The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review

Background

Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use.

Objectives

The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes.

Method

The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded.

Results

From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety.

Conclusion

Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.

Evaluating the impacts of patient engagement on a national health research network: results of a case study of the Chronic Pain Network

BACKGROUND

The Chronic Pain Network (CPN) is a pan-Canadian research network focused on innovating and improving the quality and delivery of pain prevention, assessment, management and research for all Canadians. An important focus of the CPN is to work in collaboration with patient partners. Patient partners, researchers and clinicians work together in all aspects of the research network including on funded research projects and in the governance of the Network. Given this focus, the CPN identified the importance of evaluating their patient engagement work to understand its functioning and impact.

METHODS

The objective of this exploratory evaluation case study was to understand the impacts of patient engagement on the CPN. The CPN worked with an external evaluation team which established an arms-length approach to the evaluation. Interviews were conducted with CPN members, including patient partners, leadership, funded researchers and committee co-chairs, at three discrete time points to trace the evolution of the patient engagement program within the Network. Key Network documents were also collected and reviewed. Data were analyzed following each set of interviews using content analysis guided by the principles of constant comparison and qualitative description. A final round of analysis was conducted using the Engage with Impact Toolkit, an impact measurement framework, to identify impacts of engagement.

RESULTS

Impacts of patient engagement were identified at the individual, network, funded research project and research community levels. These impacts were observed in the following areas: (1) building community; (2) developing knowledge, skills and resources; (3) increasing confidence; (4) influencing priorities and decisions; (5) enabling additional opportunities; (6) promoting culture change; and, (7) coping with experiences of living with chronic pain.

CONCLUSIONS

While not without challenges, the patient engagement efforts of the CPN demonstrates the impact engaging patient partners can have on a national research network and related policy activities. Understanding the approaches to, and impacts of, patient engagement on health research networks can illuminate the value of having patient partners engaged in all aspects of a research network and should serve as encouragement to others who look to take on similar work.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study

PURPOSE

A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs.

METHODS

We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures.

RESULTS

A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff.

CONCLUSIONS

Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

Impact of the Opioid Epidemic and Associated Prescribing Restrictions on People Who Live With Chronic Noncancer Pain in Canada

OBJECTIVES

Little is known about the consequences of the opioid epidemic on people living with chronic noncancer pain (CNCP). This study examined this issue in people who lived in the most impacted province by opioid overdoses in Canada (British Columbia [BC]) or one of the least impacted (Quebec [QC]), and examined the factors associated with opioid use.

MATERIALS AND METHODS

This cross-sectional study was carried out in adults living in BC (N=304) and QC (N=1071) who reported CNCP (≥3 months) and completed an online questionnaire that was tailored to their opioid status.

RESULTS

Almost twice as many participants in BC as in QC were proposed to cease their opioid medication in the past year (P<0.001). The proportion who reported having hoarded opioids in fear of not being able to get more in the future was also significantly higher in BC (P<0.001) compared with QC. In addition, they were significantly more likely to have had their opioid dose decreased than those in QC (P=0.001). No significant association was found between opioid discontinuation and province of residence. Two-thirds of the BC participants felt that the media coverage of the opioid crisis was very to extremely detrimental to CNCP patients in general, this percentage being significantly higher than in QC (P<0.001).

DISCUSSION

The opioid epidemic and associated prescribing restrictions have had harmful effects on Canadians with CNCP. The clinical community, the general public, and the media need to be aware of these negative consequences to decrease patients' stigmatization and minimize inadequate treatment of CNCP.

Conversations About Opioids: Impact of the Opioid Overdose Epidemic on Social Interactions for People Who Live With Chronic Pain

The objective of this study was to understand the impact of the opioid overdose epidemic on the social lives of people suffering from chronic pain, focusing on interactions within their personal and professional circles. The study was based on 22 in-depth interviews with people living with chronic pain in Canada. Using thematic analysis, we documented three main impacts of the opioid overdose epidemic: (a) increased worries of people in pain and their families regarding the dangers of opioids; (b) prejudices, stigma, and discrimination faced during conversations about opioids; and (c) stigma management attempts, which include self-advocacy and concealment of opioid use. This study represents important knowledge advancement on how people manage stigma and communicate about chronic disease during everyday life interactions. By showing negative effects of the epidemic's media coverage on the social experiences of people with chronic pain, we underscore needs for destigmatizing approaches in public communication regarding opioids.

Chronic pain experience and health inequities during the COVID-19 pandemic in Canada: qualitative findings from the chronic pain & COVID-19 pan-Canadian study

BACKGROUND

Chronic pain affects about 20 % of the Canadian population and can lead to physical, psychological and social vulnerabilities. However, this condition remains poorly recognized and undertreated. During 2020, as the COVID-19 pandemic disrupted daily living and health care systems, the situation of people with chronic pain has drawn little public attention.

METHODS

This qualitative study was part of a pan-Canadian mixed-methods project and aimed to understand the experiences and challenges of people living with chronic pain during the COVID-19 pandemic in Canada. Between May and August 2020, we conducted in-depth semi-structured interviews with 22 individuals living with chronic pain across the country. We used reflexive thematic analysis to interpret data.

RESULTS

Our findings underscored four dimensions of the chronic pain experience during the pandemic: (1) Reinforced vulnerability due to uncertainties regarding pain and its management; (2) Social network as a determinant of pain and psychological condition; (3) Increasing systemic inequities intermingling with the chronic pain experience; (4) More viable living conditions due to confinement measures. Though several participants reported improvements in their quality of life and reduced social pressure in the context of stay-at-home orders, participants from socio-economically deprived groups and minorities reported more challenges in accessing pain relief, health care services, and psychosocial support.

CONCLUSIONS

The COVID-19 pandemic has revealed and intensified pre-existing disparities and challenges among people living with chronic pain in terms of material resources, psychosocial condition, social support, and access to care. In post-pandemic times, it will be essential to address flaws in health and welfare policies to foster equity and social inclusiveness of people with chronic pain.

"They think you're trying to get the drug": Qualitative investigation of chronic pain patients' health care experiences during the opioid overdose epidemic in Canada

Background: The opioid overdose epidemic has led health care providers to increased vigilance for opioid-related risks in the treatment of chronic non-cancer pain (CNCP). Media have conveyed stigmatizing representations of opioid analgesics. Aims: This study aimed to understand how the opioid overdose epidemic has impacted health care experiences among people living with CNCP in two Canadian provinces (British Columbia, Quebec). Methods: This qualitative study proceeded through 22 semi-structured interviews conducted in 2019. Participants were recruited from a cross-sectional survey examining the effects of the opioid overdose epidemic on individuals with CNCP. We collected in-depth narratives that we analyzed using a thematic framework. The sample included 12 women and 10 men aged 20 to 70 years, with 11 from each province. Results: Several participants described increased difficulty in accessing medical services for pain since the onset of the opioid overdose epidemic. They reported that some physicians urged them to taper opioids regardless of their pain severity and functional limitations. Some participants reported facing discrimination and care denials as they were labeled "drug-seeking," especially in hospital. Depending on their educational resources, they were unequally able to counter providers' stigmatizing behaviors. However, participants described empathetic relationships with providers with whom they had a long-term relationship. Some participants drew distinctions between themselves and the stigmatized status of "addict" in ways that reinforced stigma toward people who are dependent on opioids. Conclusions: Health policies and provider education programs aimed at reducing opioid-related stigma are needed to counter detrimental consequences of the opioid overdose epidemic for people living with CNCP.

A cross-sectional study of pain status and psychological distress among individuals living with chronic pain: the Chronic Pain & COVID-19 Pan-Canadian Study

BACKGROUND

The COVID-19 pandemic has had a disproportionate impact on vulnerable populations, including individuals with chronic pain. We examined associations between geographical variations in COVID-19 infection rates, stress and pain severity, and investigated factors associated with changes in pain status and psychological distress among individuals living with chronic pain during the pandemic.

METHODS

This investigation is part of a larger initiative, the Chronic Pain & COVID-19 Pan-Canadian Study, which adopted a cross-sectional observational design. A total of 3159 individuals living with chronic pain completed a quantitative survey between 16 April and 31 May 2020.

RESULTS

Two-thirds (68.1%) of participants were between 40 and 69 years old, and 83.5% were women. Two-thirds (68.9%) of individuals reported worsened pain since pandemic onset. Higher levels of perceived pandemic-related risks (adjusted odds ratio: 1.27; 95% confidence interval: 1.03-1.56) and stress (1.21; 1.05-1.41), changes in pharmacological (3.17; 2.49-4.05) and physical/psychological (2.04; 1.62-2.58) pain treatments and being employed at the beginning of the pandemic (1.42; 1.09-1.86) were associated with increased likelihood of reporting worsened pain. Job loss (34.9% of individuals were employed pre-pandemic) was associated with lower likelihood (0.67; 0.48-0.94) of reporting worsened pain. Almost half (43.2%) of individuals reported moderate/severe levels of psychological distress. Negative emotions toward the pandemic (2.14; 1.78-2.57) and overall stress (1.43; 1.36-1.50) were associated with moderate/severe psychological distress.

CONCLUSIONS

Study results identified psychosocial factors to consider in addition to biomedical factors in monitoring patients' status and facilitating treatment access for chronic pain patients during a pandemic.

Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study

INTRODUCTION

Multimodal treatment is recognized as the optimal paradigm for the management of chronic pain (CP). Careful balance between pharmacological and physical/psychological approaches is thus desirable but can be easily disrupted.

OBJECTIVES

This study aimed at exploring the impact of the COVID-19 pandemic on pharmacological and physical/psychological treatments of CP.

METHODS

A Pan-Canadian cross-sectional web-based study was conducted between April 16th and May 31st 2020 among adults living with CP when the country was in the ascending slope of the first COVID-19 pandemic wave.

RESULTS

A total of 2864 participants shared their treatment experience (mean age: 49.7 years and women: 83.5%). Among medication users (n = 2533), 38.3% reported changes in their pharmacological pain treatment. The main reasons were as follows: (1) changes in pain symptoms, (2) lack of access to prescribers/cancellation of medical appointments, and (3) increased medication intake in compensation for stopping physical/psychological treatments because of the pandemic. Among participants who used physical/psychological pain management approaches before the pandemic (n = 2467), 68.3% had to modify their treatments or self-management strategies. Common reasons were lack of access to clinics/exercise facilities and the need to compensate for having to stop another type of physical/psychological treatment because of the pandemic-related public health safety measures.

CONCLUSIONS

Our study underlines the negative impact of the COVID-19 pandemic on access to pain relief, which is considered a fundamental human right. Results will help to justify resource allocation and inform the development of interventions to be better prepared for waves to come and future health crises.

Factors affecting the toxicity of trace metals to fertilization success in broadcast spawning marine invertebrates: A review

Significant amounts of trace metals have been released into both nearshore and deep sea environments in recent years, resulting in increased concentrations that can be toxic to marine organisms. Trace metals can negatively affect external fertilization processes in marine broadcast spawners and may cause a reduction in fertilization success at elevated concentrations. Due to its sensitivity and ecological importance, fertilization success has been widely used as a toxicity endpoint in ecotoxicological testing, which is an important method of evaluating the toxicity of contaminants for management planning. Ecotoxicological data regarding fertilization success are available across the major marine phyla, but there remain uncertainties that impair our ability to confidently interpret and analyse these data. At present, the cellular and biochemical events underlying trace metal toxicity in external fertilization are not known. Metal behavior and speciation play an important role in bioavailability and toxicity but are often overlooked, and disparities in experimental designs between studies limit the degree to which results can be synthesised and compared to those of other relevant species. We reviewed all available literature covering cellular toxicity mechanisms, metal toxicities and speciation, and differences in methodologies between studies. We conclude that the concept of metal toxicity should be approached in a more holistic manner that involves elucidating toxicity mechanisms, improving the understanding of metal behavior and speciation on bioavailability and toxicity, and standardizing the fertilization assay methods among different groups of organisms. We identify opportunities to improve the fertilization assay that will allow robust critical and comparative analysis between species and their sensitivities to trace metals during external fertilization, and enable data to be more readily extrapolated to field conditions.

The effects of metals of emerging concern on the fertilization success of gametes of the tropical scleractinian coral Platygyra daedalea

The demand for nickel and cobalt as important commodities has increased significantly over the past decade and a decline in the global nickel sulphide reserves has resulted in a shift toward the exploitation of the less favourable nickel laterite ores. These deposits, which are found associated with cobalt, are located predominantly in the tropical regions of the world where there is limited understanding of the toxicities of their extracted products and wastes. This study investigated the effects of nickel, cobalt and combinations of nickel and cobalt on the fertilization success of the common and widespread scleractinian coral Platygyra daedalea. We also present the first assessment of the effect of copper on fertilization success of this species. The EC50 value for copper was 33 μg L(-1) (95% confidence limits: 30-37 μg L(-1)) and is consistent with published values for other coral species. Our results provide the first EC50 value for the effect of nickel on fertilization success in a scleractinian coral, with an estimated value of 1420 μg L(-1) (95% confidence limits: 1160-1780 μg L(-1)). Concentrations of cobalt as high as 2500 μg L(-1) did not significantly reduce fertilization success nor did combinations of nickel (500 μg L(-1)) and cobalt (up to 1000 μg L(-1)). These are important findings given the emerging nickel-cobalt mining industry in the tropics and provide much needed toxicity data regarding the early-life histories of ecologically relevant tropical marine species.

Ethanol and the NMDA receptor

The actions of glutamate, the major excitatory amino acid in the CNS, are mediated by three receptor subtypes: kainate, quisqualate and N-methyl-D-aspartate (NMDA) receptors. Ethanol, in vitro, is a potent and selective inhibitor of the actions of agonists at the NMDA receptor. Following chronic ethanol ingestion, the number of NMDA receptor-ion channel complexes in certain brain areas is increased. This increase may contribute to the generation of ethanol withdrawal seizures, since administration of an NMDA receptor antagonist can reduce these seizures. The results suggest that certain acute behavioral effects of ethanol, such as effects on memory, as well as certain aspects of ethanol withdrawal, may involve the NMDA receptor.

Ethanol withdrawal seizures and the NMDA receptor complex

Prior biochemical and electrophysiological studies have shown that low doses of ethanol inhibited calcium influx through the N-methyl-D-aspartate (NMDA) receptor/ionophore. The present data show that chronic ethanol treatment results in an increase in the number of NMDA receptor/ionophore complexes in the hippocampus, a brain area known to be associated with ethanol withdrawal seizure activity. Treatment during withdrawal with NMDA-exacerbated handling induced withdrawal seizures in the ethanol-dependent mice, while administration of the NMDA receptor-associated calcium channel antagonist MK-801 decreased the occurrence and severity of the withdrawal seizures in a dose-dependent manner. The results are consistent with the hypothesis that the up-regulation of the NMDA receptor systems following chronic ethanol treatment may mediate the seizures associated with ethanol withdrawal in dependent animals.

Increased dihydropyridine-sensitive calcium channels in rat brain may underlie ethanol physical dependence

Ethanol physical dependence can be viewed as a state of latent hyperexcitability in brain which is exposed on withdrawal of the drug. This hyperexcitability may reflect an increased sensitivity to Ca2+ of central neurones. Dihydropyridine (DHP) binding sites which represent a subtype of neuronal Ca2+-channel, are increased in brains from ethanol-dependent rats as are functional effects of the DHP Ca2+-channel activator, BAYK8644. These effects are reversed by DHP Ca2+ inhibitors, which also prevent the ethanol physical withdrawal syndrome. These results suggest that an increase in DHP-sensitive Ca2+-channels on central neurons may represent the molecular basis for ethanol physical dependence.

Effect of ethanol in vitro and in vivo on Ca2+-activated metabolism of membrane phospholipids in rat synaptosomal and brain slice preparations

Phospholipase C (PLC) activity was measured by the incorporation of [3H]-inositol into lipids and by the breakdown of [3H]-inositol-labelled phosphatidylinositols (PI) and polyphosphatidylinositols (PPI) to [3H]-inositol phosphates; phospholipase A2 (PLA2) activity by the breakdown of [3H]oleic acid-labelled phosphatidylcholine [( 3H]PC) to [3H]oleic acid and the enzymes of phospholipid base exchange (PLBE) by the incorporation of [14C]serine into membrane lipids. The activities of these enzymes in rat brain preparations were all increased by procedures which increase intracellular Ca2+, and were all inhibited to a varying extent by the presence of ethanol, 50 mM, in vitro. In contrast, the activities of PLA2 and PLBE enzymes were markedly increased in preparations from animals which had received ethanol chronically in vivo. Similarly, although the basal activity of PLC was only slightly increased in such preparations, depolarization induced the breakdown of a significantly greater fraction of radiolabelled PI than that which was obtained in control preparations. The results suggest compensatory alterations in the activity of Ca2+-activated enzymes of phospholipid metabolism in brain tissue during the continued presence of ethanol in vivo.