In this podcast, Claire discusses the role of clinician communication and its impact on acute pain management.
Claire explains how pain management outcomes can be optimised by enhancing patient expectations of benefit via patient-provider communication.
Firstly, what we say to patients matters. Secondly, how we say it also matters.
Pain is a complex phenomenon and managing expectations of pain and people’s experience of empathy is crucial.
As healthcare professionals, we see multiple patients and are often run off our feet, but, as the studies clearly demonstrate… communication matters. And it matters a lot in pain management.
This presentation shares research demonstrating the impact of clinician communication.
Specifically, this includes how clinicians' talk about pain and pain management. Claire discusses the importance of patients' experience of pain, the effectiveness of pain management and patients' treatment outcomes.
From CodaZero Live, tune in to a fascinating discussion on the importance of communication.
For more like this, head to https://codachange.org/podcasts/
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The importance of communication in pain management
1. The University of Sydney
Non-pharmalogical
approaches to pain
management: The role
of clinician
communication
Claire Ashton-James, PhD
Associate Professor, Pain Management
University of Sydney School of Medicine
2. Page 2
The University of Sydney
• Injury/nociception is not sufficient to cause pain
• Pain is a bio-psycho-social phenomenon
What is pain?
Evaluation of
sensations as
unpleasant
Feelings of
distress
Construal of
actual or potential
harm
3. Page 3
The University of Sydney
Feelings of distress?
Dark Mofo Festival – Winter solstice nude swim
5. Page 5
The University of Sydney
Managing pain involves managing feelings and
thoughts about pain
Evaluation of
sensations as
unpleasant
Feelings of
distress
Construal of
actual or potential
harm
What we say
matters
How we say
it matters
6. Page 6
The University of Sydney
Positive expectations
enhance analgesic
effectiveness
“I am going to give you a
powerful pain medication to
make you feel more
comfortable”
We must inform the patient
that we are providing pain
What we say matters: expectations shape
experiences
Open vs. hidden paradigm
7. Page 7
The University of Sydney
What we say matters: expectations shape
experiences
Amanzio, Pollo, Maggi, & Bennedetti, 2001
Analgesic dose needed to reduce pain by
50%
Time course of analgesic efficacy
8. Page 8
The University of Sydney
What we say matters: expectations shape
experiences
“We are going to give you a strong
painkiller now (morphine)”
“We are going to stop giving you the
strong painkiller now (morphine)”
Benedetti F, Maggi, Lopiano, Lanotte, Rainero, Vighetti & Pollo. 2003.
9. Page 9
The University of Sydney
What we say matters: expectations shape
experiences
Bingel U, Wanigasekera V, Wiech K, Mhuircheartaigh RN, Lee MC, Ploner M, Tracey I. 2011.
Remifentanil dose is constant after baseline
10. Page 10
The University of Sydney
Pre-surgery visit from anaesthetist:
– Informed about pain that patients typically
experience
– Reassured that having pain was normal after
abdominal surgery
– Informed that pain is not a sign of harm
– Informed that medications can be used to
help them to relax
What we say matters: expectations shape
experiences
Egbert et al 1964, NEJM
11. Page 11
The University of Sydney
How we say it matters: The role of empathy
• RCT of treatment for IBS
with three arms:
• waitlist
• placebo acupuncture
(limited interaction)
• placebo acupuncture
(augmented interaction)
• Augmented interaction
included:
• Warm and friendly manner
• Active listening
• Acknowledgement (“I can
understand how difficult IBS must
be for you”
• Thoughtful silence
• Communication of optimism and
positive treatment expectations (“I
have had many positive
12. Page 12
The University of Sydney
Outcomes at 3 weeks
Kaptchuk, Kelley, Conboy et
al. Bmj. 2008 May
1;336(7651):999-1003.
13. Page 13
The University of Sydney
Outcomes at 6 weeks
Kaptchuk, Kelley, Conboy et
al. Bmj. 2008 May
1;336(7651):999-1003.
14. Page 14
The University of Sydney
How we say it matters: The role of empathy
Schupp, Berbaum, Berbaum, &
Lang, 2005:
– 236 patients undergoing
vascular and renal
interventions
– All have access to PCA with
fentanyl and midazolam
– Randomized to 3 groups:
– Standard care
– Structured empathic
attention
– Self-hypnotic relaxation
Structured empathic interaction:
• matching patients’ verbal and
nonverbal communication patterns,
• attentive listening
• provision of perception of control
(eg, “let us know at any time what
we can do for you”)
• Encouragement (“you’re doing well”)
• emotionally neutral descriptions
(“what are you experiencing?”)
• avoidance of negative suggestions
(“you will feel a pinch or burning”).
15. Page 15
The University of Sydney
**significantly less pain medication requested and used by Empathy groups
16. Page 16
The University of Sydney
Managing pain involves managing feelings
and thoughts about pain
Evaluation of
sensations as
unpleasant
Feelings of
distress
Construal of
actual or potential
harm
What we say
matters
How we say
it matters
17. Page 17
The University of Sydney
Claire Ashton-James, PhD
Associate Professor, Pain Management
University of Sydney School of Medicine
CONTACT:
Email: Claire.ashton-james@sydney.edu.au
Twitter: @drashtonjames
Notes de l'éditeur
relapse of pain happened faster and pain intensity was greater when patients were told morphine was being stopped than when treatment interruption was hidden; this suggests that hidden interruption prolonged the analgesia. The faster relapse of pain after the open compared with the hidden interruption could be attributed to a “nocebo” effect, in which knowledge that the treatment has been stopped leads to an increase in anxiety. In other words, the fear of pain relapse (because analgesics are no longer provided) might have a hyperalgesic effect.
relapse of pain happened faster and pain intensity was greater when patients were told morphine was being stopped than when treatment interruption was hidden; this suggests that hidden interruption prolonged the analgesia. The faster relapse of pain after the open compared with the hidden interruption could be attributed to a “nocebo” effect, in which knowledge that the treatment has been stopped leads to an increase in anxiety. In other words, the fear of pain relapse (because analgesics are no longer provided) might have a hyperalgesic effect.
The "special-care" group consisted of 46 patients who were told about postoperative pain. They were informed where they would feel pain, how severe it would be and how long it would last and reassured that having pain was normal after abdominal operations.
Finally, they were told that at first they would find it difficult to relax completely. If they could not achieve a reasonable level of comfort, they should request medication
During the afternoon after operation (day zero) the anesthetist visited his patients receiving special care. He reiterated what he had taught the patients the night before and reassured them that the pain they were experiencing was normal; they were again told to request pain medication whenever they could not make themselves tolerably comfortable.
The independent observer recorded that the special-care patients appeared to be more comfortable and in better physical and emotional condition than the control group. This was emphasized by the surgeons, who, although unaware of the care each patient received, sent the special-care patients home an average of two and seven-tenths days earlier than the control group (p less than 0.01)
a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).
a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).
a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).