Preemptive and Preventive Pain Psychoeducation and its Potential Application as a Multimodal Perioperative Pain Control Option

A Systematic Review

Audrey Horn, BS; Kelly Kaneshiro, BS; Ban C. H. Tsui, MD, FRCPC


Anesth Analg. 2020;130(3):559-573. 

In This Article

Abstract and Introduction


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 opioid 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 surgery and would include information about regional or neuraxial analgesia, while preventive psychoeducation occurs throughout the perioperative period. The content and presentation of preemptive 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.


Opioids including morphine, fentanyl, and others have been the mainstay of primary analgesia for most surgical patients.[1] Adverse effects of opioid use include postoperative nausea and vomiting, constipation, delirium, and respiratory depression.[1] Thus, overreliance on opioids for postoperative pain management may be associated with adverse drug events that can increase length of stay and hospital costs.[2] When patients utilized opioid-sparing treatments for postoperative pain, fewer resources were expended, including a shorter hospital length of stay, lower nursing workload, and improved recovery profile.[1,2] Proper postoperative pain management is crucial because excessive postoperative pain can not only hinder the healing and recovery process but can also lead to chronic pain.[1] Two important analgesic concepts have been introduced and are gaining popularity in perioperative pain practice: preemptive analgesia[3,4] and multimodal regimen approach.[5] However, within the extensive literature on preemptive and multimodal concepts, most research has only focused on pharmacological means with little attention dedicated on the relationship between psychological intervention and perioperative pain management (Figure).


Schematic diagram of nonpharmacological preemptive pain psychoeducation as a part of multimodal perioperative pain control option. NMDA indicates N-methyl-D-aspartate; NSAID, nonsteroidal anti-inflammatory drugs.

Specifically, psychological intervention is as follows: What preoperative information should patients be informed of regarding the pain they will experience after surgery? Does the education about the modalities to manage their postoperative pain influence patient's recovery? What evidence is there concerning the merit of psychological intervention in patient pain outcomes? All these questions have been rarely addressed in today's anesthesia and pain literature. To address this shortcoming, 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.

The goal of this study is to examine the roles and evidence in utilizing preoperative psychoeducational intervention as a new concept of preemptive multimodal strategy on postoperative pain, outcomes to enhance recovery, prevent chronic postsurgical pain (CPSP), and minimize the opioid epidemic. Anticipated pain,[6] procedural pain knowledge,[7] anxiety and pain catastrophizing effect,[8] delivery strategy,[9] and cost[10] have been identified as major influences on postoperative pain, and this review will specifically look at the effects of education/information in respect to these 5 categories on assessing the quality of preoperative psychoeducation and its effects on the outcome of surgery.