Perioperative Pain Management:

Setting Appropriate Expectations

“An understanding of patient attitudes and concerns about postoperative

pain is important for identifying ways health care professionals can improve
postoperative care."i

Innumerable variables impacting perioperative pain exist: opioid tolerance, previous

experience, comorbidities, age, gender, type of surgery, type of anesthetic, etc. This
variety of influences makes a patient’s perioperative pain experience unpredictable.
Further, conflicting resources (internet, friends, past experience) may inappropriately
or incorrectly prepare the patient. Unrealistic expectations set the stage for
dissatisfaction. Setting reasonable expectations, therefore, is crucial to optimizing a
patient’s course.

Multidisciplinary literature demonstrates that patient expectation is tethered to

outcome. Though no standard definition or measure of patient expectation exists, the
literature suggests that practitioners can and should take steps to maximize the
benefit of patient expectations.ii,iii,iv

Cornerstones of setting patients’ perioperative pain expectations include:

1) It is likely not possible, or safe, to reduce the patient’s postoperative pain

score below his or her baseline – Even if the surgery aims to improve the
patient’s chronic pain, there will be an acute component postoperatively. The
patient needs to be aware, prior to surgery, that a degree of discomfort is
expected after the surgery.
2) Limiting the preoperative opioid regimen is in the patient’s best interest –
This may be difficult to convey to patients that are dependent on opioids;
limiting pre-op opioids leaves more room for safe escalation of these
medications following the surgical insult.v
3) Patients should be open to opioid adjuncts in the perioperative period – The
perioperative team may suggest procedures (epidurals, nerve blocks) or
medications (gabapentin, ketamine, Tylenol, etc) with which the patient may not
be familiar. It should be reinforced that such measures are in the patient’s best
interest and should be considered with an open mind.
4) Pain control expectations, patient participation and surgical outcome – Poor
communication and pain treatment after surgery can impair function, ADL
participation/ambulation, physiologic function (circulation, respiration, GI
function, etc.), psychological well-being and quality of life. Two-way
communication between patients and providers is essential. Further, patients
must own an active role in their recovery, working through expected pain, to
optimize outcome.
 5) The goal of pain control is to restore function – A principle of chronic pain
management is functional restoration. This should also be a perioperative goal
for patients on high-dose opioids. Providers will work with patients to establish
a safe level of pain relief, allowing patients to meaningfully participate in
recovery activities (incentive spirometery, physical therapy).
6) Expectations and pain management should not end at hospital discharge –
Recovery from surgery takes weeks to months; patients will likely experience
increased pain during this period. Depending on the goal and outcome of the
surgery, the patient’s baseline pain may be altered. Surgery is not an “easy fix,”
it takes dedication and hard work on the part of both patients and primary
providers.
Keeping these principles in mind, patient education is both a responsibility and an
opportunity to improve a patient’s perioperative experience. The provider must strive
to learn what the patient expects, then help shape those expectations to be congruent
with a realistic goal.

Effective education is more than just information transfer; empathy, concern,

understanding, patience, an emotional connection and even provider body language
galvanize education and patient expectations. Sensitivity to a patient’s prior
experiences and cultural beliefs is equally important.

Investing time and effort in expectation setting prior to surgery will not only
improve the patient’s experience, but also may save time and resources after
surgery.

As we strive to promote patient and family-centered care, the perioperative team at the
University of Michigan depends on every patient encounter and every level of provider
to reinforce reasonable expectations for perioperative pain. Your time and efforts are
important and appreciated.

                                                                                                                       
i
 Apfelbaum  JL,  Chen  C,  Mehta  SS,  Gan  TJ.    Postoperative  pain  experience:  results  from  a  national  survery  suggest  
postoperative  pain  continues  to  be  undermanaged.  Anesth  Analg.  2003  Aug;97(2):534-­‐40.  
ii
  Bialosky,   JE,   Bishop,   MD,   Cleland   JA.   Individual   Expectation:   An   Overlooked,   but   Pertinent,   Factor   in   the  
Treatment  of  Individuals  Experiencing  Musculoskeletal  Pain.  Phys  Ther.  2010  Sept;  90(9):1345–1355.  
iii
Keltner  JR,  Furst  A,  Fan  C,  Redfern  R,  Inglis  B,  Fields  HL.  Isolating  the  modulatory  effect  of  expectation  on  pain  
transmission:  a  functional  magnetic  resonance  imaging  study.  J  Neurosci.  2006  Apr  19;26(16):4437-­‐43.  
iv
 Stomberg  MW,  Oman  UB.  Patients  undergoing  total  hip  arthroplasty:  a  perioperative  pain  experience.  .J  Clin  
Nurs.  2006  Apr;15(4):451-­‐8.  
v
 Bohnert  AS,  Valenstein  M,  Bair  MJ,  Ganoczy  D,  McCarthy  JF,  Ilgen  MA,  Blow  FC.  Association  Between  Opioid  
Prescribing  Patterns  and  Opioid  Overdose-­‐Related  Deaths.  JAMA.  2011;305(13):1315-­‐1321  

Disclaimer: This document is for informational purposes only and is not intended to take the place of the care and attention of your
personal physician or other professional medical services. Talk with your doctor if you have Questions about individual health concerns or
specific treatment options.

©2012 The Regents of the University of Michigan

Author: Peter Stiles MD, Paul Hilliard MD
Last Revised 09/2012