Increasing use of behavioral care helps patients recover faster from surgery

The integration of behavioral medicine and perioperative care is gaining traction, helped by improved technology that enables online consults and education as well as by better models of integration.

An emphasis on integrating behavioral medicine into perioperative pain care "has been minimal to absent [in most medical settings] until recently," said Beth Darnall, Ph.D., an associate professor at Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine. She also directs the Stanford Pain Relief Innovations Lab.

Darnall and Maxwell Slepian, Ph.D., a registered clinical and health psychologist who works as a staff psychologist in Toronto General Hospital's Transitional Pain Service, will speak during ASRA's Sept. 25 virtual Persistent Perioperative Pain Symposium. Their session is titled "Perioperative Behavioral Medicine for Pain: More than Cognitive Behavioral Therapy."

While cognitive behavioral therapy is the most well-known and common psychological intervention used in medical settings, Slepian said he will highlight others during the session. He will discuss alternative evidence-based interventions such as the use of "third-wave" therapies, including Acceptance and Commitment Therapy, Dialectic Behavior Therapy, and hypnosis for pain management.

Perioperative care refers to coordinating and optimizing a patient's care before, during and after surgery. This requires the patient's medical team—prior to the surgery—to assess many factors, ranging from preexisting conditions and whether the patient smokes or has a substance addiction to the adequacy of the patient's post-surgical support at home.

"We can help people before or after surgery, whether it's in the hospital or at home. Behavioral medicine can work alongside medications and other methods to help optimize a patient recover," Darnall said.

How providers integrate behavioral care into perioperative care "is largely driven by resources. There are perioperative programs that have staff psychologists and the resources to deliver one-on-one behavioral care," she said, adding that most programs don't. Perioperative behavioral care can require the coordination of several providers, and hospital rhythms can make it difficult to find assessment or therapy time with patients.

Darnall developed an online perioperative program, My Surgical Success (MSS), that gives patients tools to self-manage pain or stress related to their surgery; it can be received at home or in the hospital without therapist contact. Her team's 2019 pilot study in Pain Medicine found that breast-cancer surgery patients who used the online tool stopped taking post-surgery opioids as many as 6.5 days sooner than patients who did not access MSS.

Such studies are adding to a slowly growing body of evidence about perioperative behavioral pain therapy's effectiveness in pain reduction—and its cost effectiveness in treating chronic pain.

"Chronic pain presents a serious economic burden, with incremental yearly costs exceeding $1,700 per person in Ontario and $10+ Billion annually in Canada (Hogan et al., 2016). Those numbers are higher in the US. Persistent pain after surgery is a major driver of those costs," Slepian said.