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CME / ABIM MOC / CE

Can Your Expectations of Post-Op Pain Affect Your Outcomes?

  • Authors: News Author: Anna Goshua; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/23/2021
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 7/23/2022
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Target Audience and Goal Statement

This activity is intended for pain management clinicians, psychiatrists, surgeons, family medicine/primary care clinicians, hospital medicine clinicians, internists, nurses, pharmacists, and other members of the health care team who treat and manage patients about to undergo surgery.

The goal of this activity is to describe independent associations between certain perioperative characteristics (preoperative baseline pain, patients' expectations about postoperative pain, and other potential factors) and lingering postsurgical pain in a diverse surgical cohort from the observational Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys study.

Upon completion of this activity, participants will:

  • Assess independent associations between certain perioperative characteristics and lingering postsurgical pain in a diverse surgical cohort from the observational Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) study
  • Determine clinical implications of independent associations between certain perioperative characteristics and lingering postsurgical pain in a diverse surgical cohort from the observational Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) study
  • Outline implications for the healthcare team


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Anna Goshua

    Freelance writer, Medscape

    Disclosures

    Disclosure: Anna Goshua has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor

  • Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Hazel Dennison, DNP, RN, FNP-BC, CHCP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


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CME / ABIM MOC / CE

Can Your Expectations of Post-Op Pain Affect Your Outcomes?

Authors: News Author: Anna Goshua; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 7/23/2021

Valid for credit through: 7/23/2022

processing....

Clinical Context

Pain lingering beyond the early weeks after the acute postoperative period is an important risk factor for chronic postsurgical pain. Patients with chronic postsurgical pain (~10%-50% of surgical patients) require more healthcare resources, have impaired quality of life, and often become chronic opioid users in the months after surgery.

Study Synopsis and Perspective

Patients who expect their pain to worsen after surgery may be at higher risk for lingering postsurgical pain, according to a study published in Anesthesiology. Factors associated with lingering postsurgical pain remain poorly understood.

Researchers retrospectively analyzed a single-center cohort of 3628 postsurgical patients who underwent operations between February 2015 and October 2016 at a US tertiary-care hospital. These patients participated in an observational study called the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) study.

During their preoperative assessments, patients completed the Veterans RAND 12-item health questionnaire and a survey about their baseline pain, the reason for surgery, and their expectations about pain 1 month after the operation.

One to 3 months after surgery, patients were asked to fill out a follow-up survey that included questions about whether they were still experiencing pain and, if so, to rank its intensity on a scale of 0 to 10. The investigators defined "lingering postsurgical pain" as an affirmative response to the question, "Currently, do you have any pain in your surgical incision or area related to your surgery?"

Preoperatively, 67% of patients (n = 2414) had positive expectations that they would have no postsurgical pain if they did not have baseline pain, or that they would experience an improvement in pain if they did have baseline pain 1 month after surgery. Nineteen percent of patients (n = 686) expected new pain if they reported no pain at baseline or expected their pain to stay the same or worsen if they did have baseline pain.

The remaining 24% said they did not know whether they'd have postoperative pain.

Although 44% of patients with positive expectations had surgeries that are usually performed to relieve pain, only 26% of patients with negative expectations had those types of surgeries.

A total of 36% of patients (n = 1308) reported lingering postoperative pain. The mean severity was ranked 3.8 on a scale of 0 to 10 (standard deviation, 2.1). Patients who expressed negative expectations were more likely to report lingering postsurgical pain (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.23-1.98; P<.001).

Compared with patients with positive expectations, patients with negative expectations were twice as likely to report new or more severe pain (23% vs 11%; < .001). Other significant risk factors included recollection of severe acute postoperative pain (OR, 3.13; 95% CI, 2.58-3.78; P<.001), undergoing a procedure typically meant to alleviate pain (OR, 2.18; 95% CI, 1.73-2.75; P<.001), and preoperative pain related to surgery (OR, 1.91; 95% CI, 1.52-2.40; P<.001).

"There are risk factors that are better known, like age and perhaps preexisting chronic pain issues," said Simon Haroutounian, PhD, the senior author of the study and the chief of clinical pain research at the Washington University Pain Center, St. Louis, Missouri, in an interview with Medscape Medical News. "We found that patient expectations, particularly if they have negative expectations, may be independent predictors of patients who are doing worse and still having pain somewhere between 1 and 3 months after surgery," he said.

Lingering postoperative pain can lead to chronic pain, said W. Michael Hooten, MD, a pain specialist at the Mayo Clinic in Rochester, Minnesota, in an interview with Medscape Medical News. "It's important to differentiate between lingering pain and chronic pain. This is a critical time point during which there might be interventions to mitigate the risk of developing chronic pain," said Dr Hooten, who was not involved in the study.

Patient expectations did not always align with their pain outcomes: 26% of patients with positive expectations reported new, unabated, or worsening pain and 61% of patients with negative expectations experienced no lingering pain or an improvement in their preexisting pain.

It is important to note that the study included "a high degree of heterogeneity in the surgical types and patient populations," said Beth Darnall, PhD, the director of the Pain Relief Innovations Lab at Stanford University, Stanford, California, in an interview with Medscape Medical News. For some patients who undergo major surgeries such as total knee replacements, expecting to still be in pain a month after the procedure is perfectly reasonable, she explained. Patient expectations may be influenced by the type of surgery and the preoperative counseling they receive.

More research is needed to understand how patient expectations affect pain outcomes. The effects of negative expectations may range from altering a patient's willingness to participate in rehabilitation to changing pain processing on a physiologic level, Dr Hooten pointed out.

For their next steps, the researchers aim to create a prediction model that could be used to evaluate an individual patient's risk of having chronic pain after surgery, Dr Haroutounian said.

The parent study was funded through institutional and departmental support, including a grant from the Barnes-Jewish Hospital in St. Louis. Dr Haroutounian and Dr Hooten have disclosed no relevant financial relationships. Dr Darnall is the chief science advisor at AppliedVR.

Anesthesiology. 2021;134:915-924.[1]

Study Highlights

  • Between February 2015 and October 2016, 3628 patients underwent various surgeries at a single US tertiary hospital and participated in SATISFY-SOS.
  • Preoperatively, patients were surveyed regarding their expectations about pain 1 month postoperatively.
  • Lingering postsurgical pain, defined as pain in the surgical area during a follow-up survey 1 to 3 months postoperatively, occurred in 36% of the cohort.
  • Two thirds expected their postsurgical pain to be absent or improved from baseline, and 73% of these had their positive expectations fulfilled.
  • 19% anticipated new, unabated, or worsened pain, and only 39% of these had their negative expectations fulfilled.
  • Negative expectations were most common in patients with presurgical pain unrelated to the surgical indication and in those undergoing surgeries not usually performed to help relieve pain.
  • Having negative expectations was independently associated with lingering postsurgical pain (OR, 1.56; 95% CI, 1.23-1.98; P<.001).
  • Other factors associated with lingering postsurgical pain were recollection of severe acute postoperative pain (OR, 3.13; 95% CI, 2.58-3.78; P<.001), undergoing a surgery usually performed to help relieve pain (OR, 2.18; 95% CI, 1.73-2.75; P<.001), and preoperative pain related to surgery (OR, 1.91; 95% CI, 1.52-2.40; P<.001).
  • Female sex was associated with more, and older age with less, postoperative pain.
  • The investigators concluded that lingering postsurgical pain is relatively common after various surgeries and is associated with both fixed surgical characteristics and potentially modifiable characteristics, such as pain expectations and severe acute postoperative pain.
  • Despite being at high risk for lingering postsurgical pain, patients with preexisting pain related to the reason for surgery had higher expectations for postoperative pain improvement or resolution.
  • Negative expectations for postoperative pain were associated with increased lingering postsurgical pain, independent of whether the surgical procedure is usually performed to help alleviate pain.
  • As fewer than 40% of patients with negative expectations went on to experience new or unabated pain, there appears to be a significant gap in which educational initiatives might help patients form optimistic yet realistic pain expectations.
  • Optimistic patients with better psychologic resilience may have more positive pain expectations and better outcomes.
  • As most surgical patients are unaware of the risk for lingering and chronic postsurgical pain, understanding the relationship between preoperative pain expectations and patient-reported lingering postsurgical pain may inform education and interventions to reduce lingering pain and patients' dissatisfaction with surgical outcomes.
  • The period of subacute pain, ~1 to 3 months after surgery, may be an important, often missed opportunity for interventions to prevent the development of chronic postsurgical pain, but longer-term longitudinal data are needed.
  • Study limitations include possible recall and selection bias and the inability to differentiate the psychologic, or wishful, component of patient expectations from their innate predictive ability to know what will happen to themselves.

Clinical Implications

  • Lingering postsurgical pain is relatively common after various surgeries and is associated with potentially modifiable characteristics such as pain expectations and severe acute postoperative pain.
  • Understanding the relationship between preoperative pain expectations and patient-reported lingering postsurgical pain may inform education and interventions to reduce lingering pain and patients' dissatisfaction with surgical outcomes.
  • Implications for the Health Care Team: Members of the healthcare team should be aware that the period of subacute pain, ~1 to 3 months after surgery, may be an important, often missed opportunity for interventions to prevent the development of chronic postsurgical pain.

 

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