Psychological Interventions To Reduce Postoperative Pain and Opioid Consumption: A Narrative Review of Literature

Review
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102434 on 25 May 2021. Downloaded from http://rapm.bmj.com/ on March 3, 2022 at Post Graduate Institute of Medical
Psychological interventions to reduce postoperative
pain and opioid consumption: a narrative review
of literature
Kevin Gorsky,1 Nick D Black ‍ ‍,2 Ayan Niazi,3 Aparna Saripella,1
Marina Englesakis ‍ ‍,4 Timothy Leroux,5 Frances Chung,6 Ahtsham U Niazi ‍ ‍1
►► Additional supplemental ABSTRACT The annual global surgical output comprises over
material is published online Background Evidence suggests that over half of 300 million procedures; more than half of these
only. To view, please visit the
patients undergoing surgical procedures suffer from
journal online (http://d x.doi.org/
patients suffer from postoperative pain.8–11 Periop-
10.1 136/rapm-2 020-102434). poorly controlled postoperative pain. In the context of erative pain is complex and requires timely access to
1 an opioid epidemic, novel strategies for ameliorating appropriate treatment, as inadequately controlled
Department of Anesthesia and
Pain Management, University postoperative pain and reducing opioid consumption postoperative pain may lead to the development
of Toronto, Toronto, Ontario, are essential. Psychological interventions defined as of chronic pain disorders, depression, opioid toler-
Canada strategies targeted towards reducing stress, anxiety, ance, addiction and abuse.12 13
2
Department of Anaesthesia, negative emotions and depression via education, Opioids are the mainstay of perioperative anal-
Belfast Health and Social Care gesia and are effective at managing acute pain;
Trust, Belfast, UK therapy, behavioral modification and relaxation
3
Department of Biology, Trent techniques are an emerging approach towards these however, overprescription and a better under-
Education & Research. Protected by copyright.

University, Peterborough, endpoints. standing of their detrimental effects have led clini-
Ontario, Canada Objective This review explores the efficacy of cians to seek alternatives.14 15 Many other analgesic
4
Library & Information Services, options have been used including regional anes-
University Health Network, psychological interventions for reducing postoperative
Toronto, Ontario, Canada pain and opioid use in the acute postoperative period. thesia, multimodal analgesia and psychological
5
The Arthritis Program, Evidence review An extensive literature search was interventions.14 16
University Health Network, conducted in MEDLINE, Cochrane Central Register of Evidence indicates that negative emotions can
Toronto, Ontario, Canada decrease the pain perception threshold and preop-
6
Anesthesia, Toronto Western
Controlled Trials, Cochrane Database of Systematic
Reviews, Medline In-Process/ePubs, Embase, Ovid Emcare erative expectations of pain.17 In addition, depres-
Hospital, University Health
Network, University of Toronto, Nursing, and PsycINFO, Web of Science (Clarivate), sion and anxiety can contribute to the severity of
Toronto, Ontario, Canada PubMed-NOT-Medline (NLM), CINAHL and ERIC, and two postoperative pain.18–20 Psychological interventions
trials registries, ClinicalTrials.Gov (NIH) and WHO ICTRP. have been used throughout the perioperative period
Correspondence to Included studies were limited to those investigating adult and focus on the reduction of anxiety, distress
Dr Ahtsham U Niazi, Department
human subjects, and those published in English. and depression, which in turn may reduce pain.21
of Anesthesia and Pain Psychological therapies include (1) relaxation,
Management, University of Findings Three distinct forms of psychological
Toronto, Toronto, ON M5S, interventions were identified: relaxation, psychoeducation (2) psychoeducation and (3) cognitive behavioral
Canada; therapy (CBT). Relaxation therapies span a diversity
and behavioral modification therapy. Study results
a htsham.niazi@u toronto.ca of interventions including music therapy, combina-
showed a reduction in both postoperative opioid use
tion of music and relaxation, guided imagery and
Received 29 December 2020 and pain scores (n=5), reduction in postoperative opioid
hypnosis. Psychoeducation describes specific educa-
Accepted 13 May 2021 use (n=3), reduction in postoperative pain (n=5), no
Published Online First tion for patients about their pain condition, strate-
significant reduction in pain or opioid use (n=7), increase
25 May 2021 gies to cope with their pain and can include didactic
in postoperative opioid use (n=1) and an increase in
instruction and educational materials.22 CBTs
postoperative pain (n=1).
comprise strategies for cognitive restructuring,
Conclusion Some preoperative psychological
reframing and reappraisal based on the patients’
interventions can reduce pain scores and opioid
individual needs.23 This method of therapy focusses
consumption in the acute postoperative period; however,
on challenging maladaptive behaviors while devel-
there is a clear need to strengthen the evidence for these
oping personal coping skills targeted to a specific
interventions. The optimal technique, strategies, timing problem.23
and interface requires further investigation. This review seeks to evaluate if preoperative
psychological interventions, when compared with
standard of care treatment, can reduce acute post-
operative pain and opioid consumption in surgical
© American Society of Regional
INTRODUCTION patients.
Anesthesia & Pain Medicine
2021. No commercial re-use. In North America, the rate of opioid overdose
See rights and permissions. has tripled since 1999.1–4 The ‘opioid epidemic’ is METHODS
Published by BMJ. one of the major factors fueling a recent decrease Search strategy
To cite: Gorsky K, in American life expectancy.2 5 6 This alarming A medical information specialist (ME) conducted
Black ND, Niazi A, et al. escalation in opioid abuse is multifactorial, but searches in MEDLINE, Cochrane Central Register
Reg Anesth Pain Med undoubtedly correlates with postoperative opioid of Controlled Trials, Cochrane Database of System-
2021;46:893–903. prescribing.7 atic Reviews, Medline In- Process/ePubs, Embase,
Gorsky K, et al. Reg Anesth Pain Med 2021;46:893–903. doi:10.1136/rapm-2020-102434 893
Review
Ovid Emcare Nursing and PsycINFO (all on the Ovid platform), (age>17) who received a defined psychological intervention in
Web of Science (Clarivate), PubMed- NOT- Medline (NLM), the preoperative period. The interventions were psychological
CINAHL and ERIC (on the EbscoHost platform) and two therapies as defined as: (1) relaxation based therapies (relax-
trials registries, ClinicalTrials.Gov (NIH) and WHO ICTRP. All ation, relaxation and music, hypnosis and guided imagery), (2)
searches were conducted on April 3, 2019 and repeated prior to psychoeducation and (3) CBT delivered, at least in part, preop-
submission in November 2020. eratively. The comparator for included studies was treatment as
Controlled vocabularies such as MeSH in Medline or EMTree usual or best clinical practice. The coprimary outcomes were
descriptors in Embase as well as text words were used as search patient reported pain scores (Visual Analog Scale (VAS), Numer-
terms in the concept blocks of: Preoperative+(Psychological or ical Rating Scale (NRS) and so on) and opioid consumption in
Psychiatric Interventions)+Opioids+Studies. the acute postoperative period (postanesthetic care unit, ward,
home and so on). Studies were unrestrained by length of patient
Study selection and inclusion criteria follow-up.
All English language randomized controlled published after The study followed the guidelines of the Preferred Reporting
1806 were included. The studies included adult surgical patients Items for Systematic Reviews and Meta- Analyses (figure 1).
Figure 1 PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
894 Gorsky K, et al. Reg Anesth Pain Med 2021;46:893–903. doi:10.1136/rapm-2020-102434
Review
The resultant search yielded 3000 papers after duplicates were
Table 1 Included studies categorized by surgical subspecialty: opioid
purged.
and pain outcomes
Articles were excluded if they did not measure pain scores and
opioid consumption as an endpoint, if no surgical procedure Number
Number of studies of studies
was performed, if the intervention occurred exclusively during
demonstrating demonstrating
or after the procedure or if the intervention was procedural in reduction in reduction in
nature (ie, acupuncture). Selected manuscripts were analyzed postoperative postoperative
and subgrouped according to the category of psychological Studies by surgical subspecialty opioid consumption pain scores
intervention. Orthopedics (n=4)34 42 43 45 0 1
General surgery (n=8)25 28–30 32 33 35 41 2 5
Types of outcome measures Gynecology (n=2)27 31 0 1
Articles were analyzed in accordance with an original data Spine surgery (n=1)24 0* 0
extraction tool (online supplemental table 1). The coprimary Dental surgery (n=2)37 42 2 0
outcomes of interest were opioid use and pain scores. Secondary Breast reconstruction (n=2)26 38 1 1†
outcomes included length of stay, adjunct analgesic use, method Cardiac surgery (n=1)36 1 1
of intervention delivery, length of intervention, complications, Plastic surgery (n=2)39 40 2 1
patient satisfaction, mortality, Quality of Recovery score, cost of
*One study demonstrated an intervention arm increase in opioid consumption.
the intervention and patient anxiety.
†One study demonstrated an intervention arm increase in pain scores.
Data extraction and review

Three reviewers (AS, AN, KG) reviewed all abstracts, ensuring Psychological interventions were studied in patients under-
each abstract was read by at least two reviewers, and extracted going various surgical procedures (table 1).
data using a tool developed specifically for this review. A third Five studies demonstrated a reduction in both postoperative

reviewer (AUN) adjudicated disagreement. Three full-text review opioid use and pain scores,25 26 33 36 39 three showed only a reduc-
cycles were completed to ensure the accuracy of data extraction. tion in postoperative opioid use38 41 45 and five only a reduction
A total of 22 articles were retained and analyzed. Complete data in postoperative pain.29–32 42 Seven studies presented no signif-
will be made available on reasonable request to the authors. icant reduction in pain or opioid use,27 28 34 35 41 43 45 while one
showed an increase in postoperative pain38 and one displayed an
RESULTS increase in postoperative opioid use.24
Out of 3000 studies screened, 22 met inclusion criteria (figure 1).
Studies included in this review specifically examined the reduc- Relaxation therapy
tion of postoperative pain and opioid consumption. Three distinct Sixteen studies involved the use of relaxation-based therapies
psychological interventions were identified. These were (1) throughout the perioperative period (n=16)24–39 (tables 2–5).
relaxation (n=4),24–27 music and relaxation therapy (n=5),28–32 These therapies involve the administration of relaxation
music (n=3)33–35 and hypnosis (n=4),36–39 (2) psychoeduca- (n=4),24–27 music and muscle relaxation (n=5),28–32 music
tion (n=3)40–42 and (3) CBT (n=3).43–45 Included studies were therapy (n=3)33–35 and hypnosis (n=4).36–39
conducted in the USA (n= 11),24 28–33 40 42 43 45 France (n=1),38 Twelve studies (n=12),24–35 involved the administration of
Iran (n=1),25 Romania (n=1),26 Poland (n=1),41 China (n=1),44 relaxation (n=4),24–27 music and muscle relaxation (n=5),28–32
Sweden (n=1),37 Taiwan (n=1),34 Turkey (n=3)35 36 39 and Neth- music therapy (n=3)33–35 either via recording or by a trained
erlands (n=1).27 Collectively, these papers analyzed data from professional, targeted at reducing pain and opioid consumption
3108 participants (2167 receiving psychological interventions in the perioperative setting.
and 941 controls). Collectively, seven of these studies (n=7)24 26 29–33 demon-
Twenty- two studies on psychological interventions were strated pain reduction, while three (n=3)25 26 33 demonstrated
performed during the preoperative period,24–45 with one opioid reduction. Relaxation and music therapies were delivered
having a combination of preoperative and intraoperative inter- via recording (n=9),27–35 in person (either by trained researchers
vention27 and eight spanning the preoperative and postopera- or psychologists) (n=2)25 26 or by brochure (n=1).24 In one
tive periods.28–34 Interventions lasted from 5 min to 4 weeks. study, information was administered via a brochure, and no post-
Methods of intraoperative anesthesia included general anesthetic operative opioid or pain reduction was observed.24 However,
(n=15),24–36 38 39 general or neuraxial±peripheral nerve block studies that employed an in-person method of therapy adminis-
(n=2),44 45 local (±sedation) (n=4)37 40–42 and not specified tration, for example, Zagai et al demonstrated NRS pain scores
(n=1).43 The background of the person administering the inter- of 0.24 vs 1 at 24-hour postop, and Hasanpour-Dehkordhi et al
vention was variable. Some medical professionals underwent described 77% of relaxation group patients achieving ‘very low’
specific training for the intervention (n=4).25 36 42 43 A consid- pain vs 65% of controls at the same time marker.25 26 Further,
erable proportion of interventions were administered in-person these studies showed significant reduction in opioid consump-
(face-to-face) (n=9).25 26 36 38–40 42–44 Those who adminis- tion as measured in morphine equivalents (2.5 times less
tered interventions were trained nurses (n=1),43 psychologists morphine required through the study period in the progressive
(n=2),26 44 anesthesiologists (n=3),36 38 39 surgeons (n=1)40 and muscle relaxation group vs controls) or mean tramadol require-
clinical researchers (n=2).25 42 The remainder were administered ments (95 vs 195 mg of IV tramadol on POD#1).25 26 Of the
by various media (n=13),24 27–35 37 41 45 including audiocassette nine studies27–35 that used recorded audio, significant decrease in
(n=10),27–35 37 brochure (n=1),24 telephone (n=1)45 or multi- pain perception was observed in five,29–33 while opioid sparing
media module (n=1).41 Length of stay, anxiety metrics, compli- effects were demonstrated in only one.34
cations and various quality outcomes were collected (online In four studies,36–39 hypnosis was validated as an interven-
supplemental table 1). tion capable of reducing postoperative opioid consumption,
Review
Table 2 Included studies and primary outcomes on relaxation: relaxation-based psychological interventions
Opioid
Study/year Country Type of surgery Patients (n) Study description Control Pain Score (PS) consumption
Relaxation
Gavin et al, USA Lumber and spine 49 Patients randomized into the Standard of care NS Opioid use >in the
200624 surgery experimental group were provided relaxation group on
with a brochure that contained a POD 1+POD 2.
relaxation protocol, which included The intervention
deep breathing and guided imagery. group used more
The intervention lasted for 20–30 opioids than control
min and patients were encouraged
to perform it preoperatively.
Postoperative activities that could
help distract the patient from pain
were also included in the brochure.
Hasanpour- Iran Elective upper and 70 Patients were randomized to perform Standard of care Reduction in Significant decrease
Dehkordi et al, lower gastrointestinal PMR—a technique that involves postoperative pain in morphine
201925 system surgery. relaxation of muscles by sitting in a intensity at 3 hours requirements in
comfortable position with your eyes (p<0.000), 12 hours the PMR group.
closed, and slowly and sequentially (p<0.000) and 24 2.5× less morphine
loosening all the muscles of the body, hours (p<0.003) as equivalents
from the soles of the feet up. Patients measured by NRS. required, no values
were provided PMR for 20 min every provided.
6 hours for 2 days until 2 hours before
surgery.

Zgâia et al, Romania Elective MRM for breast 102 A relaxation and psychological Standard of care The counseling Significant decrease
201626 cancer. counseling intervention was group demonstrated in postoperative
applied preoperatively. Psychologist significantly less pain analgesic
established the protocol for the by NRS at multiple requirements in
relaxation techniques. The session time points including the intervention
was 50 min long. In the first 25 immediately postop vs control group.
min, patients had a short clinical (p<0.001) and 24-hour Decreased
semistructured interview regarding postop (p=0.001) in tramadol
the history of the disease and the requirements POD
treatment of the patients. In the 1+2 (p<0.001).
second 25 min, patients underwent
an autogenous training exercise,
which combined visual imagery and
suggestions to experience relaxation
and peace.
van der Laan Netherlands Elective gynecologic 60 Patients were randomized into Group 3, reading NS NS
et al, 199627 surgery three groups: Group 1 received of the stories
a tape of positive therapeutic with no positive
suggestions preoperatively and therapeutic
the story of Robinson Crusoe suggestions.
intraoperatively; Group 2 heard the
story of Peter Pan preoperatively
and positive therapeutic suggestions
intraoperatively; Group 3 heard the
Crusoe story preoperatively and the
Peter Pan story intraoperatively.
MRM, modified radical mastectomy; NRS, Numerical Rating Scale; NS, not significant; PMR, progressive muscle relaxation; POD, postoperative day; VAS, Visual Analog Scale.
non-steroidal anti-inflammatory requirements, length of venti- mcg) and morphine bolus requirements (4.9 mg vs 13.6 mg)
lator assistance in the intensive care unit and ambient and in coronary artery bypass grafting patients.36 Amraoui et al
procedure-related anxiety.36 37 Three studies demonstrated demonstrated contrasting results, whereby hypnosis was associ-
reduction in opioid consumption,36 37 39 two showed reduc- ated with increased postoperative VAS pain scores in the PACU
tion in postoperative pain scores,35 39 while one large study setting, although this increase in pain scores did not persist
by Amraoui et al demonstrated increased pain scores in the by evening evaluation, or on more long- term follow- up.38
hypnosis group.38 Enqvist et al demonstrated the efficacy of a
The study by Ozgunay et al (n=30) exemplified the utility of
hypnotherapy regimen administered via audio recording in the
preoperative hypnosis in septorhinoplasty, whereby postoper-
weeks preceding dental surgery.37 This study showed a reduc-
tion in postoperative analgesic requirements, whereby a statis- ative VAS pain scores at 2 and 3 hours were reduced in the
tically significant proportion of the intervention group patients intervention arm.39 However, pain scores converged by 4 hours
used less Codeine #3 (Paracetamol 500 mg-Codeine phosphate and demonstrated no statistical difference by patient discharge.
30 mg) tablets “in doses according to routine use”, during POD Intraoperative remifentanil use was significantly lower in the
1–5.37 Akgul et al showed that preoperative hypnosis reduced hypnosis group, yet postoperative opioid use did not statisti-
VAS pain scores, and both remifentanil (2711 mcg vs 3825.9 cally differ.39
Review
Table 3 Included studies and primary outcomes on relaxation: music and relaxation-based psychological interventions
Opioid
Music and relaxation
Good et al, USA Elective abdominal 84 The intervention was applied Casual conversation for NS NS
199528 surgery both preoperatively and 10 min. in place of the
postoperatively. The three tape+standard of care
groups received either
music, jaw relaxation or a
combination of both.
The techniques were applied
postoperatively 2 min before
first ambulation, and then
subjects used their taped
interventions for 48 hours
after the first ambulation for
pain management.
Good et al, USA Abdominal surgery 617 The interventions such as Casual conversation (10 The treatment groups had NS
199929 jaw relaxation, music or a min) and quiet time (15 significantly less pain than the
combination of relaxation min)+standard of care controls (p=0.028–0.000).
and music were taught
preoperatively with an
introductory tape using
earphones and tested
with a treatment tape
postoperatively during
ambulation and at rest on
days 1 and 2.

In the jaw relaxation, subjects
heard an introductory tape
using earphones. It explained
the purpose and effects of
relaxation and described the
jaw relaxation technique.
In the music group, subjects
listened to one of the five
different types of music.
In combination group, both
the relaxation and music
techniques were used.
Good et al, USA Major abdominal 468 The interventions such as The control group received 10 Significant decrease in Not assessed
200130 surgery jaw relaxation, music or a min of casual conversation postoperative pain in the
combination of relaxation preoperatively and 15 min of intervention groups
and music were taught rest postoperatively+standard
preoperatively. of care.
In jaw relaxation, subjects
In the combination group,
both the relaxation and music
techniques were used.
Postoperatively, 60 min
intervention tapes were used.
Good et al, USA Gynecologic (GYN) 311 The interventions such as The control group received 10 The intervention groups had NS
200231 surgery jaw relaxation, music or a min of casual conversation significantly less post-test pain
combination of relaxation preoperatively and 15 min of than the control group (p=0.022–
and music were taught rest postoperatively+standard 0.001)
preoperatively with of care
introductory tapes.
In jaw relaxation, subjects
In the combination group,
both the relaxation and
music techniques were used.
Postoperatively, 60 min
intervention tapes were used.
Continued
Review
Table 3 Continued
Opioid
Good et al, USA Abdominal surgery 517 The interventions were PT, Standard of care The RM and PTRM groups NS
201032 RM, a combination (PTRM) showed significantly lower pain
and control. The PT, RM than the control group on POD
and PTRM interventions 1 and 2.
were recorded on 5–10 min
introductory audiotapes used
preoperatively, and a 60
min intervention tape used
postoperatively.
NS, not significant; PT, pain management; PTRM, combination pain management, relaxation and music; RM, relaxation and music ; VAS, Visual Analog Scale.
Psychoeducation CBT program prior to knee arthroplasty in reducing pain scores

Three studies examining psychoeducation met inclusion crite- or opioid consumption. However, this study did prove an inter-
ria40–42(table 6). Two demonstrated a significant reduction in ventional reduction in presurgical catastrophizing.
postoperative opioid use.40 42 Alter et al administered a psycho-
educational regimen specific to the dangers of opioid misuse and DISCUSSION
abuse, which effectively reduced postoperative opioid consump- This review has collated all the available evidence pertaining to
tion.40 The counseled group consumed a mean of 1.4 Acetamin- the impact of preoperative psychological interventions. Positive
ophen #3 (Acetaminophen 300 mg and Codeine Phosphate 30 outcomes have been demonstrated across a variety of individual
mg) tablets compared with 4.2 tablets in the control group.40 An studies, but results appear incongruent when grouped by type
opioid misuse prevention program was administered by Dere- of intervention, type of surgery or timing of intervention. This

finko et al, achieving a similar reduction in opioid consump- narrative review provides evidence that alternate methods for
tion.42 Pierściński et al examined the effect of a preoperative managing postoperative pain and reducing postoperative opioid
multimedia presentation demonstrating the course of a patient requirements exist.
undergoing hernioplasty, without demonstrating efficacy.41 Five studies included in this review showed both a reduction
in opioid consumption and pain score postoperatively. Three
Cognitive behavioral therapy of these studies used types of relaxation therapy,25 26 33 while
Three studies evaluated the efficacy of CBT on reducing post- two demonstrated the success of hypnotherapy.36 39 These
operative pain and opioid consumption43–45 (table 7). Dindo et relaxation psychotherapies included guided imagery, progres-
al43 studied the effects of preoperative acceptance and commit- sive muscle relaxation techniques and relaxation with expert
ment therapy (ACT). Though this study showed earlier secession counseling. In these five convincingly positive studies, four
of opioid intake in the interventional group and reduced pain demonstrated a significant reduction in anxiety in the treat-
scores, their results were not statistically significant.43 Wong et ment arm,25 26 33 36 while this outcome was not measured in the
al44 examined the effect of a single preoperative session of CBT Ozgunay et al trial.39 This correlation suggests that the mech-
on postoperative pain in traumatic patients with limb fracture anism whereby psychological interventions reduce pain and
set to undergo surgery. This study showed significant reduction opioid consumption works through modulating anxiety. Carr
in reported pain scores in the interventional arm throughout the et al46 demonstrated that higher preoperative anxiety scores
7-day postoperative study period, with the largest difference are correlated with increased postoperative pain, while lower
in magnitude on POD 4 (VAS 29.8 vs 42.7).44 Buvanendran et anxiety levels correlate with higher pain thresholds. Further, a
al45 failed to demonstrate the efficacy for a 4-week preoperative study examining opioid use in shoulder surgery patients found
Table 4 Included studies and primary outcomes on relaxation: music-based psychological interventions
Opioid
Music
Tusek et al, USA Colorectal surgery 130 Intervention groups were made to listen to a Standard of The imagery group Total opioid
199733 guided imagery tape 3 days preoperatively: a care demonstrated requirements were
music-only tape during induction, during surgery reduction in pain significantly lower
and postoperatively in the recovery room. A scores vs controls in the imagery
guided imagery tape was provided to this group (p<0.001) group (p<0.001)
during each of the first 6 postoperative days.
Chen et al, Taiwan TKR 30 The music intervention was given in the Standard of NS NS
201534 preoperative ward (Phase I) and in the surgical care
waiting area (Phase II) for 30 min at each site.
In Postoperative recovery (Phase III), music was
played for 60 min. In total, each subject listened
to music for 120 min.
Akelma et al, Turkey Inguinal hernia 117 Listened to choice of favorite music at volume Standard of NS Not assessed
202035 surgery of 50–60 dB using headphones for 15 min, care
preoperatively.
NS, not significant; TKR, total knee replacement; VAS, Visual Analog Scale.

Table 5 Included studies and primary outcomes on relaxation: hypnosis-based psychological interventions
Study/year Country Type of surgery Patients (n) Study description Control Pain Score (PS) Opioid consumption
Hypnosis
Akgul et al, 201636 Turkey CABG 44 The patients in the intervention group received Information on the surgical Pain scores in the hypnosis Significant reduction in morphine
preoperative hypnosis administered by an intervention by the same group vs control group and remifentanil use was
anesthesiologist. The hypnosis was performed anesthesiologist+standard of care improved significantly observed in the hypnosis group
on the patients after the first evaluation of the vs controls
anxiety indexes (on the same day that they were
hospitalized) for 30 min.
Enqvist et al, Sweden Surgical removal of third 69 The intervention group received a 20 min Standard of care NS Significant reduction in
199737 mandibular molars tape, which contained hypnotic techniques postoperative Citodon
preoperatively. They were required to listen to the (Tylenol+Codeine) consumption
tape daily for a week before the surgery. in the hypnosis group vs controls.
Gorsky K, et al. Reg Anesth Pain Med 2021;46:893–903. doi:10.1136/rapm-2020-102434

Amraoui et al, France Breast cancer 148 Short individual hypnosis session (15 min) that Standard of care Mean VAS pain scores NS
201838 was personalized to each patient was performed assessed immediately before
preoperatively in all centers by a trained PACU discharge were higher
anesthesiologist who had been practicing the in the hypnosis arm (p=0.004)
technique for more than 1 year.
Ozgunay et al, Turkey Open SRP 22 Patients in the hypnosis group received a total Standard of care Hypnosis group Postoperative Intraoperative total
201939 of three sessions of hypnotic induction. The first VAS scores were significantly remifentanil consumption
two were administered 3 days and 1 day prior lower at the second and third was significantly lower in the
to surgery, respectively, and the last session was hour (p=0.028, and p=0.047, hypnosis group than in controls
administered in the hospital the day of surgery. respectively) (p=0.034). Postoperative
Hypnosis induction was given by the same opioid consumption was not
anesthesiologist. significantly different.
CABG, coronary artery bypass grafting; NS, not significant; SRP, septorhinoplasty; VAS, Visual Analog Scale.
Review
899
Review
Table 6 Included studies and primary outcomes on psychoeducation-based psychological interventions
Pain
Score
Study/year Country Type of surgery Patients (n) Study description Control (PS) Opioid consumption
Psychoeducation
Alter et al, 201740 USA CTR 40 Preoperative opioid counseling The control group did NS Significant reduction
consisted of formally explaining not receive any opioid in postoperative opioid
the significance and problems counseling+standard of care consumption for counseling
associated with the opioid vs controls
epidemic and five formal
preoperative recommendations.
Pierściński et al, Poland Elective surgical 31 The study group was Traditional preoperative NS NS
200741 hernioplasty administered a computer education by medical
presentation illustrating the personnel+standard of care
course of treatment for a
72-year-old male patient with
inguinal hernia. The surgeon-
patient conversations covered
the nature of the condition,
indications for and methods
of surgical repair, possible
complications, the course of
hospital stay and postoperative
recommendations.
Derefinko et al, USA Tooth extraction 72 The intervention arm provided Traditional preoperative NS The intervention group self-
202042 educational counseling about education by medical reported less opioid use (in
risks and appropriate use of personnel+standard of care MMEs) than the TAU group
opioid medication as well as 28 (37.94 vs 47.79, effect size

tablets of ibuprofen (200 mg) d=0.42).
and 28 tablets of acetaminophen
(500 mg) for weaning off opioid
medication. The session included
a 10 min discussion with active
participation from the patient.
CTR, carpel tunnel release; MME, morphine milligram equivalent; NS, not significant; VAS, Visual Analog Scale.
that anxiety was one of the main risk factors correlated to an pain and opioid use.48 We postulate that Gavin et al’s paradox-
increase in opioid consumption in the postoperative period.47 ical results may be further explained by the increased lag time
A similar mechanism is proposed to explain the increased VAS (up to 1 week) between the intervention and surgery—with
pain scores experienced by hypnosis-arm patients in the study by more time spent dwelling on the upcoming surgery potentially
Amraoui et al whereby no improvement in anxiety scores in the creating a negative feedback loop of ruminations and stress.24
treatment group was documented.38 Preoperative pain educa- This review indicates that methods to lower perioperative
tion can ameliorate anxiety, improve acute pain management anxiety may reduce postoperative pain perception and opioid
and theoretically reduce the incidence of chronic post-surgical consumption in the postoperative period.
Table 7 Included studies and primary outcomes on cognitive behavioral therapy-based psychological interventions
Opioid
Cognitive behavioral therapy
Dindo et al, 201843 USA Orthopedic 76 Patients received a 1-day ACT Standard of care/ NS NS
surgery workshop for prevention of TAU)
chronic pain and opioid use in
the preoperative period. 2 clinical
psychologists provided the 5-hour
ACT workshops.
Wong et al, 201044 China Orthopedic 125 The experimental group received Standard of care Significant reduction NS
surgery CBEI preoperatively. A trained nurse in postoperative
conducted all CBEI. It was provided pain scores by VAS
over a 30 min duration. in the CBEI group vs
controls
(p=0.008)
Buvanendran et al, USA Orthopedic 77 A 4-week tele-health CBT program Non-CBT NS NS
202145 surgery was compared with non-CBT standard of care
standard of care to assess short
and long-term outcomes following
primary TKA in patients with high
pain catastrophizing scores.
ACT, acceptance and commitment therapy; CBEI, cognitive behavior education intervention; CBT, cognitive behavioral therapy; NS, not significant; TAU, treatment as usual; TKA,
total knee arthroplasty; VAS, Visual Analog Scale.

Review
Opioid counseling and CBT have both shown some benefit of the procedure or the procedure itself. The extent and type of
in reducing opioid consumption and pain postoperatively.40 42 44 surgery has been previously demonstrated to impact preopera-
These techniques have similarities—opioid counseling is specific tive anxiety and pain.59
to the psychoeducation around opioids and their effects, whereby There were limited examples of potential downsides to
the CBT model used by Wong et al44 expands on education by psychological interventions identified in this review. The study
the inclusion of CBT tools for attitude and cognitive realign- by Gavin et al24 did demonstrate an increase in opioid consump-
ment.44 Previous research has demonstrated that preoperative tion in the relaxation study arm as compared with control, and
opioid cessation counseling was more likely to stop postopera- Wong et al showed a transient increase in opioid consumption
tive opioid use early compared with no counseling.49 Both Alter on POD#2 in a 7-day study window, but these findings were not
et al and Derefinko et al demonstrated that opioid counseling repeated in other studies.44 Further, Amraoui et al demonstrated
reduced opioid consumption after outpatient surgery.40 42 Both an increase in PACU pain scores, but this effect had resolved
regimens highlighted the benefit of non-opioid analgesics and by the evening of surgery and was not correlated to increased
the appropriate limited use of opioids. Preoperative opioid use opioid consumption.38
is a significant risk factor for chronic opioid consumption, while Psychological interventions are not capable of replacing
opioid consumption in the first 7 days postoperatively is related analgesic medications, nor are they designed too. Patients with
to a 44% increase in long-term opioid use.50 51 Moreover, Center existing chronic pain disorders, major psychiatric illness and
for Disease Control data have demonstrated that the likelihood chronic opioid consumption were most often excluded in the
of chronic opioid use increases with each additional day of medi- analyzed studies.25–27 33 35 36 38–40 42–45 This significant subgroup
cation supplied starting with the third day of prescription.52 The of patients represents a considerable portion of the perioper-
cognitive behavior education intervention described by Wong et ative population and may contribute to reduced generaliz-
al demonstrated a transient increase in opioid consumption on ability of conclusions.60 Interestingly, the studies conducted by
POD 2 and this may represent an intervention effect on pain Good et al28–32 included patients with substance use disorders,
scores. However, pain was persistently reduced on POD 4–7.44 chronic pain, opioid dependence and psychotic mental illness.
ACT used by Dindo et al43 in their study failed to demonstrate None of these five studies demonstrated opioid reduction and

statistical outcomes on the reduction of either pain or opioid use. this may represent a more negative outlook on music and relax-
ACT is a type of CBT focused more on the patients’ relation- ation therapies in patients with chronic pain. It is unlikely that
ship with their thoughts and emotions than their content.53 This a brief preoperative psychological intervention is sufficient to
pilot study demonstrated promising HRs for ameliorating pain treat the complex biopsychosocial phenomena of chronic pain
and opioid consumption, and the authors phrased their results disorders. Further, the transferability of interventional efficacy
as a success, yet all the relevant confidence intervals crossed 1. across surgical procedures is not guaranteed and certain types
Further, Buvanendran et al,45 in a well conducted study, failed of surgical pain may be more or less amenable to psychological
to show the efficacy of CBT, even in patients with high base- based interventions.58 Moreover, these factors likely preclude
line catastrophizing. Larger CBT studies adequately powered to the usefulness of many of these interventions in urgent and emer-
detect these outcomes are recommended. gency procedures. Interventions such as CBT and psychological
Nine interventions were administered via a person-to-person training programs require significant buy-in from the patients
interface,25 26 36 38–40 42–44 and the majority of these interven- themselves. Many patients prefer a more passive approach to
tions resulted in significant improvement in pain perception their medical care, and these techniques may not fit their criteria.
(n=5)25 26 36 39 44 and opioid reduction (n=5).25 26 36 39 40 42 A
human interface may correlate with enhanced efficacy of these
Limitations
interventions. A meta-analysis on the efficacy of hypnosis for
Limitations to our review include several of the included studies
surgery and medical procedures determined that hypnosis had
being published by the same authors and institution. These
larger effects when it was delivered face-to-face (live) than via
studies from Good et al28–32 represent a significant number of
tape and that hypnosis was more effective when it was imple-
the papers examining music and relaxation therapy and repre-
mented preoperatively compared with intraoperatively.54 Similar
sent four out of the seven positive results for music and relax-
results have been seen in two Cochrane reviews conducted on
ation pain reduction. Multiples studies from the same research
psychological therapies for the management of chronic and
group introduce a potential source of bias and skewing of the
recurrent pain in children and adolescents.55 56 These reviews
data. Further, analyzed studies examined the effects of various
showed that psychological interventions delivered face-to-face
types of opioid medications: morphine, hydrocodone, oxyco-
are effective at reducing pain outcomes, with less clear evidence
done, codeine, tramadol and remifentanil. These drugs repre-
for remotely administered therapies.
sent the spectrum of opioid potency and half- life and thus
Psychological interventions failed to reduce opioid use in
creates a limitation in comparability. The studies by Hasanpour-
orthopedic surgery and spine surgery. This may indicate that
Dehkordi et al25 and Enqvist et al37 fail to specify the amount of
orthopedic procedures are more refractory to psychological
opioid used. Moreover, some included studies were of a small
interventions. A cross-sectional study examining preoperative
sample size, Ozgunay et al (n=22),39 Chen et al (n=30)34 and
opioid use across different surgical populations demonstrated
Pierściński et al (n=31),41 increasing the chance of type II error
opioid prescription rates of 40% for lower leg surgery and over
and false negative results. These shortcomings make their conclu-
50% for spine surgery patients.57 Moreover, a study examining
sions more difficult to interpret. In addition, this review focused
predictors of severe postoperative pain recognized orthopedic
on interventions with a portion of therapy performed during the
surgery as an independent risk factor, noting that the level of
preoperative period and is thus limited in scope to this criterion.
preoperative pain, incision size and type of surgery all impact
postoperative pain.58 The only included study examining
psychological intervention in spine was ineffective.24 This may CONCLUSION
reflect the burden of preexisting pain in these patients, preoper- In conclusion, certain psychological interventions can reduce
ative opioid use, ambient stress and anxiety related to the nature pain and opioid consumption, possibly by reducing preoperative
Review
anxiety by a person-to-person interaction. Opioid counseling 15 Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia—when is enough
and education have shown to be of benefit as they improve too much? A review of opioid-induced tolerance and hyperalgesia. The Lancet
2019;393:1558–68.
patient’s knowledge on how to appropriately use their 16 Ziehm S, Rosendahl J, Barth J, et al. Psychological interventions for acute pain after
prescribed narcotics and supplement with non-opioid analge- open heart surgery. Cochrane Database Syst Rev 2017;7:CD009984.
sics, thus limiting their opioid consumption in the postopera- 17 Sakura S, Nonoue T, Nomura T, et al. Assessment of postoperative pain: contributing
tive period. However, current literature is not robust enough to factors to the differences between patients and doctors. J Anesth 1994;8:277–83.
18 Arpino L, Iavarone A, Parlato C, et al. Prognostic role of depression after lumbar disc
support a strong recommendation, and there is a clear need to surgery. Neurol Sci 2004;25:145–7.
strengthen the evidence for these interventions. Given the mixed 19 Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of
results observed in randomized trials, the likelihood of benefi- postoperative pain intensity: a prospective study. Clin J Pain 2005;21:439–45.
cial integration into wide clinical practice is low. This is until 20 Linn BS, Linn MW, Klimas NG. Effects of psychophysical stress on surgical outcome.
Psychosom Med 1988;50:230–44.
optimal technique, strategies, timing and interface are further 21 Rainville P, Bao QVH, Chrétien P. Pain-Related emotions modulate experimental pain
investigated. perception and autonomic responses. Pain 2005;118:306–18.
22 Devine EC. Effects of psychoeducational care for adult surgical patients: a meta-
Twitter Nick D Black @nickdblack and Ahtsham U Niazi @AhtshamNiazi analysis of 191 studies. Patient Educ Couns 1992;19:129–42.
23 Sveinsdottir V, Eriksen HR, Reme SE. Assessing the role of cognitive behavioral therapy
Contributors KG helped in data analysis, reviewing of literature, data extraction in the management of chronic nonspecific back pain. J Pain Res 2012;5:371–80.
and preparation of manuscript. NDB helped in data analysis and preparation 24 Gavin M, Litt M, Khan A, et al. A prospective, randomized trial of cognitive
of manuscript. AN helped in protocol development, reviewing of literature and intervention for postoperative pain. Am Surg 2006;72:414–8.
data extraction. AS helped in protocol development, reviewing of literature and 25 Hasanpour-Dehkordi A, Solati K, Tali SS, et al. Effect of progressive muscle
data extraction. ME helped in protocol development and literature search. TL relaxation with analgesic on anxiety status and pain in surgical patients. Br J Nurs
helped in protocol development, conduct of study and review of manuscript. 2019;28:174–8.
FC helped in protocol development and review of manuscript. AUN helped in 26 Zgaia A, Florina P, Achimas-Cadariu P. The impact of relaxation technique and pre-
protocol development, conduct of study, data analysis, preparation and review of operative psychological counselling on pain, analgesic consumption and psychological
manuscript. symptoms on patients scheduled for breast cancer surgery: a randomized clinical
Funding The authors have not declared a specific grant for this research from any study. Journal of Evidence-Based Psychotherapies 2016;16:205–20.
funding agency in the public, commercial or not-for-profit sectors. 27 van der Laan WH, van Leeuwen BL, Sebel PS, et al. Therapeutic suggestion has not

effect on postoperative morphine requirements. Anesth Analg 1996;82:148–52.
Competing interests None declared. 28 Good M. A comparison of the effects of jaw relaxation and music on postoperative
Patient consent for publication Not required. pain. Nurs Res 1995;44:52–7.
29 Good M, Stanton-Hicks M, Grass JA, et al. Relief of postoperative pain with jaw
Provenance and peer review Not commissioned; externally peer reviewed. relaxation, music and their combination. Pain 1999;81:163–72.
Data availability statement Data are available on reasonable request to Dr 30 Good M, Stanton-Hicks M, Grass JA, et al. Relaxation and music to reduce
Ahtsham U Niazi at a htsham.niazi@utoronto.ca. postsurgical pain. J Adv Nurs 2001;33:208–15.
31 Good M, Anderson GC, Stanton-Hicks M, et al. Relaxation and music reduce pain after
ORCID iDs gynecologic surgery. Pain Manag Nurs 2002;3:61–70.
Nick D Black http://o rcid.org/0000-0001-8580-3897 32 Good M, Albert JM, Anderson GC, et al. Supplementing relaxation and music for pain
Marina Englesakis http://orcid.org/0000-0002-2199-1056 after surgery. Nurs Res 2010;59:259–69.
Ahtsham U Niazi http://orcid.org/0 000-0001-6447-4393 33 Tusek DL, Church JM, Strong SA, et al. Guided imagery: a significant advance in
the care of patients undergoing elective colorectal surgery. Dis Colon Rectum
1997;40:172–8.
34 Chen H-J, Chen T-Y, Huang C-Y, et al. Effects of music on psychophysiological
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BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Reg Anesth Pain Med
Supplemental Table 1: Included Studies Primary and Secondary Outcomes
Study/year Type of Patients Study Control Pain Opioid Adjunct Length of Length Patient QoR Cost Complications Mortality Anxiety
surgery (n) Description Score Consumption Analgesic Intervention of Stay Satisfaction
Use
Relaxation: Relaxation
Gavin et al., 24 Lumber and 49 Patients Standard of NS Opioid use Not recorded 30 minutes Not Not recorded Recorded Not Not recorded Not recorded Recorded, no
2006 spine Surgery randomized into care (milligrams of IV recorded and favors recorded difference
the experimental morphine per hour) psychology
group were was higher in the
provided with a relaxation group on
brochure that POD 1 (1.14 ± 0.94
contained a vs 0.54 ± 0.55) and
relaxation POD 2. (0.86 ±
protocol, which 0.73 vs 0.50 ±
included deep 0.61)
breathing and The intervention
guided imagery. group used more
The intervention opioids than
lasted for 20-30 control
min and patients The difference was
were significant
encouraged to
perform it
preoperatively.
Postoperative
Gorsky K, et al. Reg Anesth Pain Med 2021;0:1–11. doi: 10.1136/rapm-2020-102434

activities that
could help
distract the
patient from
pain were also
included in the
brochure.
Dehkordi et al., Elective upper 70 Patients were Standard of A statistically The amount of Not recorded In each patient, Not Not recorded Not Not Not recorded Not recorded Recorded,
25
2019 and lower randomized to care significant morphine for the the PMR recorded recorded recorded favors
gastrointestinal perform difference in case was 2.5 times intervention intervention
system Progressive the pain less than that of would be
surgery. muscle intensity control. performed for 20
relaxation between (The control group minutes every 6
(PMR) - a intervention were prescribed hours for 2 days
technique that vs control was morphine 0.15 until 2 hours
involves observed at 3 mg/kg/day) before the
relaxation of hours (p-value These results were operation
muscles by < 0.000), 12 significant
sitting in a hours (p-value
comfortable < 0.000) and
position with 24 hours (p-

your eyes value < 0.003)
closed, and postoperatively
slowly and
sequentially
loosening all the
muscles of the
body, from the
soles of the feet
up. Patients
were provided
PMR for 20
minutes every 6
hours for two
days until 2
hours before
surgery.
Armeana Elective 102 A relaxation and Standard of The Postoperative NSAIDs 50 minutes Not Not recorded Record Not Not recorded Not recorded Recorded,
26
Zgâia,et al., Modified psychological care Psychological analgesic recorded and favors recorded favors
2016 Radical counseling counseling requirements in the psychology intervention
Mastectomy intervention was group had intervention vs
(MRM) for applied maximum pain control group::
breast preoperatively. intensity 4 /10 (1) intravenous
Cancer. Psychologist while the opioid (expressed
established the control group in number of
protocol for the showed 8/10

relaxation on Numerical ampoules of 100
techniques. The Rating Scale mg tramadol)
session was 50 (NRS). Day 1-(0.95 vs
min long. In the Results were 1.95)
first 25 min, significant Day 2- (0.12 vs
patients had a 0.77).
short clinical (2) NSAIDs
semi-structured (expressed in
interview number of
regarding the ampoules of 100
history of the mg ketoprofen)
disease and the Day1- (0.91 vs
treatment of the 1.39)
patients. In the Day 2-(0.45 vs
second 25 min, 0.86)
patients (3) Paracetamol
underwent an (expressed in
autogenous number of bottles
training of 1g paracetamol)
exercise, which Day1-(0.14 vs
combined visual 0.36)
imagery and Day2- (0.09 vs
suggestions to 0.05)
experience Results were
significant

relaxation and
peace.
Van der Laan et Elective 60 Patients were No control NS NS Not recorded 5 minutes of Recorded Not recorded Recorded Not Not recorded Not recorded Recorded, no
al., 27 1996 Gynecologic randomized into arm positive and and did not recorded difference
Surgery 3 groups: suggestions. favored favor
Group 1 psychology psychology
received a tape
of positive
therapeutic
suggestions
preoperatively,
and the story of
Robinson
Crusoe
intraoperatively;
Group 2 heard
the story of
Peter Pan

preoperatively
and positive
therapeutic
suggestions
intraoperatively;
Group 3 heard
the Crusoe story
preoperatively
and the Peter
Pan story
intraoperatively.
28
Good et al., Elective 84 The intervention Casual NS NS Not recorded Preoperative: 20 Not Not recorded Not Not Not recorded Not recorded Recorded, no
1995 Abdominal was applied both conversation minutes recorded recorded recorded difference
Surgery. pre and for 10 min. Postoperative: 2
postoperatively. in place of minutes
The three groups the tape +
received either standard of
music, jaw care
relaxation, or a
combination of
both
The techniques
were applied
postoperatively
2 minutes before

first ambulation,
and then
subjects used
their taped
interventions for
48hrs after the
first ambulation
for pain
management.

Study/year Type of Patients Study Control Pain Score Opioid Adjunct Length of Length Patient QoR Cost Complications Mortality Anxiety
surgery (n) Description Consumption Analgesic Intervention of Stay Satisfaction
Use
Relaxation: Relaxation and Music
Good et al., 29 Abdominal 617 The Casual The treatment NS Not recorded Not recorded Not Not recorded Not Not Not recorded Not recorded Not
1999 Surgery interventions, conversation groups had recorded recorded recorded recorded
jaw relaxation, (10 min) and significantly
music, or a Quiet time less pain than
combination of (15 min) + the controls (P
relaxation and standard of = 0.028–0.000).
music, were care
taught
preoperatively
with an
introductory
tape using
earphones, and
tested with a
treatment tape
postoperatively
during
ambulation and
at rest on days 1
and 2.
In the jaw
relaxation,

subjects heard
an introductory
tape using
earphones. It
explained the
purpose and
effects of
relaxation and
described the
jaw relaxation
technique.
In the music
group, subjects
listened to one
of the 5 different
types of music.
In combination
group, both the
relaxation and
music
techniques were
used.
Good et al., 30 Major 468 The The control Intervention Not assessed Not recorded 15 minutes Not Not recorded Documented Not Not recorded Not recorded Not
2001 abdominal interventions, group v.s. control: recorded recorded recorded
surgery jaw relaxation, received 10 Postoperative

music, or a minutes of pain was
combination of casual decreased 15 -
relaxation and conversation 26% across
music, were preoperatively days and
taught and 15 min of activities and
preoperatively. rest post on day 2.10 -
In jaw operatively + 15% less pain
relaxation, standard of was observed at
subjects heard care. rest than
an introductory ambulation.
tape using These results
earphones. It were
explained the statistically
purpose and significant.
effects of
relaxation, and
described the
jaw relaxation
technique.
In the music
group, subjects
listened to one
of the 5 different
types of music.

In the
combination
group, both the
relaxation and
music
techniques were
used.
Postoperatively,
60-minute
intervention
tapes were used.

31
Good et al., gynecologic 311 The The control Patients who Not recorded Preoperative Not recorded Not Not recorded Not Not Not recorded Not recorded Not
2002 (GYN) interventions, group received the tapes length recorded recorded recorded recorded
surgery jaw relaxation, received 10 interventions not recorded.
music, or a minutes of plus patient- postoperative
combination of casual controlled tapes were 60
relaxation and conversation analgesia minutes and
music, were preoperatively (PCA) had 9% postoperative
taught and 15 min of to 29% less relaxation
preoperatively rest post pain than technique
with operatively + controls who was repeated
introductory standard of used PCA at 1 minute
tapes. care alone. intervals.
In jaw The
relaxation, intervention

subjects heard groups had
an introductory significantly
tape using less posttest
earphones. It pain than the
explained the control group
purpose and (p .022-.001)
effects of on both days
relaxation, and
described the Results were
jaw relaxation statistically
technique. significant
In the music
group, subjects
listened to one
of the 5 different
types of music.
In the
combination
group, both the
relaxation and
music
techniques were
used.
Postoperatively,
60-minute

intervention
tapes were used.
Good et al., 32 Abdominal 517 The Standard of The RM and NS. Not recorded 1 minute Not Not recorded Not Not Not recorded Not recorded Not
2010 surgery interventions care PTRM groups relaxation recorded recorded recorded recorded
were Pain had 3 mm less technique
Management pain on VAS, repeated twice on
(PT), Relaxation on adjusted each 30 minute
and Music means across side of the
(RM), a five tests, intervention. The
combination compared with postoperative
(PTRM) and the PT and PTRM tape
control. The PT, control groups consisted of 5
RM and PTRM on Day 1 min of PT
interventions A.M(p<0.001), followed by 25
were recorded Day 1 min of RM on
on 5-to 10-min P.M.(p=0.04), each side.
introductory Day 2
audiotapes used A.M.(p=0.04).
preoperatively, Day 1 morning
and a 60min pain scores
intervention tape were
used significantly
postoperatively. lower in the
intervention
group.

Tusek et al., 33 Colorectal 130 Intervention Standard of Postoperatively, Total opioid Not recorded 20 minutes, 2 Recorded Recorded and Recorded Not Postoperative Not recorded Recorded,
1997 surgery group were care median increase requirements were times per day (6.2 days) favored and favored recorded complications were favors
made to listen to in the worst significantly lower and psychology. psychology same in both groups. intervention
a guided pain score was in the imagery favored
imagery tape 72.5 for the group, with a psychology
three days control group median of 185 mg
preoperatively; a and 42.5 for the vs. 326 mg in the
music-only tape imagery group control group
during (P < 0.001). (P < 0.001).
induction,
during surgery
and
postoperatively
in the recovery
room. A guided
imagery tape
was provided to
this group
during each of
the first six
postoperative
days.
Hsin-Ji Chen et TKR (Total 30 The music Standard of NS NS Not recorded Music Not Partially Not Not Not recorded Not recorded Not
al., 34 2015 Knee intervention was care intervention recorded supported that recorded recorded recorded
Replacement) given in the pre- lasted 30 minutes music

operative ward and total amount intervention was
(Phase I) and in of time each relaxing to
the surgical subject listened to patients. Study
waiting area music was 120 provided
(Phase II) for 30 minutes. evidence that
min at each site. soothing music
In Postoperative reduces patients
recovery (Phase anxiety during
III), music was POR. Yes,
played for 60 favored
min. In total, psychology.
each subject
listened to music
for 120 min.
Akelma et al., Inguinal 117 Listened to Standard of NS NS Not recorded 15 minutes. Not Patient Not Not Not recorded Not recorded Recorded,
35
2020 hernia choice of care. recorded satisfaction recorded recorded favors
surgery favorite music at score was intervention
volume of 50-60 significantly
dB using higher in Group
headphones for M than in Group
15 minutes, C (7 [6–7] vs. 6
preoperatively. [6–7]; median
(first-third
quartiles); p =
0.017). Yes,

favored
psychology.

Study/year Type of Patients Study Control Pain Score Opioid Adjunct Length of Length Patient QoR Cost Complicati Mortality Anxiety
surgery (n) Description Consumption Analgesic Intervention of Stay Satisfaction ons
Use
Relaxation: Hypnosis
Akgul et al., 36 CABG 44 The patients in Information on Pain scores in Postoperatively, in NSAIDs 30 minutes. Recorded Not recorded Recorded Not Not recorded Not recorded Recorded,
2016 (coronary artery the intervention the surgical the experimental vs and favored and recorded favors
bypass ) group received intervention by experimental control group the psychology. favored intervention
preoperative the same group vs total dose of: psychology
hypnosis anesthesiologist control group 1-Remifentanil -
administered by + standard of improved (34.4 ±11.4 vs 50.0
an care significantly ± 13.6 mg)
anesthesiologist. from 8 hr 2- Morphine -(4.9
The hypnosis (1.64±1.1 vs ± 3.3 vs. 13.6 ± 2.7
was performed 3.00 ±1.3) to mg) were
on the patients 24hr (1.50±1.1 decreased.
after the first vs 2.27±0.9) Both results were
evaluation of the postoperatively. statistically
anxiety indexes Results were significant
(on the same statistically
day that they significant
were
hospitalized) for
30 min.
Enqvist et al., 37 Surgical 69 The intervention Standard of NS Postoperative Not recorded 20 minutes. Not Patient mean Recorded Not Recorded, NS Not recorded Recorded,
1997 removal of third group received a care opioid recorded appreciation and NS recorded difference favors
20-minute tape, consumption in the rating of the difference. intervention

mandibular which contained intervention group audiotape was
molars hypnotic was less than 9.1 and patient
techniques controls. mean
preoperatively. Patients requiring effectiveness
They were >3 Citodon evaluation of the
required to listen (Tylenol+Codeine): audiotape was
to the tape daily Control group-28% 6.2. Yes, favored
for a week experimental psychology.
before the group- 3%
surgery. Results were
statistically
significant
Amraoui et al., Breast Cancer 148 Short individual Standard of The mean (SD) Drug consumption Lidocaine, 15 minutes Recorded; Satisfaction Not Not Not recorded Not recorded Recorded, no
38
2018 hypnosis session care breast pain was similar overall Ketamine The median evaluated on the recorded recorded difference
(15 minutes) score (range, 0- except for doses of PACU day after surgery
that was 10), assessed propofol and length of was 8.9 (1.5) in
personalized to immediately sufentanil, which stay was 60 the control arm
each patient was before PACU were both lower in minutes vs 9.5 (1.1) in
performed in all discharge: was the hypnosis arm: (range, 20- the hypnosis arm
centers by a 1.75 (1.59) in the doses in the 290 (P = .02) (Table
trained the control arm control vs hypnosis minutes) in 2). NS if favored
anesthesiologist vs 2.63 (1.62) arms were 240 mg the control psychology.
who had been in the hypnosis (range, 120-450 arm vs 46
practicing the arm (P = .004) mg) vs 200 mg minutes

technique for (difference, (range, 100-450 (range, 5-
more than 1 −0.88; 95% CI, mg) (P = .01) for 100
year. −1.45 to propofol and 19 μg minutes) in
−0.29). -higher (range, 10-30 μg) the
in hypnosis arm vs 15 μg (range, hypnosis
10-25 μg) (P = .05) arm (P =
for sufentanil .002). Yes,
citrate. favored
psychology.
Ozgunay et al., Open 22 Patients in the Standard of Postoperative The intraoperative Not recorded 40 minutes and Not Patient Not Not Not recorded Not recorded Not recorded
39
2019 Septorhinoplasty hypnosis group care VAS scores total remifentanil 20 minutes recorded satisfaction recorded recorded
(SRP) (HG) received a were consumption was score was
total of three significantly significantly lower significantly
sessions of lower at the in HG than in CG. higher in HG
hypnotic 2nd and 3rd than in CG (3.82
induction. The hour in the HG ± .40 versus 3.18
first two were than in the CG. ± .40,
administered 3 At other respectively; p <
days and 1 day postoperative .01), whereas
prior to surgery, hours, the VAS surgeon
respectively, and scores in the satisfaction
the last session HG and CG did score for the two
was not differ groups did not
administered in significantly. differ sig-
the hospital the nificantly (ns).

day of surgery. Pain Yes, favored
Hypnosis evaluations at psychology
induction was the time of
given by the nasal tampon
same removal did not
anesthesiologist differ
(S.E.O.). significantly
between the
two groups,
postoperatively
(p = .028, and p
= .047,
respectively)

Study/year Type of Patients Study Control Pain Opioid Adjunct Length of Length Patients QoR Cost Complications Mortality Anxiety
Use
Psychoeducation
Alter et al., 40 CTR 40 Preoperative The control NS Postoperative mean Non-opioid and Not recorded Not Not recorded Recorded Not 1 patient in control Not recorded Not recorded
2017 (Carpel opioid counseling group did Tylenol 3 non- recorded and favored recorded group reported
Tunnel consisted of not receive consumption for prescription psychology. constipation from
Release) formally any opioid counseling vs no painkillers such nonprescription
explaining the counseling counseling was as ibuprofren, pills. No did not
significance and + standard 1.40 vs 4.20 naproxen,and favor psychology.
problems of care Results were acetaminophen.
associated with significant Yes, favored
the opioid psychology as
epidemic, and 5 more patients
formal in group with
preoperative counselling
recommendations. used
nonprescription
painkillers than
the control
group
Pierściński et Elective 31 The study group Traditional The median NS Not recorded 20 minutes. The length Not recorded Not Not Not recorded Not recorded Not recorded
al., 41 2007 Surgical was administered preoperative postoperative of hospital recorded recorded
Hernioplasty a computer education pain score stay was
presentation by medical done using shorter in

illustrating the personnel + Visual the study
course of standard of Analog Scale group than
treatment for a care (VAS, mm) in controls
72-year-old male from 6hrs to (days,
patient with 30 days in respectively:
inguinal hernia. the study 2.9 vs. 3.1),
The surgeon- group was but again
patient (37 to 9 ) the
conversations and in the difference
covered the controls was did not
nature of the ( 44 -12). reach
condition, statistical
indications for *Authors significance.
and methods of comment on Yes, favored
surgical repair, this observed psychology.
possible difference in
complications, the outcomes,
course of hospital but
stay and acknowledge
postoperative results are
recommendations. not
statistically
significant*

Derefinko et Tooth 72 RCT examining TAU NS by Sensitivity Acetaminophen 10 minutes Not Not recorded Not Not 3 patients in both the None Not recorded
al., 42 2020 Extraction the efficacy of an Wong-Baker analysis, excluding + NSAIDs Recorded recorded recorded treatment group and
opioid misuse FACES pain individuals with were the control group.
prevention score complications, recommended
program (OMPP) between indicated a and provided in
as a brief treatment significant the treatment
intervention arms. treatment group group.
immediately prior effect (N = 66,
to dental Beta = 0.24, p =
extraction .0259), such that
surgery. the OMPP group
reported less
morphine
equivalents than
the TAU group
(29.74 vs. 43.59,
effect size d =
0.56).
Study/year Type of Patients Study Control Pain Opioid Adjunct Length of Length Patients QoR Cost Complications Mortality Anxiety
Use
Cognitive Behavioral Therapy

Dindo et al, 43 Orthopedic 76 Patients Standard Patients in Patients in the Not recorded ACT was 5 hours Not Not recorded Not Not Recorded, NS Not recorded Not recorded
2018 surgery received a 1-day of care/ the ACT ACT group reached and "booster" recorded recorded recorded difference.
Acceptance and Treatment group opioid cessation session 2 to 4
Commitment as Usual reached pain early than patients weeks after
Therapy (ACT) (TAU)) cessation receiving TAU attending the
workshop for earlier than (42.5 days vs 51 workshop.
prevention of patients days)
chronic pain and receiving
opioid use in the TAU (61 *Authors comment
preoperative days vs 74 on a positive
period. 2 clinical days) outcome, yet these
psychologists results indicated
provided the 5- *Authors preliminary signals
hour ACT comment on and are not
workshops. a positive statistically
outcome, yet significant*
these results
indicated
preliminary
signals and
are not
statistically
significant*

Wong et al, 44 Orthopedic 125 The Standard Mean NS Not recorded 30 minutes. Recorded Not recorded Recorded Not Not recorded Not recorded Not recorded
2010 surgery experimental of care postoperative and favored and favored recorded
group received pain scores psychology, psychology
Cognitive by VAS in
Behavior the
Educational experimental
Intervention group vs the
(CBEI) controls
preoperatively. were:
A trained nurse T1-46.0 vs
conducted all 54.10 (day 2
CBEI. It was postop)
provided over a T2-29.8 vs
30 min. 42.70 (day 4
duration. postop)
T3-22.7 vs
30.8 (day 7
postop)
Results were
significant.
The
experimental
group had a
significantly
lower pain

barrier (t
(123) = -
3.04, p =
0.003) and
lower
intensity of
pain,
between-
subject effect
(F (1.123) =
9.46, p =
0.003) and
interaction
effect (F (3,
121) = 4.17,
p = 0.008)
Buvanendran et Orthopedic 77 Patients were Standard NS. There NS Patients were Four CBT Recorded, Not recorded Recorded. Not Not recorded Not recorded Recorded. No difference
45
al., 2021 surgery randomized to of care was transitioned sessions (time No No recorded between groups.
receive a 4 week significant to oral unspecified) over difference. difference
telehealth CBT improvement multimodal 4 weeks. between
program to in pain and analgesia as intervention
compare the functional soon as they and
reduction in pain outcomes were able to controls
catastrophizing compared take liquids.
as well as with the

postoperative preoperative No values
pain outcomes values, but recorded
compared to no
non-CBT differences
controls between
groups.

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898 Gorsky K, et al. Reg Anesth Pain Med 2021;46:893–903. doi:10.1136/rapm-2020-102434

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Supplemental Table 1: Included Studies Primary and Secondary Outcomes

the experimental morphine per hour) psychology

group were was higher in the

provided with a relaxation group on

brochure that POD 1 (1.14 ± 0.94

contained a vs 0.54 ± 0.55) and

relaxation POD 2. (0.86 ±

protocol, which 0.73 vs 0.50 ±

included deep 0.61)

breathing and The intervention

guided imagery. group used more

The intervention opioids than

lasted for 20-30 control

min and patients The difference was

Gorsky K, et al. Reg Anesth Pain Med 2021;0:1–11. doi: 10.1136/rapm-2020-102434

pain were also

gastrointestinal perform difference in case was 2.5 times intervention intervention

system Progressive the pain less than that of would be

surgery. muscle intensity control. performed for 20

relaxation between (The control group minutes every 6

(PMR) - a intervention were prescribed hours for 2 days

technique that vs control was morphine 0.15 until 2 hours

involves observed at 3 mg/kg/day) before the

relaxation of hours (p-value These results were operation

muscles by < 0.000), 12 significant

sitting in a hours (p-value

comfortable < 0.000) and

position with 24 hours (p-

Gorsky K, et al. Reg Anesth Pain Med 2021;0:1–11. doi: 10.1136/rapm-2020-102434

your eyes value < 0.003)

closed, and postoperatively

loosening all the

body, from the

soles of the feet

hours for two

2016 Radical counseling counseling requirements in the psychology intervention

Mastectomy intervention was group had intervention vs

(MRM) for applied maximum pain control group::

breast preoperatively. intensity 4 /10 (1) intravenous

Cancer. Psychologist while the opioid (expressed

established the control group in number of