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


To our knowledge, this is the first systematic review to examine the possibility of using psychological intervention in the form of preoperative psychoeducation to achieve both preemptive benefit and multimodal advantage. Although it is important to note that each surgery includes a specific psychosocial context that differs by institution, cultural history/context or other considerations may influence the need for a specific cognitive strategy. Thus, a carefully designed preoperative intervention on patient literacy and education is critical in improving postoperative outcome.

Health care professionals (anesthesiologist, surgeons, nurses, etc) should give accurate preoperative pain education and pain management options. Improper pain education can lead patients to form inaccurate expectations of postoperative pain, either inflated or deflated expectation, which increases patients' physical sensations after surgery. Proper pain education can ameliorate this problem by more accurately preparing patients. High levels of preoperative anxiety are associated with higher levels of pain directly, 1 week and 3 months postoperatively.[24,26] Patients who received specific information about pain management options experienced decreased postoperative pain 24 hours after surgery and better physical function scores 6 months out.[19] Because high anxiety and pain catastrophizing are significantly correlated with a patient's risk for developing chronic pain, preoperative information can help lower anxiety and acute postoperative pain, ultimately lowering a patient's risk for developing CPSP. Using lay terms is important to enable patients to participate in open discussions with their physicians. Better education can help lower the risk for developing chronic pain, which ultimately decreases health care costs.[24,51]

The quantity of preoperative pain information given to patients still needs to be researched. In a review article by Wells and Kaptchuk,[52] they discuss the idea that disclosing every possible side effect of a medication may induce a nocebo effect in patients; causing more harm in a patient than good. Because of this psychological phenomenon, it is pertinent to research the quantity of psychoeducation necessary to minimize acute pain and the possibility of a nocebo effect.

This review focused on preoperative education as a form of psychoeducational pain management. However, there are other proposed methods described in the literature for lessening acute pain. Sears et al[53] evaluated a holistic perioperative medicine program called "Steps to Surgical Success" (STEPS) and its effect on patient preoperative anxiety and pain and postoperative outcome. With STEPS, 111 patients were given a 1-hour healing therapy session on preadmission and education day. Patients experienced reduced pain levels directly after therapy and reported that the STEPS program eased their overall surgical experience.[53] Ridgeway and Mathews[15] conducted a psychological preparation study with 60 hysterectomy patients split into 3 groups: cognitive coping techniques, information about surgical procedure and effects, and general information about the hospital ward (control). The cognitive coping group used the least amount of analgesics compared to the information group and control group.[15] Dindo et al[54] conducted a randomized control trial to analyze the efficacy of Acceptance and Commitment Therapy (ACT—a type of cognitive–behavioral therapy) on chronic pain and opioid use of "at-risk" veterans. This study illustrated that patients who participated in the ACT workshop ceased opioid use and had reduced pain sensation compared to the control group.[54] This emphasizes the importance of conducting further research on psychological intervention, not only on psychoeducation, but also on optimal cognitive coping techniques.

Different characteristics can also increase a patient's risk for developing CPSP. Althaus et al[55] found that capacity overload, preoperative pain at the proposed surgical site, other chronic preoperative pain, presence of ≥1 stress symptoms, and postsurgical acute pain are risk factors for developing CPSP. Hence, physicians need to recognize those at increased risk (signs of psychological distress) and tailor psychoeducational methods based on patient needs.[38,55] Physicians may also want to consider the PCS to recognize at-risk patients or incorporate ACT to address psychological risk factors for developing CPSP.[27,35]

Longer duration of acute pain can increase patients' risks of developing chronic pain.[51] Secondary hyperalgesia is thought to be a basis for CPSP and results from central nervous system changes that increase patients' pain perceptions in the previously injured area.[56] A major issue is the current use of medications to treat CPSP. Many prescribed opioids have limited success with preventing chronic pain.[56] To make the situation worse, opioids can also directly activate award associations in the brain causing patients to form learned associations eventually resulting in drug cravings, opioid misuse, and addiction.[57,58] Opioid exposure induces tolerance to the medication and may trigger paradoxical opioid-induced hyperalgesia.[59] In the United States, such overuse and abuse of opioids has led to the current opioid epidemic. Opioids are now reported as the second most common cause of poisoning in North America after alcohol intoxication.[60] About 488,000 emergency department visits were attributed to nonmedical use of prescription opioids in 2011 as well as 16,235 deaths in 2013.[60] A study done in 2012 found that the number of opioid prescriptions written by physicians in the United States has increased from 76 million in 1991 to 219 million prescriptions in 2011.[61]

We attempted to address the importance of education for optimal postsurgical recovery. However, we are limited by the lack of recent literature available and scope of the studies reviewed. Many of the studies published were from the 80s and 90s while only a few were from 2010 and onward. Because information from older studies may no longer be accurate, there is an obvious need for future research to validate these findings.

One major limitation of this study was that our initial search process was not complete and missed a few known important studies identified by expert reviewers that were then incorporated during the peer review process. A partial explanation may lie in the fact that it can be challenging to capture all literature in this diverging and emerging field. Readers should be reminded to exercise caution in the interpretation on the findings from this study. Nevertheless, this review provided reasonable evidence that psychological intervention in the form of the preoperative education may offer an attractive modality of nonpharmacological means in pain management. Appropriate psychological intervention may provide patients with not only preemptive benefit but also a multimodal advantage in their recovery. As aforementioned, there is a lack of research and literature exploring the option of psychological intervention in enhancing patient recovery from surgery. Future research will be needed to explore and address the specifics of psychoeducation such as timing, medical personnel in charge of education and patients' psychosocial, and cultural backgrounds in improving and enhancing postoperative recovery.