|Home | About | Journals | Submit | Contact Us | Français|
This study investigates the importance of communication in surgery and how delivering preoperative patient education can lead to better health outcomes postoperatively, via promoting tolerable pain scores and minimizing the use of narcotics after surgery. Patients who underwent outpatient surgery were randomly divided into groups to compare the pain scores of those who received preoperative patient education, the experimental group, and those who did not receive any form of patient education, the control group. Two weeks before surgery, the experimental group subjects received oral and written forms of patient education consisting of how the body responds to pain, and how endorphins cause natural analgesia. Moreover, patients were educated on the negative effects narcotics have on endorphin production and activity, as well as mechanisms of non-opioid analgesics. Of the 69 patients in the experimental group, 90% declined a prescription for hydrocodone after receiving preoperative education two weeks prior to surgery. The control group consisted of 66 patients who did not receive preoperative patient education and 100% filled their hydrocodone prescriptions. Patients in both groups were offered and received gabapentin and celecoxib preoperatively for prophylaxis of postoperative pain unless they declined. The control groups were found to have average pain scores significantly greater (P <.05) than the experimental groups and also a significantly longer (P <.005) duration of pain. This study illustrates the power of patient education via oral, written and visual communication, which can serve as an effective means to minimize narcotic analgesia after surgery.
The role of communication is emphasized to physicians from the earliest stages in their training in medical school. The value of communication in medicine lies within effectively obtaining a patient history, collaborative communication between members of the treatment team, patient education, informed consent, and forming a therapeutic alliance between physician and patient. The importance of patient communication in surgery is paramount and is not only a means of educating the patient but is also a method for preserving a patient's well-being after a surgical procedure. There is an art behind delivering information to patients and this topic has been reported on extensively in the literature.1 It has been reported that optimal physician-patient communication can improve the patient's health outcomes in various ways including symptom resolution, emotional healing and recovery, and pain control.1 If the surgeon is able to apply this in the preoperative setting, positive surgical outcomes are more likely. Here, we investigate the power of patient education on pain mechanisms and endorphin physiology in order to promote the movement toward discouraging the use of narcotics in postoperative pain management.
It has been shown that the body's endogenous opioids are responsible for counteracting physical stressors, as well as maintaining our mental wellbeing via acting on the mu receptors in the central nervous system. Universal post-surgical pain management usually involves the use of opioid narcotics. Unfortunately, the negative effects of opioid medications, like morphine, on our endogenous network of endorphins are detrimental to our natural analgesic response to pain. Narcotics alter our pain response by decreasing the production of endorphins as well as down-regulating the expression of mu receptors acted on by both endorphins and exogenous narcotics. By inhibiting the activity of endorphins via two mechanisms (production of endogenous peptides and mu receptor expression), patients on chronic morphine regimens actually experience a paradoxical increase in pain, or hyperalgesia.2–4 Moreover, with chronic pain and low levels of endorphins, the patient is more susceptible to suffer from psychiatric illnesses including depression and feelings of hopelessness.5 An overall insult on one's wellbeing—physically and mentally—is the main concern when using opioid narcotics postoperatively.
Studies where alternative pain regimens are being proposed in replacement of opioids for postoperative pain management have been done to address this concern. Parsa, et al, investigated the effectiveness of patient education regarding the role of endorphins and the negative effects of narcotics on endorphins combined with the preoperative administration of gabapentin and celecoxib. The biological rationale for the authors' use of gabapentin and celecoxib is the drugs' opioid-sparing mechanisms; celecoxib acts through cyclooxygenase-2 inhibition, while gabapentin is postulated to reduce excitability of the dorsal horn neurons of the central nervous system.6 The results of the study were successful in showing that the combination of gabapentin and celecoxib yielded less need for postoperative analgesia (hydrocodone or acetaminophen) as the pain scales were impressively nil to mild in patient-reported ratings.6 The use of communication was shown to effectively convince patients to disregard their prescription of opioid analgesics as the patients were educated about the importance of endorphins.
In order to further investigate the power of patient education regarding the body's natural analgesic system, this study tests the management of postoperative pain with patient education being the main variable between the experimental and control groups. The authors hypothesize that in most surgeries of lower severity, patients' postoperative pain can be effectively managed without supplemental narcotics if patients are properly educated preoperatively about the body's endogenous opioids.
Between January 2008 and October 2011, 135 patients undergoing elective outpatient aesthetic procedures were asked to volunteer for this study. Patients who were excluded from the study were those who suffered from chronic pain, had a history of substance abuse or a recent history of long-term opioid use (used any opioid analgesics for longer than 30 days in the 5 years prior to surgery). Moreover, patients with an allergy to acetaminophen, COX-2 inhibitors, gabapentin or hydrocodone were excluded from the study. The patients were 58.4% Asian or of mixed-Asian ancestry. The remaining identified themselves as Caucasian, Filipino, part-Hawaiian, or “other.” No opioids, including morphine, meperidine, or fentanyl, were administered during the procedure. These qualifying patients were randomly divided into experimental and control groups.
The experimental group contained a total of 69 patients who were educated about the importance of “endorphins” or “natural narcotics” (these two words were used repeatedly throughout the session for better understanding). Not only were the patients educated on the side effects of opioid narcotics, including nausea and vomiting, but they were also taught the negative effects of “synthetic narcotics” or “fake narcotics” (two words also repeated for better understanding) have on the body's endorphins. The experimental group underwent two educational sessions led by the same surgeon, each lasting from 15 to 30 minutes: one session was held about two weeks before the surgical procedure, and the second session was done on the same day before the procedure. The earlier session, two weeks prior to the procedure, included both oral and written forms of communication where the patient underwent a 15 to 30 minute preoperative patient education session as well as received a handout re-emphasizing the main points about endorphins. During the pre-operative session, a schematic was used to illustrate the ligand protein-receptor nature between the mu receptor and its ligands, eg, endorphins. The surgeon explains that if synthetic narcotics, such as hydrocodone or oxycodone, are administered, they will block the receptors and thus have a dual effect of blocking the action of the natural narcotics (endorphins) as well as diminishing their production. Patients were educated that as a result, patients using opioid analgesics not only face the side effects of narcotics (nausea/vomiting), but also have more intense pain for a longer period since it takes time for the endorphins/natural narcotics to be produced.
The preoperative teaching sessions also included information about non-opioid analgesics, namely gabapentin, celecoxib, and acetaminophen. Specifically, patients learned that these drugs are known to produce analgesic effects though opioid-sparing mechanisms. Taking these medications would preserve the body's natural endorphin production and response, while avoiding the negative side effects of narcotics.
After receiving instruction, the patients had the choice to receive preoperative treatment consisting of oral administration of 600mg of gabapentin and 400mg of celecoxib 30–60 minutes before surgery. The patients who preferred no prescription of hydrocodone as well as gabapentin and celecoxib after patient education were separated into experimental group A. Experimental group B consisted of patients who received preoperative patient education, refused to take a prescription of hydrocodone, but accepted preoperative administration of gabapentin and celecoxib. Those who accepted a prescription for hydrocodone, in case acetaminophen (Tylenol) was not adequate, were put into experimental group C.
The control group consisted of 66 patients who received 600mg of gabapentin and 400mg of celecoxib 30–60 minutes before surgery, but did not receive any pre-operative oral or written patient education regarding endorphin physiology. Patients were handed prescriptions for the preoperative medications (gabapentin and celecoxib) and hydrocodone. These patients were divided into control group A (those who did not request refills on hydrocodone) and control group B (those who requested refills on hydrocodone).
All patients had access to acetaminophen (1000mg every 6 hours as needed) postoperatively. The rationale for the administration of celecoxib and gabapentin was explained to the patients by the operating surgeon during their preoperative visit, which occurred approximately 2 weeks before surgery, and was re-emphasized on the day of the procedure prior to the operation. However, control group patients did not receive preoperative education on the mechanisms of preserving endorphin function in these non-opioid analgesics. Rather, the patients were simply informed that celecoxib and gabapentin would be used for prophylaxis of postoperative pain. Additionally, 500mg of cephalexin was given to all patients 30–60 minutes before surgery for infection prophylaxis, following the surgeon's usual infection protocol. The incidence of nausea and vomiting in the post-anesthesia care unit for both control and experimental groups was recorded.
Beginning on the day of surgery and ending on the fifth post-operative day, patients were asked to self-rate their perceived level of pain intensity daily. Pain intensity was quantified using the following 0–5 scale: 0 for none, 1 for mild pain (annoying, nagging), 2 for discomforting (trouble- some, nauseating, grueling, numbing), 3 for distressing (miserable, agonizing gnawing), 4 for intense (dreadful, horrible, vicious, cramping), and 5 for excruciating pain (unbearable, torturing, crushing, tearing). This pain scale is consistent with the scale used by Parsa, et al, in their study on the combined use of celecoxib and gabapentin in postoperative pain management.6 Self-rating was done on a daily basis. If patients experienced different intensities of pain throughout the day, they were asked to record the time and intensity of their perceived pain accordingly. Patients who required analgesic medication were asked to record the date, time, type of medication (Tylenol or hydrocodone), and the intensity of their pain on a provided form.
The questionnaires were collected on postoperative day 5. The investigators calculated an average pain score for each patient over the five days. These scores were compiled and organized in the following fashion: nil to mild pain, pain score of 0 to 1.99; mild to moderate pain, pain score of 2 to 2.99; intense pain, pain score of 3 to 5. Additionally, a combined average pain score for each of the 5 subject groups was calculated. Patients' use of opioid analgesics and self-rated pain are the primary outcome measures of this study. Statistical analyses were conducted using Fisher's exact test with mid-P, two-sided values of P <.05 considered significant.
Of the 69 patients in the experimental group, 63 (90%) declined taking home a prescription of hydrocodone at the preoperative session two weeks prior to surgery (Figure 1). These 63 patients expressed clear understanding of the role endorphins/natural narcotics played in postoperative pain control and the need to preserve the body's own natural narcotics. Moreover, none of these patients called the office requesting hydrocodone postoperatively. The results for the experimental and control groups are summarized in Table 1.
In experimental group A, 43 patients (62% of experimental group) did not take preoperative celecoxib and gabapentin. The mean pain score for the first 5 days postoperatively was 2.6. Experimental group B consisted of 20 patients (29% of experimental group) who chose to take celebrex+gabapentin preoperatively on the morning of surgery. The mean pain score for the first 5 days postoperatively was 2.0 and 100% of patients believed that Tylenol alone provided adequate postoperative analgesia. The average duration of pain was 1.9 days.
Among the 6 patients who despite preoperative education, insisted on receiving a prescription of hydrocodone (experimental group C), 33% filled and utilized hydrocodone after surgery. Patients who utilized hydrocodone had intense pain with average pain scores of 4.4 and 4.2. One patient filled the hydrocodone prescription but did not utilize it, and had a pain score of 2.9 (moderate pain). Three patients requested hydrocodone but did not fill their prescriptions and had an average pain score of 2.2 (moderate pain). In this group, those who utilized hydrocodone had a higher pain score than those who did not use the drug (P <.05). Overall, the pain score in this group (experimental group C) was higher than in patients who did not request hydrocodone for their postoperative use, as in the experimental groups A and B (P <.05). The average duration of pain was 3.1 days in this group.
In control group A, where no education was provided and hydrocodone was provided, but no refill was requested, the average pain score was 3.2. This average is significantly (P <.05) greater than that of the experimental groups recieving patient education. In control group B, where patients received no preoperative education, all patients utilized hydrocodone postoperatively and in addition asked for refills at least on one occasion, the average pain score was 3.1. This value is similar to those who requested no refill and also significantly higher than patients who had received preoperative education (P <0.05). Of note is that the average duration of pain in these latter two groups (control group A and control group B) was significantly longer (P <.005) than in those patients who had received preoperative education: 4.2 days in control group A and 4.9 in control group B (combined average of 4.5) compared to the average of 2.6 days when the experimental groups A (average 2.8 days), B (average 1.9 days) and C (average 3.1 days) are combined.
Opioid narcotics carry multiple side effects which can complicate postoperative recovery including ileus, anorexia, nausea and vomiting, sedation, respiratory depression, and addiction.7 The harm inflicted on the body due to the intake of opioid narcotics is being investigated and has been shown to negatively affect our endogenous neuropeptides called endorphins. Endorphins act on the mu opioid receptors throughout our nervous system and naturally disrupt the pathways involved in pain transmission. Proopiomelanocortin (POMC) is the precursor to beta-endorphins and is secreted by the anterior pituitary. Studies have shown that after prolonged exposure to exogenous opioids like morphine, the production of POMC from the anterior pituitary is reduced and thus beta-endorphin levels decrease.8 In premenstrual dysphoric disorder, a study found that patients with the disorder had lower levels of plasma beta-endorphins which correlated to lower pain thresholds and increased pain sensitivity.9 In addition to pain modulation, endorphins have also been involved in behavior and mood. Stanley, et al, investigated the cerebral spinal fluid levels of endorphins in those with self-injurious behavior and found that those who were depressed and suffered from feelings of hopelessness had significantly lower levels of CSF endorphins.5
New advances toward managing postoperative pain without narcotics are underway. In this study, the use of patient education via oral, written, and visual communication was shown to be an effective way to minimize narcotic analgesia after surgery. This was successfully illustrated as 90% of patients who received preoperative teaching declined a hydrocodone prescription at the time of their preoperative visit, and did not request narcotics postoperatively. Conversely, 100% of patients who did not receive preoperative teaching filled their narcotic prescription when it was offered to them. Moreover, the average pain scores in experimental group A and experimental group B were lower than those who filled and utilized their narcotic prescription (experimental group C and control groups). In other words, those who requested and used hydrocodone postoperatively reported significantly more intense (P <.05) postoperative pain than those who did not utilize hydrocodone, suggesting that the use of opioids has an adverse effect on the intensity of postoperative pain (Table 1). The duration of postoperative pain was also found to be significantly longer (P <.005) in patients receiving opioids (average 4.5 days) than those only utilizing postoperative acetaminophen for pain relief (average 2.6 days). Additionally, patients who utilized hydrocodone postoperatively had nausea and vomiting of varying degrees in contrast to none of the patients in other groups who did not use opioids (P <.001). These results were similar to a meta-analysis investigating the positive outcomes after preoperative and postoperative patient education in order to alleviate psychological distress and postsurgical pain.10 Various postoperative improvements were seen with patient education including decreased length of stay in the hospital, decreased blood loss, and reduced time to regain bowel function.10–12
Studies have shown that visual aid use is an effective strategy to educate patients of different cultural and educational backgrounds.13,14 Given the substantial difference between the experimental and control groups, it can be postulated that the use of visual aids was an effective method in illustrating the ligand-receptor nature of opioids and endorphins with their respective receptor. In addition to the benefit of educating the patient on endorphins, patients perhaps also experience a sense of control in their care as opposed to the historical paradigm of physician paternalism.15 Numerous studies have shown that when patients are adequately informed about their medical conditions and take an active part in decision-making, improved outcomes are more likely.15,16 In regards to pain tolerance, a correlation has been found between a sense of control in the patient and increased pain tolerance.16 This phenomenon could have been involved with educating the patient on the mechanism of pain and endorphins and thus giving the patient a choice in whether to accept a prescription for a narcotic or not. Authors also note that the amount of time spent between patient and physician; differences in age between the experimental and control groups; and severity of surgical procedures represent potential confounding factors.
Another phenomenon that could have been present in this study was the placebo effect. In this study, authors offered a preoperative educational intervention, not an inert treatment. However, it is possible that the educational intervention described in this study did elicit the same physiological response seen in the placebo effect. A 2005 meta-analysis of 40 years of literature studying the placebo effect came to the conclusion that there is evidence that endogenous opiates are mediators in the mechanism of the placebo effect.17 This concept has been repeated in multiple studies in which an administered placebo could achieve pain reduction in experimental and postoperative pain. Moreover, administering naloxone, an opioid antagonist, would reverse this response and thus increase pain responses.17 The authors acknowledge that pain scores analyzed in this study are self-reported by the patients. Thus, patient perception and reporting bias should be considered in the interpretation of the findings. Additionally, the patients may have behaved in manners they perceived to be socially desirable. In this case, social desirability bias could have been introduced and is a limitation of this study.
The importance of effective communication with the patient should be emphasized with not only the operating surgeon, but also the anesthesiologist and possibly with other members of the surgical team. Ideally, the concept of “endorphins” should be reviewed with the patient in the preoperative evaluation visit with the anesthesiologist. This collaboration is paramount to the patient's quality of recovery as demonstrated in this study. That endorphins are involved in many aspects of our wellbeing including pain sensitivity and psychological wellbeing, it is crucial to educate patients undergoing surgery on the importance of endorphins and eliminating the need for narcotics in postoperative pain management. By empowering the patient with a sense of control and proper education, it is possible to minimize and in many instances eliminate the use of opioid analgesics. Other non-opioid analgesics such as acetaminophen and COX-2 inhibitors are available that have fewer side-effects in postoperative pain management. This study illustrates the power of communication and how influential a physician can be in the mental and physical management of the surgical patient.
The authors have no financial interest in the medications reported in this study. The authors report no conflict of interest.