Mind Over Matter: Reducing Perioperative Opioid Use through Patient Education

There is growing recognition of the role of perioperative opioids in the prescription opioid epidemic. Surgical patients are at increased risk for chronic opioid use compared to non-surgical patients¹, with data from retrospective studies showing that 3–7% of previously opioid naïve patients continue to use opioids 1 year after surgery.^2,3 Some clinical interventions aimed at reducing the risk of prolonged opioid use after surgery include using alternative methods for analgesia (i.e., regional techniques), multimodal analgesia and limiting postoperative opioid prescribing.⁴ However, these interventions may have limited effect on longer-term opioid use if patients are not properly educated regarding expectations for pain and opioid use after surgery. Surprisingly, little attention has been paid to the role of the patient education in reducing perioperative opioid use and risk for long-term dependence. In this issue of Anesthesia & Analgesia, two articles examine and summarize the literature on patient education and postoperative pain and opioid use.

Horn et al. present a systematic review of preemptive and preventive psychoeducation methods in reducing postoperative pain.⁵ The authors found that preemptive education to improved knowledge of procedural pain may help to reduce preoperative anxiety and postoperative recovery time, particularly for patients who display high levels of preoperative anxiety and pain catastrophizing. Similarly, in their narrative review, Lee and colleagues discuss how patient education may be used to improve pain management after surgery and safe opioid use.⁶ The authors note that a majority of patients do not receive counseling regarding options for postoperative pain management, safe use and disposal of opioids, and long-term risk for opioid dependence.

Together, these two articles demonstrate that improved patient education is vital to engage patients in the effort to reduce perioperative opioid use. However, a key conclusion from both articles is that appropriate education is often lacking at the present. Thus, an immediate takeaway from these articles is that anesthesiologists need to play a stronger role in ensuring that patients are properly educated regarding postoperative pain management. Such education should include the following components: discussion of patient’s goals for postoperative pain management, information about proper usage, weaning and disposal of opioids as well as common side effects and risks for dependence, and planned use of alternative methods for pain control including regional, neuraxial and multimodal analgesic techniques.

These studies raise several important questions about our role as anesthesiologists in helping to better educate patients. For example, who is the best person to deliver patient education? Should pain education be discussed by the surgeon during the preoperative visit or by the anesthesiologist or nurse in the pre-anesthesia clinic? Future studies are also needed to determine the optimal timing of patient education. Is there a benefit to education throughout perioperative period or after discharge? The majority of studies reviewed in these articles focused on preoperative patient education. Ideally, patient education should be a coordinated effort by both surgical and anesthesia teams. As both Horn and Lee suggest, patient education beginning at the preoperative surgery clinic visit with a discussion of the expected perioperative course and continuing throughout the perioperative period with thorough discussion of analgesic options, the risks and benefits of each and opportunity for patient input and questions, has the highest likelihood of success.

Current initiatives to improve perioperative care, such as enhanced recovery programs and the Perioperative Surgical Home, provide a natural vehicle for patients to receive this education. Anesthesiologists play a key role in these initiatives as they are instrumental in facilitating the use of multimodal analgesics and may help wean patients from opioids during the postoperative period.⁷ One way that this may be accomplished is through the development of a Transitional Pain Service such as the one at Toronto General Hospital.⁸ In this model, anesthesiologists may provide a continuum of care through preoperative assessment of high risk patients, such as those with prior opioid use, history of chronic pain or psychological comorbidities, developing a comprehensive perioperative analgesic plan, and facilitating post-discharge pain treatment planning, including weaning from opioid medications, assessment of addiction risk and an opioid agreement contract.

Postoperative opioid prescription may be further reduced by pairing patient education about the risks of opioids with shared decision-making approaches, which have been shown to improve patient outcomes and satisfaction in the several clinical settings. Among women undergoing cesarean delivery, use of a shared decision-making approach in which patients received information on typical pain trajectories and then chose the number of tablets of oxycodone to be prescribed resulted in a 50% reduction in the number of tablets prescribed.⁹ Shared-decision making approaches that utilize internet or app-based technology would allow healthcare providers to provide patient education and outreach to patients with limited access to healthcare.

Pain psychoeducation is just one type of psychological intervention. Recent studies have shown a benefit of prehabilitation programs aimed at improving functional capacity prior to surgery to reduce pulmonary complications. Psychological prehabilitation including cognitive behavioral therapy, relaxation techniques and coping strategies may be especially helpful in patients with anxiety, depression, catastrophizing symptoms and those at high risk for opioid addiction.¹⁰

The influence of patient demographics and cultural approaches to pain is another area for future research. Horn and Lee discuss the limited number of studies exploring the influence of culture on the experience of pain. Disparities in the treatment of acute and chronic pain among patients of minority racial and ethnic groups have been well described.^11,12 Recognition that the experience of pain is influenced by gender, race and ethnicity¹³ has led to the development of culturally specific pain catastrophizing questionnaires.¹⁴ The use of culturally-sensitive patient education materials may be of benefit to patients with low levels of cultural immersion, as demonstrated by a randomized controlled trial of immigrant patients of German primary care clinics.¹⁵ Improved understanding of the influence of culture on the pain experience will better inform patient educational efforts to reduce opioid consumption.

Finally, future studies are needed to determine the cost and benefit of pain education programs. Horn et al. presented limited evidence that pain psychoeducation may decrease hospital recovery time and reduce cost; however, few studies performed a cost benefit analysis for the implementation of pain psychoeducation programs.

It is important to consider not only the financial cost of educational programs, but also the additional costs of time and personnel. Education delivered during the preoperative assessment may require additional time and interrupt current clinical workflow. Administration of education programs is logistically challenging and involves the efforts of numerous provider types, including physicians, pain specialists, nurse educators, psychologists, and therapists. This involves intensive time and effort on the part of both patients and healthcare providers and may be difficult to coordinate within the current system which typically supports one preoperative visit a few days prior to surgery.

Lastly, how do we determine the benefit of these educational programs? Do we define success by decreased pain scores or decreased opioid consumption with no change in postoperative pain? What is the role of education in patient satisfaction? How does patient education influence long term outcomes such as chronic post-surgical pain, opioid dependence, functional recovery? Future longitudinal studies are necessary to answer these questions.

Much work has been done by physicians to raise awareness about surgery induced opioid dependence and reduce perioperative opioid use. Through patient education, we can enlist the help of our patients and work together to improve outcomes and correct the opioid epidemic.