentrated – up to one hundred times greater than the plant, and only 1–5 drops are used at a time. 

Methods of use: 

1. Inhalation – useful for depression, insomnia, sinusitis, upper respiratory tract infection. Inhale directly from tissue or float 2 drops on steaming bowl of water.  

2. Topical – useful for pain, contusions, skin complaints, muscle strain and scar tissue. Use compress, bath, massage and the ‘m’ technique®.  

3. Vaginal – useful for yeast infections or cystitis. Use diluted in carrier oil on tampon. Use essential oils high in alcohol, such as teatree.  

Perception of pain can be altered with the soothing effects the ‘m’ technique® and essential oils This method of touch is quite different from massage¹⁸. 

The ‘m’ technique®: 

A recognized, registered method of touch being used by caregivers in the USA. 

• Uses structured stroking sequences in a set pattern at a set pressure. 
• Can be used on hands, feet and face and is gentle enough for the dying. 
• Is very easy and quick to learn. 
• Can be useful prior to and during painful procedures. 
• Is especially useful with children in pain. 
• Can be taught to relatives and caregivers. 

Using touch enhances our ability to communicate with patients in a non-verbal way. Both touch and smell can have instant effects, working at physical, psychological, and molecular levels¹⁹. These affect the parasympathetic nervous system. Essential oils are highly complex and are made up of many different chemical components or molecules. These molecules travel via the nose to the olfactory bulb and on to the limbic system of the brain, an inner complex ring of brain structures below the cerebral cortex, arranged into 53 regions and 35 associated tracts²⁰. Of these regions, the amygdala and the hippocampus are of particular importance in the processing of aromas. 

The amygdala governs our emotional response. Diazepam (Valium) is thought to reduce the effect of external emotional stimuli by increasing gamma aminobutyric acid (GABA)-containing inhibitory neurons in the amygdala²¹. Lavandula angustifolia (True lavender) is thought to have a similar effect on the amygdala producing a sedative effect similar to diazepam²². This is interesting as tricyclics or benzodiazepines, which are commonly used by orthodox medicine to treat chronic pain, also inhibit the action of nociceptor neurotransmitters. Lavandula angustifolia is a common essential oil used topically for pain relief that also appears to enhance the effect of orthodox pain medication. 

Clinical Studies 

In a study of 20 hospitalized children with HIV (aged 3 months and upwards), nurses used aromatherapy to give comfort and relieve physical pain²³. Discomfort from intermittent muscle spasm (due to encephalopathy) was eased. Chronic chest pain (that had been unresponsive to regular analgesia) was eased and painful peripheral neuropathy was alleviated almost completely²³. The following essential oils were found useful: 

Botanical name / Common name 

Lavandula angustifolia – Lavender 
Chamaemelum nobile – Roman chamomile 
Citrus aurantium – Neroli 
Citrus reticulata – Mandarin 
Santalum album – Sandalwood 
Cymbopogon martinii – Palma rosa 

Another study found a 50% reduction in pain perception of 100 patients nursed in a critical care unit by using lavender (Lavandula angustifolia)²⁴. 36 patients were divided into three groups of 12: one group received massage plus lavender, one group received massage without lavender, plus a control group. Treatment consisted of twenty minutes of foot massage twice a week for five weeks. The study was not randomized or “blinded” as smell and touch are impossible to hide. 

Brownfield’s study focused on the effects of Lavender essential oil on Rheumatoid arthritis²⁵. This randomized, controlled study used a quasi-experimental design on nine in-patients. A visual analog was used as the measurement tool. Intervention was a ten-minute upper neck and shoulder massage, with or without lavender. Despite the inconclusive results which the author concluded could be because many patients with RA “have difficulty distinguishing pain from stiffness”, patients reported that they slept better or were able to roll over in bed. 83% (n = 5) expressed a desire for further aromatherapy treatment. This study, although limited, does highlight that perception plays an important role in pain, and that perception can be affected by touch and smell. 

Wilkinson investigated the effects of 1% Roman chamomile (Chamaemelum nobile) on 51 patients with cancer in a randomized study²⁶. 45% of the participants were receiving morphine with the remainder on weak opioids, nonopioid or nothing. 76% of the participants had metastases. Tools used were Mann-Whitney U tests, Rotterdam Symptom and Spielberger State Trait Anxiety Inventory (STAI). Only the preliminary results from the first 51 patients were presented. Reduction in tension, anxiety and pain was statistically significant (P=0.003). One patient is quoted as saying “I know now, almost definitely, that it (aromatherapy) has helped me in my quest for pain relief. Since my last massage over 2 weeks ago I have started to have pain again. I have told Dr R at the pain clinic how pain free I was whilst having regular (aromatherapy) treatment”. 

Ritter writes of the positive effects of aromatherapy for a patient with bladder cancer and bone metastases²⁷. Her patient was in severe pain (8 on the Numeric Pain Intensity Scale) despite having PCA (patient controlled analgesia) of morphine. Positioning the patient in bed was hard as no position appeared to alleviate her discomfort. Two drops of lavender and rose essential oils were applied to a cotton handkerchief that was pinned on the patient’s nightgown. The effect was dramatic and almost instant – the patient took some deep breaths, opened her clenched fists and smiled for the first time for many weeks. Although the terminal nature of her disease was not affected, the quality of her life appeared to be considerably improved. 

Nurses and health workers throughout the world have been using aromatherapy for the reduction of pain and stress²⁸ ²⁹ ³⁰ although there is a shortage of formal published research. The analgesic effects of aromatherapy are thought to be caused by several factors: a complex mixture of volatile chemicals reaching the pleasure memory sites within the brain, certain analgesic components within the essential oil, which may or may not be known, affecting the neurotransmitters dopamine, serotonin and noradrenaline at receptor sites in the brain – the interaction of touch with sensory fibers in the skin which could possibly affect the transmission of referred pain – the rubefacient effect of baths or friction on the skin. 

Finally, during a study on the effects of aromatherapy in a critical care unit in the United Kingdom, patients were asked to comment on the treatment they had received. One of the comments was “you were the first person who didn’t hurt me”³¹. Nurses don’t mean to hurt their patients, but much of what they do can be painful or distasteful, and it is rare they can focus on giving pleasure. 

There is tremendous emphasis on ‘doing’ in the Western World. But illness takes away our ability to ‘do’ and forces us to address our being on a much broader scale. Aromatherapy using gentle touch and familiar smells can do much to help put back the hospitality into our hospitals and care into our health care.  

BIBLIOGRAPHY 

1 Peterson F. 1999. Gray Dawn. Times Books. New York 
2 Berman B M, Swyers J P. 1997. Establishing a research agenda for investigating alternative medical interventions for chronic pain. Primary Care. 24 (4) 743-758 
3 Hanson R W, Gerber K E. Coping with chronic pain. Guildford Press. New York. 1990 
4 Pennisi E. Racked with pain. New Scientist. March 9. 1996. 27-29 
5 Bullock M, Pheley A M, Kiresuk T J et al. Characteristics and complaints of patients seeking therapy at a holistic-based alternative medicine clinic. J Alt Comp Med. 1997. 3:1. 31-37 
6 Mackensie A. Care of the person with chronic health problems. Nursing Practice and Health Care. 2nd edn. ed Hinchcliffe S, Norman S, Schober J. Arnold, London. 1999 
7 Buckle J. 1998. Clinical Aromatherapy and Touch. Critical Care Nurse. 19 (5)54-61 
8 Lindberg B. Advisory Ruling: Board of Registration in Nursing. The Commonwealth of Massachusetts Division of Registration, Government Center, 100 Cambridge Street, Boston, MA 02202. Sept 10th 1997 
9 Welsh C. 1997. Complementary therapies in hospice care: touch with oils – a pertinent part of holistic hospice care. The American Journal of Hospice and Palliative Care. Jan/Feb. 42-44 
10 Tisserand R, Balacs T. 1995. Essential Oil Safety. Churchill Livingstone, London 
11 Buckle J. 1997. Clinical Aromatherapy in Nursing. Arnold, London 
12 Price S & Price L. 1995. Aromatherapy for Health Professionals. Churchill Livingstone, London 

Aromatherapy Journal Vol. 11 No. 1 Spring 2001