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Preemptive and Preventive Pain Psychoeducation and Its Potential

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Chronic Pain Medicine E SYSTEMATIC REVIEW ARTICLE Preemptive and Preventive Pain Psychoeducation and 08/17/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZkD2PQTEnA3Z5k45NO+rAW3K+Jb0SmLKd+CtiOggV9Fpu0p+fXQJTeeueVW2LOflbf9WymT8A9qYl9dGsEbJRO3uww+U9U71BP0OnQSQG7Jy0Lo7jgRold/85IKDVUNqmO6LIP7fTeR03GxtHrZ8PUA== by https://journals-lww-com.laneproxy.stanford.edu/anesthesia-analgesia from Downloaded Its Potential Application as a Multimodal Perioperative Downloaded Pain Control Option: A Systematic Review from https://journals-lww-com.laneproxy.stanford.edu/anesthesia-analgesia Audrey Horn, BS, Kelly Kaneshiro, BS, and Ban C. H. Tsui, MD, FRCPC * See †Articles, p 555, p 556, p 574 ‡ The common treatment for postoperative pain is prescription opioids. Yet, these drugs have limited effect in preventing chronic pain from surgical intervention and have in part contributed to the opi- oid epidemic. Recently, preemptive analgesia and multimodal analgesia have been proposed with widely gained acceptance in addressing the pain issues. However, both analgesic approaches have been focused on pharmacological means while completely neglecting the psychological aspect. To address this epidemic, we have conducted a systematic review of preoperative educational methods to explore its application as both a preemptive and a preventive psychological approach to decrease postsurgical pain and improve outcome. Preemptive psychoeducation occurs before by surgery and would include information about regional or neuraxial analgesia, while preventive psy- BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZkD2PQTEnA3Z5k45NO+rAW3K+Jb0SmLKd+CtiOggV9Fpu0p+fXQJTeeueVW2LOflbf9WymT8A9qYl9dGsEbJRO3uww+U9U71BP0OnQSQG7Jy0Lo7jgRold/85IKDVUNqmO6LIP7fTeR03GxtHrZ8PUA== choeducation occurs throughout the perioperative period. The content and presentation of preemp- tive psychoeducation can help patients form accurate expectations and address their concerns of surgical outcome, leading to a significant decrease in patients’ anxiety levels. By addressing the psychological needs of patients through preoperative education, one can decrease postoperative recovery time and postsurgical acute pain. Reduced postsurgical acute pain results in fewer opioid prescriptions, which theoretically lowers the patient’s risk of developing chronic postsurgical pain (CPSP), and potentially offers a novel concept using preemptive pain psychoeducation as a part of multimodal pain management solution to the opioid epidemic. (Anesth Analg 2020;130:559–73) GLOSSARY ACT = Acceptance and Commitment Therapy; ADVANCE = Anxiety-reduction, Distraction, Video modeling and education, Adding parents, No excessive reassurance, Coaching, and Exposure/shap- ing; APSP = acute postsurgical pain; COPE = Coping Orientation to Problems Experienced; CPSP = chronic postsurgical pain; DNIC = diffuse noxious inhibitory controls; ER = emergency room; fMRI = functional magnetic resonance imaging; FORCE-TJR = Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement; KOOS/HOOS = hip disability and osteo- arthritis outcome score/knee injury and osteoarthritis outcome score; Max = maximum; N/A = not applicable; NMDA = N-methyl-D-aspartate; NSAID = nonsteroidal anti-inflammatory drugs; ODI = Oswestry Disability Index; PACU = postanesthesia care unit; PCA = patient-controlled analge- sia; PCS = Pain Catastrophizing Scale; postop = postoperative; preop = preoperative; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-analyses; RALP = robotic-assisted lap- aroscopic prostatectomy; RCT = randomized controlled trial; STEPS = Steps to Surgical Success; TSA = thermostimulator; VAS = visual analogue scale pioids including morphine, fentanyl, and oth- of opioid use include postoperative nausea and vom- ers have been the mainstay of primary analge- iting, constipation, delirium, and respiratory depres- Osia for most surgical patients.1 Adverse effects sion.1 Thus, overreliance on opioids for postoperative pain management may be associated with adverse From the Department of Psychological and Brain Sciences, University drug events that can increase length of stay and hos- of California Santa Barbara, Santa Barbara, California; Department of 2 Osteopathic* Medicine, Western University of Health and Sciences, Lebanon, pital costs. When patients utilized opioid-sparing Oregon; and Department of Anesthesiology, Perioperative† and Pain treatments for postoperative pain, fewer resources Medicine, Stanford University School of Medicine, Palo Alto, California. ‡ were expended, including a shorter hospital length of Accepted for publication May 28, 2019. stay, lower nursing workload, and improved recovery Funding: Departmental/institutional. profile.1,2 Proper postoperative pain management is The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations crucial because excessive postoperative pain can not appear in the printed text and are provided in the HTML and PDF versions of only hinder the healing and recovery process but can this article on the journal’s website (www.anesthesia-analgesia.org). also lead to chronic pain.1 Two important analgesic Reprints will not be available from the authors. concepts have been introduced and are gaining popu- Address correspondence to Ban C. H. Tsui, MD, FRCPC, Department of An- esthesiology, Perioperative and Pain Medicine, Stanford University School larity in perioperative pain practice: preemptive anal- on 08/17/2020 of Medicine, 300 Pasteur Dr, 3rd Floor, Room H3584, MC 5640, Stanford, CA gesia3,4 and multimodal regimen approach.5 However, 94305. Address e-mail to [email protected]. within the extensive literature on preemptive and Copyright © 2019 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000004319 multimodal concepts, most research has only focused March 2020 • Volume 130 • Number 3 www.anesthesia-analgesia.org 559 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Preemptive Psychoeducation Figure. Schematic diagram of non- pharmacological preemptive pain psy- choeducation as a part of multimodal perioperative pain control option. NMDA indicates N-methyl-D-aspartate; NSAID, nonsteroidal anti-inflammatory drugs. on pharmacological means with little attention dedi- to these 5 categories on assessing the quality of pre- cated on the relationship between psychological inter- operative psychoeducation and its effects on the out- vention and perioperative pain management (Figure). come of surgery. Specifically, psychological intervention is as fol- lows: What preoperative information should patients METHODS be informed of regarding the pain they will experience We conducted a literature review using Medline, after surgery? Does the education about the modalities Google Scholar, and PubMed. The term “psychologi- to manage their postoperative pain influence patient’s cal intervention”11 and following keywords were used recovery? What evidence is there concerning the merit when finding articles—“anxiety,” “postoperative of psychological intervention in patient pain outcomes? pain,” “preoperative expectations,” “recovery,” “edu- All these questions have been rarely addressed in cation,” “pain management,” “coping,” “postopera- today’s anesthesia and pain literature. To address this tive outcome,” and “pain catastrophizing.” Preferred shortcoming, we have conducted a systematic review Reporting Items for Systematic Reviews and Meta- of preoperative educational methods to explore its analyses (PRISMA) guidelines were followed for the application as both a preemptive and a preventive psy- identification, screening, and inclusion of articles for chological approach to decrease postsurgical pain and analysis. Inclusion criteria for the study were set to improve outcome. include individual case-controlled studies, original The goal of this study is to examine the roles and research studies, and systematic reviews. Expert opin- evidence in utilizing preoperative psychoeducational ion was excluded from the study. We selected stud- intervention as a new concept of preemptive mul- ies that focused on pain management education and timodal strategy on postoperative pain, outcomes postoperative recovery. Studies involving cognitive– to enhance recovery, prevent chronic postsurgical behavioral techniques were included. To broaden the pain (CPSP), and minimize the opioid epidemic. search on the topic and studies, bibliographies within Anticipated pain,6 procedural pain knowledge,7 anxi- identified publications were also manually reviewed ety and pain catastrophizing effect,8 delivery strategy,9 and included. We narrowed our search to human and cost10 have been identified as major influences on clinical trials and clinical studies in English. The evi- postoperative pain, and this review will specifically dence in the literature was also categorized and ana- look at the effects of education/information in respect lyzed based on 5 interrelated psychological domains, 560 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E SYSTEMATIC REVIEW ARTICLE Table 1. Summarized Interpretations for 5 Domains of Preemptive and Preventive Pain Psychoeducation Domains Summary of Interpretation Preoperative anticipated A mismatch between pain expectation (either too much or too little) and physical sensation can lead to increased pain education
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