Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

Abstract

Objective:

Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.

Design:

We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.

Setting:

All participants underwent surgery at a single, academic tertiary-care center.

Participants:

Adult patients who had a general surgery operation in the prior 60 days.

Outcome measure:

Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.

Results:

Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.

Conclusions:

Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

INTRODUCTION

In 2016, opioid overdoses accounted for over 42,000 deaths in the United States, with over 17,000 of these from prescription opioids.¹ In addition to the tragic and avoidable loss of life, this national epidemic has an economic burden of $78.5 billion annually.² Nearly 10 percent of all opioid prescriptions in the United States are written by surgeons for post-operative pain management.³ Most patients (67–90 percent) do not use their entire opioid prescription following inpatient surgery, with 42–71 percent of pills left unused.⁴ These large opioid prescriptions and leftover pills can place patients at risk for opioid use disorders, with 6.5 percent of patients persistently relying on opioids after major surgery.^5,6 Overprescribing opioids also leads to increased access to opioids among the general public. Concern over these issues has led to significant efforts over the past decade to curb opioid prescribing, including the generation of guidelines to limit the number of opioids prescribed after common surgical procedures and provider-based educational initiatives.^7–9

Patient voices have largely been left out of the conversation regarding post-operative pain management and opioid stewardship.¹⁰ Opioids are rarely prescribed in a patient-centered way and little evidence exists to inform prescribers about how patients think about pain expectations, pain management, and opioid use following surgery.^11,12 Efforts to reduce opioid prescribing have generally focused on a “one-size-fits-all approach of hard thresholds” for writing opioid prescriptions.¹³ This approach often fails to adequately involve patient perspectives in their own pain management and lacks flexibility to allow for opioid prescribing in a patient-centered manner.^13–15 Most post-operative patient opioid education studies have focused on the task of educating patients instead of eliciting the patients’ own experiences and expectations regarding opioids and post-operative pain.^16,17

This qualitative study explores patients’ thoughts regarding their preparation for surgery, experiences of pain and pain management post-operatively, and views on opioid disposal. A better understanding of patient perspectives is needed to develop and refine patient-centered interventions aimed at improving opioid stewardship. A greater awareness of patient experiences will help providers personalize patient education and improve opioid stewardship without sacrificing individual patient preferences and satisfaction.

METHODS

This study was deemed exempt by the Institutional Review Board at the University of Utah. We performed a qualitative study evaluating patient expectations of pain following surgery and perceptions of post-operative pain control. English-speaking adult participants (age 18 or older) who had undergone an operation by a general surgeon at our institution were recruited to participate. A convenience sample of patients who had recently undergone a general surgical operation was included. Interviews were conducted in a sequential manner, and we continued to recruit patients until theoretical saturation was reached and obtaining new information from participants was unlikely. Participants were excluded if they declined to be audio recorded.

Each participant was initially invited to participate by a single member of the research team (JE) in person or by phone, who discussed the requirements of participation with patients. After obtaining informed consent from each participant, we performed semi-structured, open-ended interviews, 45 minutes to 1 hour in length, within 60 days of their operation. All interviews were conducted by a single investigator (JE), either by phone or in person at a follow-up clinic appointment, between October 2018 and September 2019. Participants did not receive any compensation for participation.

Interview guide

A semistructured interview guide was developed based on recent research on patient expectations of post-surgical pain and opioid use and misuse following surgery, as well as the investigators’ personal clinical experience with the delivery of post-operative pain control (Appendix). At our institution, at the time of this study, there was no standard education on post-operative pain management for surgical patients. Questions were designed to query patient attitudes, beliefs, and knowledge about pain and opioids with respect to their recent experience with surgery. The final guide included questions on three main topics: pain expectations prior to surgery, pain management post-operatively, and knowledge of opioid disposal methods. Participants were asked about their expectations of post-operative pain and what factors contributed to this expectation. They were then asked about what methods they used to control post-operative pain—including opioid medications, nonopioid medications, and nonpharmaceutical approaches—in addition to how successful their approach to pain control was. Questions regarding opioid disposal assessed patient knowledge of appropriate disposal methods, education by providers on disposal methods, and patients’ actual practice regarding opioid disposal. This section of the interview guide aimed to identify gaps in patient education and barriers to opioid disposal.

Data analyses

All interviews were audio recorded and transcribed verbatim. Content and thematic analysis was performed by two of the investigators (JB and JE) on a random sample of 10 percent of the interview transcripts to identify key themes and concepts from the interviews. An initial codebook was generated, then revised using an additional 10 percent of the study sample using a constant comparative method.^18,19 The investigators met to discuss about addition or removal of new codes, ensuring all themes in the interviews were represented by a code and that each code was unique. This process was repeated until both coders felt the codebook was complete and concise, three times in total. The final codebook contained 23 codes, grouped into three categories corresponding to the interview guide: pain expectations (n = 7); post-operative pain management (n = 8); and opioid disposal (n = 8). Codes were not created based on an a priori framework. Rather, investigators allowed codes and themes to emerge from the interview transcripts. During this process, the investigators achieved a high rate of inter-rater reliability, defined as a Cohen’s κ value of 0.7 or higher for all individual codes.²⁰ Once the codebook was finalized, all interviews were coded by one of two coders. Codes were then analyzed by all investigators to identify key themes that best describe the overall participant experience. We do not report percentages or quantitative statistics. We used a semi-structured interview guide, which does not use standardized question wording and does not ensure that all questions are asked of every participant.

RESULTS

In total, 45 patients were approached for recruitment and 40 agreed to participate. Nine patients did not respond on follow-up and one interview was excluded from analysis because of poor audio quality. Of the 30 participants included, the majority of participants (n = 24) underwent a colorectal procedure, with most of these patients having a colon resection (n = 18). Other participants underwent operations for hernias (n = 2), gallbladder disease (n = 1), breast cancer (n = 2), or a gastrointestinal stromal tumor of the stomach (n = 1). Operations were performed by nine different surgeons. Most of the surgeries were conducted via a minimally invasive approach (laparoscopic [n = 13] or robotic [n = 13]), while the remainder had an open surgery (n = 4). Fourteen participants (46.7 percent) were female, and the median age of participants was 59.

Pain expectations

Many participants reported that they did not have realistic expectations preoperatively of the amount of post-operative pain they would experience before surgery. Participants differed on whether they expected high or low amounts of pain following surgery, but these expectations were not based on information from the surgical team. Pain expectations were founded on either their own research and reading, personal prior experiences with surgery or childbirth, or the experiences shared with them by friends or family who had undergone surgery previously. Those who did not seek such information and did not have prior experiences with surgery often reported having nothing to base their expectations on.

I had no idea what to expect. I’d never had a surgery before. I imagined it would be painful, but I had no references to how painful it might be or anything like that.—Participant 001

You know, I really didn’t know what to expect, to be honest with you. I knew it would probably suck, but I wasn’t sure exactly what to really go for.—Participant 019

I went into it expecting to be… for it to be pretty painful. I’ve had a few surgeries in the abdomen, so I kind of braced myself for… I like to expect the worst.—Participant 030

Only one participant mentioned a conversation with his/her surgeon about pain expectations preoperatively, stating “He had actually told me that my bottom would probably hurt the most and that they would use a [local anesthetic] block to help my abdomen so that it wouldn’t be very painful (Participant 031).”

Some participants reported having had extreme anxiety about what their post-operative pain experience would be, while others had been relatively unconcerned. Many cited their personal pain tolerance as a reason for being either fearful or unworried about pain after surgery. Regardless of what their expectations were, very few patients felt their actual experience with post-operative pain aligned with their preoperative expectations. Those who were unworried before surgery sometimes found themselves in much more pain post-operatively, unprepared to handle this shock. Others were happily relieved by the lack of pain they experienced as compared to their expectations.

Oh, I expected to have a lot of pain, but I didn’t have any.—Participant 022

Because I haven’t had that much surgery, I just assumed that it would hurt a little bit more than it does.—Participant 025

Oh, it was way worse than I thought.—Participant 010

Pain control

Participants reported having a mixed experience with pain management after surgery. Most used multiple pain control modalities including opioid and nonopioid medications, ice and heat packs, cannabis, massage, mindfulness, meditation, and prayer. All but two participants used opioids as part of their pain control plan.

Regardless of individual pain plans and opioid use, a common theme was the lack of education by providers to participants on how to best manage pain and how to use opioids. Similar to participant experiences with preoperative pain expectations, many participants learned about pain management from their own prior experiences with pain or their own personal reading and research. Several participants recalled having a conversation with nursing staff or a pharmacist about how to use opioids and balance opioid use with other pain management modalities; however, almost no participants recalled a conversation with a member of the surgical team on this topic. This led to a wide diversity of understanding among participants about how to use their opioid prescriptions.

The pharmacist was really good when they came in with my bag of prescriptions and told me how to use everything, so the hospital staff was great that way.—Participant 007

Just basically reading a lot, articles on the Internet. Actually talking with doctors; not too often.—Participant 012

On receiving preoperative education: “Not a whole lot. I mean, I’ve just kind of, you know, just from what I already knew, really, but no formal education or anything like that.” — Participant 019

Not a lot. I probably look a lot of things up on the internet if I need help with something. To understand something, I look it up. I try not to bother the doctors too much.—Participant 033

Many patients stated they used as few opioids as possible and used opioids only when absolutely necessary. Others avoided opioids secondary to side effects of the medication or a fear of opioid addiction.

I only used two of [the oxycodone]. I could’ve used more. I didn’t like how they made me feel, so I just stuck with Tylenol and ibuprofen for the days that were a little harder.—Participant 001

It makes me really cautious. I definitely do not want to become an addict. So, I try to be careful about taking those and thinking to myself, well is the pain really that bad? Before I actually swallow one.—Participant 033

Conversely, some participants reported that they took their entire opioid prescription because they felt that is what their surgeon wanted them to do, not based on their actual need for pain relief. Other patients relied on opioids for pain control as they had incorrect information regarding other pain control methods. Some patients incorrectly thought over the counter pain medications were contraindicated following surgery. Other patients reported using tramadol, a low potency opioid, over nonopioid alternatives because they thought tramadol was not an opioid. A large number of participants reported they were not consulted about having an opioid prescription filled for them.

Well, I didn’t know I had a choice. I had to have [the opioid prescription] before they’d let me out of the hospital.—Participant 014

I really didn’t have a choice. The doctor filled the [opioid] prescription, and the nurse brought it to the room, and I paid for it.—Participant 022

I was told to take it all. There shouldn’t be anything to dispose of.—Participant 007

Opioid disposal

Many participants had leftover opioids once their post-surgical pain had resolved. Some participants intentionally kept their leftover opioids in case they had pain in the future—either for a chronic disease with associated pain or for an unexpected episode of acute pain. Many participants stated they planned to dispose of leftover medications, either via an official disposal location or an alternative mechanism, although they had not got around to doing it yet. Others were very intentional about disposing of leftover opioids because of the fear that they would be stolen from them by friends or family who wanted to use the medication themselves or sell the leftover pills for money.

I plan on keeping [my leftover pills], so if I ever have a night where I’m in too much pain to sleep and I need to sleep. So yeah, I have it. I have it put it away. And I plan on keeping it.—Participant 003

On why the participant had not disposed of his or her leftover opioid medication: “I don’t know. I don’t know… I just haven’t dealt with it.”—Participant 015

On why the participant disposed of his or her leftover opioid medication: “Because there is people out there that steal it and use it for stuff they shouldn’t be and I know that.”—Participant 024

Only two participants disposed of their leftover opioids by taking them to an official disposal location. Some other participants knew that there were disposal locations for leftover medication; however, few opted to use them. One patient knew of official disposal mechanisms but did not use them because of a lack of trust that medication disposed of in this manner would be destroyed. The majority of participants with leftover opioid medications reported they did not know of any official way to dispose of them. Participants reported throwing leftover pills in the trash, flushing them down the toilet, or burning them. Almost all participants reported that they received no education on the need to dispose of leftover opioids or the correct way to do so.

You know, probably there’s not a lot of awareness that you…shouldn’t just throw them out. In our area I think that a lot of people probably don’t know that you can take them to the hospital or I believe, I don’t know if it’s the city or the county, but I believe they do a drug take back every once in a while where you take your unused medications and turn them into them. But I don’t think there’s really good awareness of those programs or awareness that…that is the proper thing to do with extra medications that you don’t need anymore.—Participant 003

No, nobody has ever told me how. Actually, now that I think of it, anytime I’ve ever gotten any kind of pain medicine, I’ve never been told how.—Participant 030

No. Not that I’m aware of, but then usually when you get instructions, you’re on drugs anyway. So, I’m probably not going to remember.—Participant 035

DISCUSSION

This study assessed patients’ experiences of preoperative expectations for post-operative pain, perioperative pain management, and post-operative opioid disposal. A main theme identified across all three aspects of patient care was a lack of communication and education between providers and patients. Some patients reported increased anxiety preoperatively because of unclear expectations regarding pain following surgery, while other patients reported feeling unprepared for the pain they experienced after surgery. Patients rarely reported receiving any formal education from their surgical team regarding opioid use, other pain management strategies, or opioid disposal.

Egbert et al.²¹ reported over 50 years ago that preoperative counseling with the goal of setting expectations regarding post-operative pain helps reduce anxiety and post-operative opioid use. Increased and improved communication between clinicians and patients can lead to many direct and indirect benefits to patient health outcomes. Education aimed at information exchange, fostering relationships, and enabling self-management can lead to increased patient understanding, satisfaction, and trust in providers, ultimately resulting in decreased suffering and improved emotional well-being for patients.²² Since this initial report, multiple studies have confirmed this finding, with preoperative education and expectation setting leading to not only decreased anxiety, pain, and opioid use but also increased use of nonopioid pain management strategies.^16,17,23,24 Patients in the present study reported prior experience with surgery, experiences of friends and family, or personal research as the sources they relied on to set expectations around surgery. This represents an opportunity to develop an intervention to help better prepare patients for surgery and ultimately decrease opioid use.

Patients in this study also reported limited formal education regarding post-operative pain management techniques. Currently, many efforts to reduce opioid prescribing have focused on providers. Educating surgical providers about guidelines to reduce opioid prescribing and the use of nonopioid pharmaceuticals for pain control can significantly reduce the quantity of opioids prescribed.^25–27 However, there remains room for improvement. Most medical students do not learn about opioid prescribing, and education on opioid prescribing is a part of only 20 percent of surgical residency programs.^28,29 Additionally, while prescribing guidelines lead to smaller opioid prescriptions, a recent study found that patients are still prescribed three times as many opioids as needed.³⁰ The current study demonstrates the need to create interventions that focus on patients, not providers alone. Informal education occurs frequently between providers and patients; however, this study demonstrates that this type of teaching does not accomplish the intended goal. Simple, formal educational interventions directed toward patients, such as providing them with a card describing what medications are appropriate for different pain severity, can help reduce opioid use in the immediate post-operative period.³¹ More research is needed to explore and validate this and other similar interventions.

One reason for a lack of patient education may be related to the time constraints of providers in our current medical system. A recent study identified physician time constraints as one of three major barriers to changing opioid prescribing patterns.³² Another study found that 81 percent of surgeons report not having enough time to educate their patients.³³ The current burden of documentation and other administrative tasks for the modern surgeon does limit the time providers have to spend with their patients, with some surgical residents spending at least 30 percent of their time at work on these tasks.^34,35 Patient education is one aspect of care that is too often omitted because of these time constraints. Time constraints must be considered when patient education interventions are developed.

Opioid disposal represents a third area where improved patient education is needed. Many patients in our study received no education regarding proper disposal methods and many did not know how to appropriately dispose of their leftover medication. The majority of patients have leftover opioids following surgery, and most patients (77–91 percent) store this medication in an unlocked location.^4,12 Fewer than 50 percent of patients routinely dispose of leftover opioids, and most do so in non-FDA-approved ways.³⁶ Simple interventions such as giving patients a brochure on opioid disposal or counseling patients on opioid disposal can significantly improve patient disposal rates.^37–39 Other interventions, such as distribution of opioid disposal kits, can also significantly increase the rates of opioid disposal.⁴⁰ Opioids maintain their potency for many years, and interventions aimed at disposal of leftover opioids can help limit the number of pills that get diverted from their initial intended use.

Opioid use and abuse presents a significant challenge to healthcare providers, and many approaches to improve opioid stewardship are needed. Interventions must be created that fulfill the objectives of maintaining adequate pain control and patient satisfaction while simultaneously minimizing opioid use. In this study, multiple educational gaps were identified. These gaps represent areas where healthcare providers can create educational interventions directed at patients—from expectation setting in preoperative clinics to improving education about the importance of safe opioid disposal after patient discharge. The findings of this study may also encourage individual providers who prescribe opioids to be more cognizant of the need for patient education. Our results can also help to encourage the creation and implementation of interventions that can improve patient education without reliance on individual providers, who are already struggling with the many demands of modern health care.

Several educational interventions have already been created, with many showing positive results in minimizing opioid use and increasing opioid disposal. One study found that providing patients with a booklet and a 20-min education session on post-operative pain intensity and effective pain control strategies helped reduce pain in the immediate post-operative period.¹⁷ Another similar study provided patients with a form and one-on-one education on how to use medications correctly, how to manage medication side effects, and how to recognize poorly controlled pain.¹⁶ This simple intervention led to decreased post-operative pain, fewer side effects from pain medications, and increased use of nonpharmacologic pain control methods. Our research suggests that these interventions should be trialed in other locations and scaled-up if proven successful in different environments. Other interventions should be developed to fill the other educational gaps identified in this study.

The generalizability of our study is limited by recruitment of participants undergoing abdominal operations (primarily colorectal surgeries) at a single academic tertiary center. Although the study was done at a single center, our participants came from seven states across the Mountain West, representing a variety of communities. Additionally, our goal, in this qualitative study, was to identify themes to guide future research and intervention development. The lack of education identified at our institution has been reported at other medical centers; however, other institutions may have different educational platforms in place for patients, leading to different experiences with post-operative pain.⁴¹ Finally, this study had the potential for recall bias, with patients failing to accurately represent events. This was minimized through the use of open-ended, nonleading questions and performing interviews within 2 months of patients’ operations.

This qualitative study explored patients’ experiences regarding pain and opioid use in the perioperative period. The recurrent theme identified was a lack of patient education. Patients reported inadequate education preoperatively to set accurate expectations of post-operative pain, inadequate education about pain management and opioids post-operatively, and inadequate education about safe opioid disposal. Improving patient education is critical to improve opioid stewardship and will create opportunities to deliver pain management in a more patient-centered way. Educational interventions exist, which have shown promise in not only reducing opioid use but also improving patient pain scores and satisfaction. These should be expanded, further validated, and improved, taking patient perspectives into account. Further research investigating barriers to patient education on opioids and pain management is needed to help build interventions that will be practicable and sustainable.

APPENDIX: INTERVIEW GUIDE

My name is [interviewer]. Thank you again for agreeing to share your thoughts. As you have heard, during this interview, we will be talking about your experience with managing pain after your surgery and how where you live may affect your access to health care. We are doing this study to find out more about barriers to health care in rural areas and the different resources related to health care available in rural areas.

We will start with questions about surgery and the resources available to you and then move onto questions about your geographic location and access to health care. After that will be questions about community support available to you. The last group of questions will ask you about your opinion and knowledge of pain medications.

There are no right or wrong answers to any of the questions. Different people can have different thoughts and beliefs. We are interested in hearing what you think.

This interview will last about 60 minute. My role will be to ask questions and listen to your responses. I want you to feel free to say anything that you are thinking.

Please remember that you may choose not to answer any question and you may stop participating at any time. I would like to ask you to turn off your phone or put it on vibrate mode, so that we can focus on the interview.

I would also like to remind you that this interview will be audio-taped, and that the records will be heard only by the research staff on this project, or by a professional transcriptionist. We will remove any identifying information in the interviews during the transcription process. We will keep all of the information you tell us during this interview confidential and will only use your responses for research purposes.

Any questions before we get started?

I am going to start taping now.

Let us begin.

I will first ask you questions about your surgery and the types of resources you had available to you.

1) What type of surgery did you have?

2) Where was it done?

Probes

1. What brought you to [location]?

   1. Tell me more about that.

3) What were your expectations about pain before your surgery?

Probes

1. Did these change after your surgery?

   1. How did they change?

2. How was the pain you experienced worse or less than what you expected?

4) There are many different ways to manage pain. These can include medications, ice and heat packs, meditation, massage, music, etc. Did you use any methods to manage your pain?

Probes

1. Which methods did you use?

2. How effective were they for you?

3. Which method do you prefer the most? Why?

4. Have you used these methods in the past to manage other pain?

5. What education have you received on different pain control methods?

5) How did your work situation affect your decision to have surgery?

Probes

1. What do your co-workers expect for recovery time?

2. How did your co-workers support you after your surgery?

3. How soon did you feel that you needed to return to work?

   1. Tell me more about that.

The following questions will ask you about your opinion and knowledge of pain medication.

6) Some people argue that doctors are prescribing too many pain medications. Do you agree with this statement?

Probes

1. Why or why not?

7) Did you receive a prescription for pain medication after your surgery?

Probes

1. Did you fill it?

   1. Why or why not?

8) Did you have any pain medication left over after your surgery?

Probes

1. If so, what did you do with it?

   1. Why?

2. What would convince you to throw away your medication?

9) Have you heard the term “opioid epidemic”?

Probes

1. What thoughts do you have about that term?

2. Have you known anyone who has struggled with an opioid addiction?

   1. If so, how has that shaped your view on opioids and addiction?

3. In your opinion, is addiction prevention the responsibility of the patient or the doctor? Why?

10) What are the difficulties you face when trying to dispose of a medication?

Probes

1. Did you receive any instruction on how to dispose of your medication?

2. How far is it to the nearest drug disposal location?

11) What problems or difficulties do you see in your area related to health care?

12) What improvements would you suggest for managing pain after surgery for patients like you who live in rural areas?

13) Anything else you would like to say?

My last questions are to find out more about you.

14) How old are you?

15) Male or female?

16) What is the highest level of school that you have completed?

1. Elementary school

2. Junior high or some high school

3. High school diploma or Graduate Equivalency Diploma (GED)

4. Some college or associate degree

5. College degree or higher

17) What is your zip code?