Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials.

BACKGROUND: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. MATERIALS AND METHODS: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias. RESULTS: Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2-3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding. CONCLUSION: This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.

Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service.

Introduction: The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods: A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results: Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions: Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications: In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.

The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management.

In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major surgery continues to be problematic. This article briefly reviews the known psychological risk and protective factors associated with the development of chronic postsurgical pain (CPSP). We begin with a definition of CPSP and then explain what we mean by a risk/protective factor. Next, we summarize known psychological risk and protective factors for CPSP. Psychological interventions that target risk factors and may impact postsurgical pain are reviewed, including the acceptance and commitment therapy (ACT)-based approach to CPSP prevention and management we use in the Transitional Pain Service (TPS) at the Toronto General Hospital. Finally, we conclude with recommendations for research in risk factor identification and psychological interventions to prevent CPSP. Several pre-surgical psychological risk factors for CPSP have been consistently identified in recent years. These include negative affective constructs, such as anxiety symptoms, depressive symptoms, pain catastrophizing and general psychological distress. In contrast, relatively few studies have examined psychological protective factors for CPSP. Psychological interventions that target known psychological risk factors while enhancing protective psychological factors may reduce new incidence of CPSP. The primary goal of our ACT intervention is to teach patients a mindful way of responding to their postsurgical pain that empowers them to interrupt the negative cycle of pain, distress, behavioural avoidance and escalating opioid use that can limit functioning and quality of life while paradoxically amplifying pain over time. Early clinical outcome data suggest that patients who receive care from TPS physicians reduce their pain and opioid use, yet patients who also receive our ACT intervention have a larger decrease in daily opioid dose while reporting less pain interference and lower depression scores.