Preemptive and Preventive Pain Psychoeducation and Its Potential

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73) 559– Two important analgesic Two 1 Chronic Pain Medicine Pain Chronic www.anesthesia-analgesia.org SYSTEMATIC REVIEW ARTICLE REVIEW SYSTEMATIC E When patients utilized opioid-sparing 2 (Anesth Analg 2020;130: Proper postoperative pain management is Proper 1,2 and multimodal regimen approach. regimen and multimodal Thus, overreliance on opioids for postoperative Thus, overreliance 3,4 = hip disability and osteo - and disability hip = KOOS/HOOS 1 within the extensive literature on preemptive and on preemptive within the extensive literature has only focused multimodal concepts, most research crucial because excessive postoperative pain can not crucial can but process recovery and healing the hinder only pain. also lead to chronic of opioid use include postoperative nausea and vom- - depres iting, constipation, delirium, and respiratory sion. concepts have been introduced and are gaining popu- and are concepts have been introduced anal- larity in perioperative pain practice: preemptive gesia pain management may be associated with adverse length of stay and hos- events that can increase drug pital costs. treatments for postoperative pain, fewer resources for postoperative pain, fewer resources treatments of length hospital shorter a including expended, were recovery lower nursing workload, and improved stay, profile. NSAID = nonsteroidal anti-inflammatory drugs;ODI -aspartate; - = postanesthesia care unit; PCA = patient-controlled analge d = visual analogue scale See Articles, p 555, p 556, p 574 See Articles, p 555, Adverse effects 1

Number 3 Number • PRISMA = Catastrophizing Scale; postop = postoperative; preop = preoperative; PCS = Pain CPSP = to Problems Experienced; pain; COPE = Coping Orientation APSP = acute postsurgical = Anxiety-reduction, Distraction, Video Distraction, = Anxiety-reduction, ADVANCE = Acceptance and Commitment Therapy; The common treatment for postoperative pain is prescription opioids. Yet, these drugs have limited these drugs have Yet, for postoperative pain is prescription opioids. The common treatment pain from surgical intervention chronic effect in preventing in part and have opi- contributed to the been proposed with have analgesia and multimodal analgesia preemptive oid epidemic. Recently, analgesic approaches have both in addressing the pain issues. However, widely gained acceptance been focused on pharmacological aspect. while completely neglecting the psychological means of preoperative educational review conducted a systematic have we address this epidemic, To psychological approacha preventive application as both a preemptive and methods to explore its Preemptive psychoeducation occurs outcome. before pain and improve to decrease postsurgical surgery psy- while preventive and would include information about regional or neuraxial analgesia, choeducation occurs The content and presentation of preemp- throughout the perioperative period. tive psychoeducation can help patients form and address their concerns accurate expectations of By addressing the to a significant decrease in patients’ anxiety levels. leading surgical outcome, one can decrease postoperative preoperative education, psychological needs of patients through recovery opioid postsurgical acute pain results in fewer time and postsurgical acute pain. Reduced painpostsurgical chronic developing of risk patient’s the lowers theoretically which prescriptions, parta as psychoeducation pain preemptive using concept offerspotentially and novel a of (CPSP), the opioid epidemic. multimodal pain management solution to chronic postsurgical pain; DNIC = diffuse noxious inhibitoryER = emergency room; fMRI controls; for FORCE-TJR = Function and Outcomes Research = functional magnetic resonance imaging; Replacement; Joint Total in Effectiveness Comparative arthritis outcome score/knee injury and osteoarthritisN/A = outcome score; Max = maximum; = N-methyl- not applicable; NMDA = Oswestry Disability Index; PACU sia; Preferred Reporting- and Meta-analyses; RALP = robotic-assisted lap Items for Systematic Reviews RCT = randomized controlled trial; STEPS = Steps to Surgical Success; aroscopic prostatectomy; TSA = thermostimulator; VAS GLOSSARY ACT and Exposure/shap- Coaching, No excessive reassurance, parents, Adding modeling and education, ing; Volume 130 Volume • pioids including morphine, fentanyl, and oth- ers have been the mainstay of primary analge- patients. sia for most surgical

DOI: 10.1213/ANE.0000000000004319 2020 March From the *Department of Psychological and Brain Sciences, University From of California Santa Barbara, Santa Barbara, California; †Department of University of Health and Sciences, Lebanon, Osteopathic Medicine, Western Perioperative and Pain Anesthesiology, and ‡Department of Oregon; Alto, California. University School of Medicine, Palo Medicine, Stanford Accepted for publication May 28, 2019. Funding: Departmental/institutional. no conflicts of interest. The authors declare citations URL Supplemental digital content is available for this article. Direct and PDF versions of in the HTML provided appear in the printed text and are this article on the journal’s website (www.anesthesia-analgesia.org). the authors. Reprints will not be available from An- MD, FRCPC, Department of to Ban C. H. Tsui, correspondence Address University School Perioperative and Pain Medicine, Stanford esthesiology, CA Room H3584, MC 5640, Stanford, Floor, 3rd of Medicine, 300 Pasteur Dr, e-mail to [email protected]. Address 94305. Society Anesthesia Research Copyright © 2019 International

‡ † * Pain Control Option: A Systematic Review Systematic Option: A Control Pain FRCPC MD, BS, and Ban C. H. Tsui, Kaneshiro, Kelly BS, Horn, Audrey Its Potential Application as a Multimodal Perioperative Perioperative as a Multimodal Application Its Potential Preemptive and Preventive Pain Psychoeducation and and Psychoeducation Pain Preventive and Preemptive O

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Figure. Schematic diagram of non- pharmacological preemptive pain psychoeducation 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,

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 postoperative pain levels, increased risk of developing CPSP, and increased postoperative analgesic use.7,12–14 Procedural pain Psychological intervention and educational approaches during surgery preparation or recovery from surgery result in a knowledge 1.25- to 2.7-day shorter hospitalization, a decrease in ER visits 12 days postoperatively, and positive effects on patient anxiety and satisfaction.11,15–21 Anxiety and pain Pain catastrophizing and preoperative anxiety are associated with increased postoperative pain and analgesic use catastrophizing and negatively impact patient recovery.22–30 Education about the postoperative care, the surgical procedure, and the effect operative environment has been shown to reduce preoperative anxiety and postoperative pain.31,32 Identifying patients at risk of catastrophizing and with preoperative anxiety can serve as a basis for initiating a more comprehensive preemptive pain psychoeducation.33 Information delivery A sympathetic patient-centered approach to care can reduce preoperative anxiety, improve surgical recovery and wound strategy healing, and increase patient satisfaction with the quality of preoperative information.34 Open conversations utilizing lay terms to explain the surgical process and outcomes can make patients more comfortable, help them regain a sense of control, and diminish fears about their surgery.14,35 Written or electronic psychoeducation should be provided along with verbal information during preoperative consulting for optimal satisfaction and maximum recovery.9,36,37 Psychoeducational cost Although there is limited existing research within this topic, some studies show that psychoeducational intervention can decrease recovery time and pain which can be cost-effective for hospitals.10 Preoperative education can reduce a patient’s anxiety which lowers their risk to complications and ultimately lowers hospitalization time and analgesic use.11,15 Abbreviations: CPSP, chronic postsurgical pain; ER, emergency room.

respectively: (1) preoperative pain anticipated educa- (Table 2). They found that an inflated expectation tion, (2) procedural pain knowledge, (3) anxiety and of pain (illustrated by longer waiting time between pain catastrophizing effect, (4) information delivery temperature stimuli) more strongly activate neural strategy, and (5) psychoeducational cost. The quality processes that sense pain and influence the physical of evidence obtained from the literature searches was sensation (R2 = 0.88, P < .0001). An inflated expectation then assessed and graded using the Oxford levels of can lead to a stronger physical sensation of pain. For evidence (Supplemental Digital Content 1, Table 1, example, a study of 567 patients undergoing breast 12 http://links.lww.com/AA/C862). surgery found that patients with inflated expectations of postoperative pain experienced more pain up to RESULTS Studies range from 1955 to 2018, including a large 7 days after surgery compared to patients who had 14 7 percentage from the 80s, were identified. The search lower expectations of pain. Furthermore, Wang et al resulted a total of 338 publications (Supplemental conducted a study of 259 surgical patients and exam- Digital Content 2, Figure 1, http://links.lww.com/ ined the effects of preoperative beliefs on postsurgi- AA/C863). All titles were manually screened by 2 cal pain score. Patients with long-term surgical fears authors. At the first stage, articles unrelated to human were significantly correlated with developing CPSP.7 subjects or not in English were excluded, leaving In addition, the patient–practitioner relationship is a total of 55 publications for further evaluation. We negatively affected when a patient is told that a pro- further excluded 31 publications due to their focuses cedure will be painless because the patient will per- having no direct relationship to pain education such ceive their pain to be abnormal and/or something to as prerehabilitation, performance of surgeons, virtual be worried about.38 Ridgeway and Mathews15 found reality, observational studies, unpublished studies, that patients who believe they understand the surgi- therapeutic play, lack of postoperative outcome mea- cal process and deny information about their surgery sures, supportive care intervention, and image guid- form a mismatch between expectation and reality. ing studies. We also evaluated an additional 6 articles These patients have consumed more analgesics and that were referred by an expert colleague to our review. report higher levels of incisional pain compared to During the peer review process, 13 additional articles informed patients.15 In addition, medical settings were evaluated as recommended by reviewers. The can lead to strong patient emotions such as anxiety result of literature assessment based on Oxford levels of evidence is summarized in Tables 1–4. and anger, impeding their abilities to communicate with medical staff.38 Patients may feel overwhelmed, Preoperative Anticipated Pain Education which can prevent physicians from having open con- Koyama et al13 conducted a study where patients were versations about medical procedures and their after- examined in functional magnetic resonance imaging math. Therefore, physicians should be truthful about (fMRI) machines, and different temperature stimu- postoperative pain to prevent a mismatch between lus was given to their legs at different time intervals patients’ pain expectations and physical sensation.

March 2020 • Volume 130 • Number 3 www.anesthesia-analgesia.org 561 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Preemptive Psychoeducation 1b 1b 2b 2b 1b 3a Levels Levels Oxford of Evidence Outcomes experienced less intense acute postsurgical pain. who expressed more presurgeryPatients concerns about long-term effects of surgery at risk for more intense were CPSP at 4-month follow-up. of psychological preparation had the best recovery and pain score. lowest significantly shape neural processes that underlie the formulation of the actual sensory experience and provide insight as to how positive expectations diminish the of chronic disease states. severity reports of preoperative pain in the area to be operated on should be recognized and assessed before surgery. Preoperative pain in the area to be operated on is a risk factor for acute and persistent pain. intensity during surgery be and analgesic use. May possible to identify patients before surgery who are at risk for experiencing more postoperative pain. the anxiety and pain experienced by both adults and the anxiety and pain experienced by medical procedures children during a variety of invasive do not and are cost-effective techniques because they or resources expensive materials, require much time, that are not readily available. Patients who reportedPatients more presurgery pain self-efficacy Patients receiving cognitive coping methods as a mode Patients A mental representation of an impending sensory can event Psychological distress, pain expectations, and patients’ pain expectations, Psychological distress, Catastrophizing served as predictor of postoperative pain Cognitive–behavioral approaches are effective in reducing Cognitive–behavioral N 70 10 61 259 563 191 studies Preoperative Anticipated Pain Education Preoperative Anticipated Pain Comments factors 24 hours before surgery, and follow-up pain intensity factors 24 hours before surgery, ratings 48–72 hours after surgery and at 4-month follow-up different groups of psychological preparation. to examine the interactions between expectations and to examine the interactions between incoming sensory information. Numerical Rating Scale for pain used to assess association and acute psychological distress, pain expectation, between postoperative pain. must have they their beliefs about why is happening, and their knowledge about the operation, the operation, their ability to understand and relate to themselves any been provided. have information they Hospital Anxiety and Depression Scale. Postoperative days 1 days Hospital Anxiety and Depression Scale. Postoperative use were PCA fentanyl and intravenous pain intensity, and 2, assessed. Self-report battery of pain experiences and psychological A study randomly placing 70 hysterectomy patients under 3 A study randomly placing 70 hysterectomy TSA II thermal stimulator, fMRI scanning, and VAS were used were and VAS fMRI scanning, TSA II thermal stimulator, Beck Depression Inventory, State-Trait Anxiety Inventory, and Anxiety Inventory, State-Trait Beck Depression Inventory, examined patients’ preoperative belief of what The review The day before surgery, Greek patients completed PCS and before surgery, The day Study Design controlled study of cognitive and behavioral interventions observational cohort study Prospective study Randomized Longitudinal design Prospective study Literary review Prospective

22 (2005) (1982) 13 (1994) Preoperative Anticipated Pain Education: A SummaryPreoperative Anticipated Pain of Literature and Its Evidence 15 (2017) (2018) 38 14 7 Matthews (2009) Table 2. Table visual analogue scale. thermostimulator; Catastrophizing Scale; TSA, VAS, Pain patient-controlled analgesia; PCS, functional magnetic resonance imaging; PCA, fMRI, Abbreviations: Horne et al Koyama et al Koyama Sipilä et al Wang et al Wang Papaioannou et al Papaioannou and Ridgeway Author(s) (Year Published) Author(s) (Year

562 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E SYSTEMATIC REVIEW ARTICLE 1c 1b 1a 1a 2b 1b 2b 1b 1a Levels Levels Oxford of Evidence Outcomes reported current pain in the last 24 hours lower and had higher function scores 6 months postoperatively. mean physical of 10 days earlier than the control group. of 10 days and control on length of stay. many types of surgical patients because the length of hospital stay types of surgical patients because the length hospital stay many about 1 of 4 days. is reduced by patient satisfaction, improved emergency room utilization, of back and alleviation of expected improvements, achievement documented with greater success. pain that were in pain intensity and unpleasantness relation to the open administration of lidocaine. preoperative management. Significant relationship between information deficits/inadequate discussion of pain management and vomiting. nausea, and increased postoperative pain, told to be on top were management than the control group. They so therapy, up with physical of their pain management to keep felt comfortablethey asking for more pain medication when they needed it. days) compared to the controlled group. days) Patients, who received information about pain management options, who received information about pain management options, Patients, Special care group used significantly fewer narcotics and left 2 7 Special care group used significantly fewer patient education Majority of studies found significant result between Brief psychoeducational interventions be cost-effective with may A single 2-hour educational session before surgery reduced predicted a substantial amount of variance Expected pain levels age and satisfaction with pain relationship between Inverse Intervention group reported a higher degree of satisfaction with pain Groups with psychological interventions a better recovery saw rate (2 N 97 18 60 49 206 110 N/A 1609 studies 47 studies Procedural Pain Knowledge Procedural Pain Comments Charlson of the Comorbidity Index for evaluation effectiveness of preoperative pain treatment option information for managing pain postoperatively. control and special care group. Control were given general control and special care group. Control were given and special care were information about the hospital, specific instructions about pain management after surgery. surgery based on various factors. brief psychoeducational interventions and the length of postsurgical hospitalization. with interactive discussions with nursing, physiotherapy, and physiotherapy, with interactive discussions nursing, staff concentrating on what patients occupational therapy and proper how to best prepare for surgery, should expect, care postsurgery. (lidocaine) or pain-inducing (capsaicin) treatment relieving controlled for the natural history of pain. and staff member attitudes patient experiences, routines, after introduction of a quality assurance in surgical wards program. before surgery can help patients obtain better pain relief. FORCE-TJR study, PCS score, KOOS/HOOS, and modified KOOS/HOOS, PCS score, FORCE-TJR study, Split patients undergoing intra-abdominal operations into Identify effectiveness of patient education for orthopedic Analyzed studies that looked at the relationships between at the relationships between Analyzed studies that looked A quantitative review of 34 controlled studies. A quantitative review before their surgery education session 3–6 weeks Two-hour received open and hidden administration of pain- Patients to assess long-term levels effects on pain management VAS assessment to test whether specific information given VAS Study Design Meta-analysis (survey) controlled trial psychological interventions on outcomes study study comparative design based on survey data experimental design Prospective study Randomized Systematic review Literary of review Retrospective cohort Prospective cohort Descriptive and Prospective

18 21 11 20

Procedural Pain Knowledge: A SummaryProcedural Pain of Literature and Its Evidence

40 16 19 17 (2017) (1964) (2015) (1982) (1983) (2019) (2014) (2003) (2003) Table 3. Table knee injury and osteoarthritis Joint Replacement; KOOS/HOOS, outcome score/hip disability and osteoarthritis outcome Function and Outcomes Research for Comparative Effectiveness in Total FORCE-TJR, Abbreviations: visual analogue scale. Catastrophizing Scale; VAS, Pain not applicable; PCS, score; N/A, Author(s) (Year Author(s) (Year Published) Petersen et al Petersen Devine and Cook Devine Eastwood et al Majid et al et al Lemay Stomberg et al Sjöling et al Egbert et al Mumford et al

March 2020 • Volume 130 • Number 3 www.anesthesia-analgesia.org 563 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Preemptive Psychoeducation 1a 1b 1a 2b 2b 1b 2b 2b 1b 3a ) ( Continued Evidence Oxford Levels of Oxford Levels Outcomes significant relationship between high levels of high levels significant relationship between preoperative anxiety or pain catastrophizing and CPSP. a reversed relationship. No studies showed diminished opioid analgesia in patients with discogenic low back pain. neuroticism, anxiety, negative affect, and depression are negative affect, anxiety, neuroticism, all associated with APSP. in pain intensity and analgesic use. Younger patients in pain intensity and analgesic use. Younger to catastrophize and reportare more likely increased postoperative pain. catastrophic thinking about pain reported the greatest of upper extremity levels of pain and lowest levels function. with increased postoperative pain. of postoperative pain directly after increased levels surgery later. and 1 week higher postoperative pain scores. to have more likely associated with higher depression scores were Patients quality of recovery. with lower the anxiety and pain experienced by both adults and the anxiety and pain experienced by medical procedures children during a variety of invasive do not and are cost-effective techniques because they or resources expensive materials, require much time, that are not readily available. Larger studies were more likely to report more likely Larger studies were a statistically High levels of psychopathologyHigh levels are associated with Greater pain expectations correlated with higher pain rating Pain catastrophizing, optimism, expectation of pain, expectation of pain, optimism, catastrophizing, Pain Catastrophizing is associated with individual differences Participants who scored high on both cognitive fusion and Increased preoperative pain catastrophizing is associated significantly correlated with Preoperative state anxiety was with higher catastrophizing scores on PCS were Patients Cognitive–behavioral approaches are effective in reducing Cognitive–behavioral 2 N 29 60 59 64 53 110 101 191 studies studies 53 studies Anxiety and Pain Catastrophizing Effect Anxiety and Pain Comments RCTs were used to investigate whether high levels of whether high levels used to investigate RCTs were preop anxiety or pain catastrophizing are associated with an increased risk of CPSP. Relief, Pain Anxiety Symptoms Scale, State-Trait Anger State-Trait Anxiety Symptoms Scale, Pain Relief, Expectations for Relief Scale to address the Index, psychopathology and diminishedassociation between noncancer pain. opioid analgesia in patients with chronic, associated with APSP. pain and the actual experience of gynecological surgeries. to investigate the relation of cognitive coping and to investigate catastrophizing to acute postoperative pain and analgesic use. interacts with pain and upper extremity physical function interacts with pain and upper extremity physical in hand surgery. verbal rating scale, hospital anxiety and depression scale, recorded to investigate and analgesia consumption were the short-term preoperative association between and anxiety, psychological variables (pain catastrophizing, depression) and postoperative pain. and Short-Form McGill Pain perceived stress scale, Questionnaire to establish the relationship between preoperative state anxiety and postoperative pain. and quality of pain scores, hospital opioid consumption, recovery spine surgery. in adults who underwent is happening, their beliefs about why they must have must have they their beliefs about why is happening, and their knowledge about the operation, the operation, their ability to understand and relate to themselves any been provided. have information they Observational cohort studies, case–control studies, and Observational cohortcase–control studies, studies, Numerical Rating Scale of Pain, Functional Measures of Numerical Rating Scale of Pain, Systematic review of psychological factors that are Systematic review expectation of Examined predictive relationship between Self-report measure of cognitive coping and catastrophizing Tested whether cognitive fusion or catastrophic thinking Tested Preoperative and postoperative pain catastrophizing scale, Monitor-blunting style scale, Anxiety Inventory, State-Trait depression on anxiety, Analyze influence of catastrophizing, The review examined patients’ preoperative belief of what The review Study Design Meta-analysis designed trial epidemiological study and behavioral and behavioral interventions Randomized crossover Randomized crossover Systematic review of RCT Systematic review Correlational studies Prospective study Prospective cohort study Prospective Repeated-measures design Prospective cohort study Literary of cognitive review

24 41 (2017) (1994) Anxiety and Pain Catastrophizing Effect: A SummaryAnxiety and Pain of Literature and Its Evidence (2018) (2012) (2000) 23 38 27 (1996) 25 26 28 (1985) (2016) 6 8 et al Butler (2012) Khan et al Wallace Table 4. Table Author(s) (Year Author(s) (Year Published) Sobol-Kwapinska Sobol-Kwapinska Özkan et al Wasan (2005) Wasan Theunissen et al Kain et al Dunn et al Horne et al Jacobsen and

564 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E SYSTEMATIC REVIEW ARTICLE 1b 1b 1b 2b 2b 1b 3b 2b Evidence Oxford Levels of Oxford Levels Outcomes intensity/VAS and preoperative PCS as well as and preoperative PCS as well intensity/VAS 3-year postoperative pain/disability and between associated postoperative PCS. Catastrophizing is always with pain intensity and disability, the intervention group compared to the control group. pain in the postanesthetic care unit. Max score and 33% greater in PACU patients with high PCS was 38% greater at 24 hours compared with pain scores in patients with low PCS scores (below the median). experience and low satisfaction were female sex, high female sex, experience and low satisfaction were high anxiety about risks and preoperative pain severity, and age (younger), low expected pain severity, problems, high willingness to report pain. preoperative and postoperative pain ratings. between classes made fewer calls to the office seeking classes made fewer reassurance after surgery. relation between greater pain-related catastrophizing and relation between a catastrophizing plays pain ratings. Pain more severe primary role in modulation of pain outcomes. more postoperative leg pain after 3 days and after more postoperative leg pain after 3 days pain. 3 months than those who did not expect any who are optimistic about not experiencing Patients postoperative pain will be less disappointed after any surgery than will be patients with more pessimistic expectations about pain. Significant correlations between preoperative pain Significant correlations between Significant difference in the reduction of anxiety and pain PCS was a significant predictor of acute postsurgical PCS was Significant correlates of both worse than expected pain pain estimation: underestimated (42.9%), Postoperative and accurate (10.7%). (46.4%), overestimated had larger discrepancies who overestimated Patients Patients who participatedPatients in preoperative educational Diminished DNIC was a significant partialDiminished DNIC was mediator of the Patients who expected to feel leg and back pain reportedPatients N 96 86 48 91 65 35 192 120 Anxiety and Pain Catastrophizing Effect Anxiety and Pain Comments assessment before and 3 years after surgery. The VAS The VAS assessment before and 3 years after surgery. assessed 3 and 6 for back and leg pain ODI were months and 1 3 years after surgery. education) or control group. Anxiety and pain were assessed at 3 different time intervals. pain obtained in the postanesthetic care unit, as well as well pain obtained in the postanesthetic care unit, Opioid and nonopioid after surgery. and 7 days 2, as 1, while patients tabulated, analgesic consumption was in the hospital and after discharge. were used to identify factors which might correlate with postoperative pain and and potentially predict severe dissatisfaction with analgesic management. PCA pain scores, brief COPE, catastrophizing scale, into account to and surgery all taken were use, severity anticipated pain, examine relationships among anxiety, and patient- postoperative pain, coping styles, controlled analgesia use. 45–60 min educational class. Catastrophizing Scale, short-form Catastrophizing Scale, McGill Pain and Negative Affect and Positive Questionnaire, Schedule examined whether DNIC mediated the catastrophizing and pain. relationship between postoperative disappointment in groups of patients with rate different expectations regarding postoperative pain, and returning to work. of recovery, PCS questionnaire used for pain catastrophizing split into interventionPatients group (received preoperative Patients completed the PCS before surgery. Measures of completed the PCS before surgery. Patients Present Pain Intensity, VAS, and McGill Pain Questionnaire and McGill Pain VAS, Intensity, Present Pain pain anticipated pain, Anxiety Inventory, State-Trait Patients undergoing RALP were encouraged to attend undergoing RALP were Patients Standard Pain Catastrophizing Scale, In Vivo Pain Catastrophizing Scale, Standard Pain VAS and disappointment questionnaires used investigate and disappointment questionnaires used investigate VAS Study Design study postoperative questionnaires volunteer Prospective cohort study Randomized control trial Prospective cohort study Prospective observational Preoperative and Prospective cohort study In vivo assessment Longitudinal design

43 42 (2005) (2015) 30 31 32 (2018) (2018) 33 44 (1998) (2005) (2009) (1999) Table Table 4. Continued Thomas et al Oswestry Disability Index; maximum; ODI, diffuse noxious inhibitory controls; Max, Coping Orientation to Problems Experienced; DNIC, chronic postsurgical pain; COPE, acute postsurgical pain; CPSP, APSP, Abbreviations: visual randomized controlled trial; VAS, RCT, robotic-assisted laparoscopic prostatectomy; preoperative; RALP, Catastrophizing Scale; preop, Pain PCS, analgesia; patient-controlled postanesthesia care unit; PCA, PACU, analogue scale. Pavlin et al Pavlin Collin et al de Groot et al Goodin et al Lee et al Kim et al Author(s) (Year Author(s) (Year Published) Logan and Rose

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Inaccurate pain expectations will lead to increased information. Six months after surgery, the informed severity of acute postoperative pain. patients also demonstrated higher mean physical function scores and were more likely to use pain man- Authors’ Interpretation. Based on 3 studies with Oxford agement practices.19 These factors may have played a levels of evidence of 1b, there is strong evidence role in decreasing their postoperative pain. Moreover, suggesting that pain expectation will have an impact when physicians provided preoperative information on postoperative recovery. Patients who are not fully about the effects of analgesics, there was a significant informed about postoperative pain may develop a placebo effect causing a decrease in neuropathic pain mismatch between pain expectation and physical intensity and unpleasantness.20 Stomberg et al21 dem- sensation.6 When physical pain sensory information onstrated a significant correlation between poor pre- matches the expected sensation, patients feel operative information and increased postoperative some degree of reassurance.15 Hence, preoperative nausea and vomiting among 110 surgical patients. A anticipated pain education should be considered by study by Sjöling et al,40 involving 60 patients under- physicians in preemptive pain psychoeducation. going total knee arthroplasty, looked at the efficacy of educating patients about the importance of postop- Procedural Pain Knowledge erative pain management and taking an active role in Preoperative procedural and pain management infor- their own pain treatment. The treatment and control mation improves patient pain control and shortens groups were given basic preoperative information, their recovery time (Table 3). A review of 34 studies but the treatment group was also educated about showed that psychological intervention and edu- their own role in pain management and instructed to cational approaches during surgery preparation or inform medical staff about their pain.40 The treatment recovery from surgery resulted in a 2.37-day shorter group reported lower preoperative state anxiety and 11 16 hospitalization. Egbert et al conducted a study increased satisfaction of care than the control group.40 where 97 patients were split into 2 groups: the con- These studies demonstrate the importance of preop- trol group was given general information about the erative patient education for patient anxiety, satisfac- hospital ward and the “special care” group was given tion, and pain. preoperative pain education. The special care group received about half the narcotics and went home on Authors’ Interpretation. In light of 3 studies with Oxford average 2.7 days earlier than the control group.16 levels of evidence 1a, 3 studies with 1b, and 1 study Devine and Cook39 did a meta-analysis of 49 studies with 1c, procedural pain knowledge has a significant and found that preoperative education about proce- impact on pain control and recovery time, and patients dural information, pain management methods, and who opted out of procedural pain education had psychological support can reduce the length of hospi- longer hospitalization and poor pain management. talization by 1.25 days. A systematic review of patient Therefore, procedural pain knowledge is a good education for orthopedic surgery patients found that potential tool for physicians to improve patient pain patient education significantly reduced the length of control and decrease length of hospital stays. hospital stays compared to those who received no patient education or information.17 Another study Anxiety and Pain Catastrophizing Effect found that participation in a single preoperative mul- The lack of preoperative information not only leads tidisciplinary educational session resulted in about a to a mismatch between pain expectation and sensa- 50% reduction in emergency room visits in the first tion but also increases anxiety and catastrophizing 12 weeks after spine surgery compared to the con- (Table 4). Catastrophizing is defined as an exaggerated trolled cohort (16 emergency room visits in the educa- negative mental state during actual or anticipated pain tion cohort and 33 visits in the no education cohort).18 experiences and is one of the most important psycho- With proper pain education and management, phy- logical predictors of pain.8,22 Studies show a signifi- sicians may be able to prescribe fewer narcotics and cant interaction between catastrophic thinking and decrease patient hospitalization. postoperative pain intensity.23 A systematic review Studies focusing on pain have shown a significant and meta-analysis of 29 studies by Theunissen et al24 relationship between inadequate preoperative infor- showed that, in a majority (55%) of studies, preopera- mation and higher postoperative anxiety and pain tive anxiety and pain catastrophizing are significantly score. In a study of 1609 elective total joint arthro- associated with greater pain 3 months postoperatively plasty patients, Lemay et al19 showed that patients and with CPSP. A study of 64 cardiac surgery patients who receive information about postoperative pain illustrated that a pain catastrophizing score above the management options report lower current pain 24 median was associated on average with a 1.8 higher hours after surgery and higher levels of pain relief postoperative pain score (based on a 10-point verbal than patients who did not receive pain management rating scale).25 In addition, Kain et al26 conducted a

566 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E SYSTEMATIC REVIEW ARTICLE 2c 3b 2b 3a 2b 3b 2b 3a 1b 1b 1b of Evidence Oxford Levels Oxford Levels Outcomes with return appointment statistically significant but also clinically relevant. multimedia for preoperative anesthetic counseling. Patients appeared to place greater importance on rare but serious complications compared to common complications. as helpful in meeting their preoperative learning needs, and as helpful in meeting their preoperative learning needs, would recommend the booklet to a friend. 95% said they recalled accurately without prompting; 36% with a prompt; and 15% recalled erroneously or not at all. anxiety and pain experienced by both adults and children anxiety and pain experienced by medical procedures and are during a variety of invasive do not require much cost-effective techniques because they or resources that are not readily expensive materials, time, available. of local pain and better wound tissue type. calls to the office seeking reassurance after made fewer surgery. pain management than the control group. They were told to were pain management than the control group. They up with physical be on top of their pain management to keep felt comfortable so they asking for more pain therapy, needed it. medication when they differently where doctors regarded consultation with clear medical solutions more highly and patients preferred opened discussing their own opinions/experiences. conversations Intervention successful at reducing emotional distress. was Verbal education from a physician had the highest compliance education from a physician Verbal The relationship between stress and wound repair is not only The relationship between Most patients prefer a clinic consult instead of audio–visual Ninety percent of responding patients described the booklet Forty-nine percent of decisions and recommendations were Cognitive–behavioral approaches are effective in reducing the Cognitive–behavioral the intervention levels lower One month postop, group showed who participatedPatients in preoperative educational classes Intervention group reported a higher degree of satisfaction with Patient and physicians evaluate the success of consultation evaluate and physicians Patient 1 2 N 21 60 N/A 129 364 189 191 104 192 studies Information Delivery Strategy Comments preoperative education (pamphlet) for compliance with return appointment. experimental, and interventional experimental, studies corroborating the impact of stress on wound healing. trained interviewers by in regard to material perceptions, risk in the anesthesia consent-taking process. their perceived value of the booklet. encounters associated with patient recall of information after 1 week. is happening, their beliefs about why they must have must have they their beliefs about why is happening, and their knowledge about the operation, the operation, their ability to understand and relate to themselves any been provided. have information they the and Pressure Ulcer Scale for Healing to evaluate influence of an empathic patient-centered approach on preop anxiety and surgical outcomes. 60-min educational class. before surgery can help patients obtain better pain relief. counter their anxiety and depression. physicians during consultations in 2 studies. Evaluated physicians the success of interaction based on individual parties’ perspective. Comparing verbal preoperative education to written Examined data and methods from observational, administered to assess patients’ Questionnaires were Booklet used for preoperative teaching. Patients reportedBooklet used for preoperative teaching. Patients Evaluated characteristics of patients and outpatient The review examined patients’ preoperative belief of what The review surgery recovery score, Anxiety Inventory Y, Form State-Trait encouraged to attend 45- undergoing RALP were Patients VAS assessment to test whether specific information given VAS Using stress inoculation in a single patient case study to Analyzed the verbal interactions between patient and Analyzed the verbal interactions between Study Design of cognitive and behavioral interventions trial study experimental design studies Quasi-Scientific study Review Cross-sectional study Descriptive survey Observational study Literary review Randomized control Prospective cohort Prospective Single case study Literature review of 2 Literature review

35 9 (2016) (2003) (1994) Information Delivery Strategy: A Summary of Literature and Its Evidence (2015) 45 (2018) 40 38 (1984) (2011) 32 (2017) 46 47 36 37 (1986) (1986) (1991) Glaser Table 5. Table Abbreviations: N/A, not applicable; postop, postoperative; preop, preoperative; RALP, robotic-assisted laparoscopic prostatectomy; VAS, visual analogue scale. VAS, robotic-assisted laparoscopic prostatectomy; preoperative; RALP, postoperative; preop, not applicable; postop, N/A, Abbreviations: Blythe and Erdahl Author(s) (Year Author(s) (Year Published) Horne et al Yek et al Yek Collin et al Miller and Shank Parrinello Winefield and Murrell Gouin and Kiecolt- et al Laws Pereira et al Pereira Sjöling et al

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study with 53 women undergoing elective abdomi- feel helpless and confused, and in turn, patients may nal hysterectomy and found that preoperative state attempt to regain control by withholding information anxiety was significantly correlated with increased from the physician, which could lead to a misdiagno- levels of postoperative pain directly after surgery and sis. Using lay terms to explain the surgical process and 1 week later (r = 0.35, P < .01; r = 0.29, P < .05). Another outcomes can help patients feel more comfortable and study found that catastrophizing, anxiety, and depres- avoid conflict of information control between both sion scores (on Pain Catastrophizing Scale, Hospital parties.38 Patients can then more easily participate in Anxiety and Depression Scale) were associated with conversations with a physician rather than blindly higher pain scores and lower quality of recovery.27 accepting the doctor’s information. In fact, patients are Some patients have a fear of the unknown, which can most satisfied when they participate in the consulta- develop into medical phobias and increase their anxi- tion by discussing their opinions and experiences with ety.38 Similarly, higher levels of pain catastrophizing the physician.34 Open conversation can help regain are linked to a weaker opioid analgesia response.28,41 a patient’s sense of control and diminish some fears Pediatric research showed that high expected pain about the surgical process.38 By educating patients is a predictor of postoperative pain.6,42,43 Adolescent about pain management and encouraging open dis- surgery patients who expected higher levels of post- cussions, patients can verbalize their postoperative operative pain experienced greater intensity post- pain at an early stage to the medical staff, and physi- operative pain and utilized more patient-controlled cians can use effective pain management methods to analgesia (PCA) medication than those who expected prevent high peaks of pain.40 lower levels of pain. In this study, adolescent antici- According to Pereira et al,45 a sympathetic patient- pated pain score was the strongest predictor of post- centered approach can reduce preoperative anxiety, 29 operative pain. Pain catastrophizing is thought to improve surgical recovery and wound healing, and interrupt descending pain inhibition signals to the increase patient satisfaction. One hundred four ambu- spinal cord preventing neuroplastic changes that nor- latory surgery patients were assigned to a control or 30 mally respond to painful stimuli. This stimulates intervention group. The intervention group received pain sensitization and can hinder pain management. a 15-minute individual interview conducted by a A study of patients undergoing lumbar spinal sur- trained nurse who sympathetically addressed ques- gery demonstrated a significant correlation between tions regarding the surgery to validate each patient’s higher preoperative Pain Catastrophizing Scale (PCS) concerns. On postoperative day 1, the intervention scores and increased 3-year postoperative pain/dis- group had lower pain levels, better surgery recovery, ability.33 Therefore, identification of patients at risk for more physical activity, and more satisfaction with the catastrophizing before surgery could serve as a basis quality of preoperative information. One month later, for initiating a more comprehensive preemptive pain the intervention group had lower levels of local pain psychoeducation.31 Education about the postopera- and better wound tissue type.45 Because anxiety is tive care, surgical procedure, and operative environ- associated with slower wound healing and more post- ment has been shown to reduce preoperative anxiety, operative pain, it is beneficial to provide sympathetic postoperative pain, and, in some cases, decreased patient-centered care to reduce patient anxiety.36 number of postsurgical calls related to reassurance of Kastanias et al48 conducted a survey of 150 sur- their recovery.32,44 gical patients’ wants and needs. The top 3 items of Authors’ Interpretation. Two studies with the Oxford importance were all related to pain expectations, 48 levels of evidence of 1a and seven 1b studies suggest experience, and severity. Patients wanted informa- that there is a strong negative relationship between tion about drugs prescribed, their effectiveness and preoperative anxiety/pain catastrophizing and side effects, and who to call if the pain is not well 48 postoperative recovery. Therefore, preemptive pain controlled. When information is given by physi- psychoeducation focusing on preoperative education cians, patients typically only accurately recall about and pain management should be considered as part of half of the recommendations and information.46 A a multimodal approach in addressing the preoperative solution would be to provide written information in psychological state of patients to improve recovery. a general format for all different types of populations undergoing surgery.48 Hospitals can create a stream- Information Delivery Strategy lined structure for preoperative patient education for Presenting information on postoperative pain before health care. Individualized information could still surgery may affect patient outcome and satisfaction be added to patient education, but the overall struc- (Table 5). Patients’ primary complaints are the lack ture would be implemented to maximize patient out- of information and the complex nature of doctors’ come and minimize postoperative pain. In fact, 90% language.35 Scientific language can make patients of patients undergoing arterial bypass surgery felt

that a preoperative educational booklet was help- of evidence of 2 1a papers and 1 1b paper strongly ful.47 However, only providing written information support that implementing preemptive pain for patient education is not adequate. In a study com- psychoeducation could decrease health care costs. paring verbal information from a nurse or physician and written handouts, more knowledge was gained DISCUSSION through verbal information.9 Yek et al37 conducted To our knowledge, this is the first systematic review to a survey in Singapore of 364 surgical patients’ pref- examine the possibility of using psychological inter- erences regarding information during the anesthe- vention in the form of preoperative psychoeducation sia consent-taking process. They found that most to achieve both preemptive benefit and multimodal patients prefer a clinic consult instead of audio–visual advantage. Although it is important to note that each multimedia for preoperative anesthetic counseling. surgery includes a specific psychosocial context that This reinforces the fact that physicians should provide differs by institution, cultural history/context or other better preoperative procedural and pain information considerations may influence the need for a specific in conjunction to distributing written materials to cognitive strategy. Thus, a carefully designed preop- patients. Preoperative education classes are another erative intervention on patient literacy and education effective method to provide procedural pain educa- is critical in improving postoperative outcome. tion to patients, but it may not be feasible due to the Health care professionals (anesthesiologist, sur- increase in time required by medical personnel to pro- geons, nurses, etc) should give accurate preopera- vide such classes.32 tive pain education and pain management options. Improper pain education can lead patients to form Authors’ Interpretation. The way health care providers inaccurate expectations of postoperative pain, either address patients and present psychoeducational inflated or deflated expectation, which increases pain information should be considered. An open patients’ physical sensations after surgery. Proper pain and sympathetic discussion between providers education can ameliorate this problem by more accu- and patients is crucial for optimal satisfaction and rately preparing patients. High levels of preopera- maximum recovery. Based on the strong Oxford level tive anxiety are associated with higher levels of pain of evidence of three 1b articles, some form of written directly, 1 week and 3 months postoperatively.24,26 or electronic psychoeducation should be provided Patients who received specific information about pain along with verbal information during preoperative management options experienced decreased postop- consulting. erative pain 24 hours after surgery and better physical function scores 6 months out.19 Because high anxiety Psychoeducational Cost and pain catastrophizing are significantly correlated Last but not least, an important question to address is with a patient’s risk for developing chronic pain, pre- the operation cost of patient education on today’s lim- operative information can help lower anxiety and acute ited resource economic environment (Table 6). It is a dif- postoperative pain, ultimately lowering a patient’s risk ficult topic to directly address because there is limited for developing CPSP. Using lay terms is important to research on the cost of increasing preoperative educa- enable patients to participate in open discussions with tion. Also, there has been a trend in hospitals to lessen their physicians. Better education can help lower the interventions that treat preoperative patient anxiety risk for developing chronic pain, which ultimately due to increasing operational costs.49 However, postop- decreases health care costs.24,51 erative complications may cost patients up to $10,000 The quantity of preoperative pain information given or more in hospital expenses.50 Through increased pre- to patients still needs to be researched. In a review arti- operative education, physicians can reduce a patient’s cle by Wells and Kaptchuk,52 they discuss the idea that anxiety which lowers their risk to complications and disclosing every possible side effect of a medication ultimately lowers hospitalization time and analgesic may induce a nocebo effect in patients; causing more use.11,16 Similarly, Devine and Cook10 did a meta-anal- harm in a patient than good. Because of this psycholog- ysis of 102 studies and found that psychoeducational ical phenomenon, it is pertinent to research the quan- intervention can decrease recovery time and pain tity of psychoeducation necessary to minimize acute which can be cost-effective for hospitals. If hospitaliza- pain and the possibility of a nocebo effect. tion, complications, and analgesics are all decreased This review focused on preoperative education with the help of preoperative pain education, then as a form of psychoeducational pain management. hospitals can potentially save thousands of dollars per However, there are other proposed methods described patient by implementing psychoeducational programs. in the literature for lessening acute pain. Sears et al53 evaluated a holistic perioperative medicine program Authors’ Interpretation. Although there is limited called “Steps to Surgical Success” (STEPS) and its existing research within this topic, the Oxford levels effect on patient preoperative anxiety and pain and

March 2020 • Volume 130 • Number 3 www.anesthesia-analgesia.org 569 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Preemptive Psychoeducation 2b 2b 1b 1a 1a of Evidence Oxford Levels Oxford Levels Outcomes intervention not only reduced children’s anxiety intervention not only reduced children’s before surgery but also reduced the incidence shortened of postoperative delirium, discharge and reduced analgesic time after surgery, Cost efficiency of consumption after surgery. intervention developed newly any is important medical–economic climate. in today’s consequences from poor-quality health care, consequences from poor-quality health care, but the greater burden falls on health care payers. earlier narcotics and left 2 7 of 10 days than the control group. better recovery compared to the rate (2 days) controlled group. pain, effects on recovery, cost-relevant and satisfaction with psychological well-being, care. A family-centered preoperative behavioral A family-centered preoperative behavioral Hospitals and payers both suffer financial Hospitals and payers Special care group used significantly fewer Groups with psychological interventions a saw Psychoeducational interventions positive, have N 97 408 47 studies 102 studies 1008 patients Psychoeducational Cost Comments Trait Anxiety Inventory, Miller Behavioral Style Miller Behavioral Anxiety Inventory, Trait Scale score to examine and Bieri Faces Scale, intervention the effectiveness of ADVANCE on reducing anxiety. Surgical Quality Improvement Program Surgical Quality Improvement database to the internal accounting data at the University of Michigan hospital to determine incur whether hospitals or payers a larger burden of increased hospital costs associated with complications. operations into control and special care given general information group. Control were and special care were about the hospital, given specific instructions about pain management after surgery. influence recovery, pain, psychological well- psychological pain, influence recovery, and satisfaction with care among being, hospitalized adult surgery patients. Modified Yale Preoperative Anxiety Scale, State- Yale Preoperative Anxiety Scale, Modified Merged clinical information from the National Split patients undergoing intra-abdominal A quantitative review of 34 controlled studies. A quantitative review Examined how psychoeducational interventions Study Design trial psychological interventions on outcomes Randomized control trial Retrospective analysis Randomized controlled Literary of review Meta-analysis

Psychoeducational Cost: A Summary of Literature and Its Evidence 50 16 (1997) 49 (1964) (2006) (1982) (1986) Dimick et al Mumford et al and Cook Devine Egbert et al Author(s) (Year Author(s) (Year Published) Kain et al Table 6. Table and Exposure/shaping. Coaching, No excessive reassurance, Adding parents, Video modeling and education, Distraction, Anxiety-reduction, ADVANCE, Abbreviation:

postoperative outcome. With STEPS, 111 patients were 2013.60 A study done in 2012 found that the number of given a 1-hour healing therapy session on preadmis- opioid prescriptions written by physicians in the United sion and education day. Patients experienced reduced States has increased from 76 million in 1991 to 219 mil- pain levels directly after therapy and reported that lion prescriptions in 2011.61 the STEPS program eased their overall surgical expe- We attempted to address the importance of educa- rience.53 Ridgeway and Mathews15 conducted a psy- tion for optimal postsurgical recovery. However, we chological preparation study with 60 hysterectomy are limited by the lack of recent literature available patients split into 3 groups: cognitive coping tech- and scope of the studies reviewed. Many of the stud- niques, information about surgical procedure and ies published were from the 80s and 90s while only a effects, and general information about the hospital few were from 2010 and onward. Because information ward (control). The cognitive coping group used the from older studies may no longer be accurate, there is least amount of analgesics compared to the informa- an obvious need for future research to validate these 15 54 tion group and control group. Dindo et al conducted findings. a randomized control trial to analyze the efficacy of One major limitation of this study was that our ini- Acceptance and Commitment Therapy (ACT—a type tial search process was not complete and missed a few of cognitive–behavioral therapy) on chronic pain and known important studies identified by expert review- opioid use of “at-risk” veterans. This study illustrated ers that were then incorporated during the peer review that patients who participated in the ACT workshop process. A partial explanation may lie in the fact that ceased opioid use and had reduced pain sensation it can be challenging to capture all literature in this 54 compared to the control group. This emphasizes the diverging and emerging field. Readers should be importance of conducting further research on psycho- reminded to exercise caution in the interpretation on logical intervention, not only on psychoeducation, but the findings from this study. Nevertheless, this review also on optimal cognitive coping techniques. provided reasonable evidence that psychological Different characteristics can also increase a patient’s intervention in the form of the preoperative education risk for developing CPSP. Althaus et al55 found that may offer an attractive modality of nonpharmacologi- capacity overload, preoperative pain at the proposed cal means in pain management. Appropriate psycho- surgical site, other chronic preoperative pain, pres- logical intervention may provide patients with not ence of ≥1 stress symptoms, and postsurgical acute only preemptive benefit but also a multimodal advan- pain are risk factors for developing CPSP. Hence, phy- tage in their recovery. As aforementioned, there is a sicians need to recognize those at increased risk (signs lack of research and literature exploring the option of psychological distress) and tailor psychoeduca- of psychological intervention in enhancing patient tional methods based on patient needs.38,55 Physicians recovery from surgery. Future research will be needed may also want to consider the PCS to recognize at-risk patients or incorporate ACT to address psychological to explore and address the specifics of psychoeduca- risk factors for developing CPSP.27,35 tion such as timing, medical personnel in charge of Longer duration of acute pain can increase patients’ education and patients’ psychosocial, and cultural risks of developing chronic pain.51 Secondary hyperal- backgrounds in improving and enhancing postopera- gesia is thought to be a basis for CPSP and results from tive recovery. E central nervous system changes that increase patients’ pain perceptions in the previously injured area.56 A DISCLOSURES Name: Audrey Horn, BS. major issue is the current use of medications to treat Contribution: This author helped perform the systematic CPSP. Many prescribed opioids have limited success review and prepare the manuscript. with preventing chronic pain.56 To make the situation Name: Kelly Kaneshiro, BS. worse, opioids can also directly activate award asso- Contribution: This author helped perform the systematic ciations in the brain causing patients to form learned review and prepare the manuscript. associations eventually resulting in drug cravings, opi- Name: Ban C. H. Tsui, MD, FRCPC. 57,58 Contribution: This author helped overlook the project, analyze oid misuse, and addiction. Opioid exposure induces the data, and revise the manuscript. tolerance to the medication and may trigger paradoxi- This manuscript was handled by: Honorio T. Benzon, MD. cal opioid-induced hyperalgesia.59 In the United States, such overuse and abuse of opioids has led to the current REFERENCES opioid epidemic. Opioids are now reported as the sec- 1. Philip BK, Reese PR, Burch SP. 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