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Re-enforcing therapeutic effect by positive expectations of pain-relief from our interventions

  • Harald Breivik EMAIL logo
Published/Copyright: January 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 14 Issue 1

In this issue of the Scandinavian Journal of Pain Valentina Ružić and co-workers publish an interesting and important study documenting how expectations of a painful stimulus can have an impressive effect on how intensely painful the stimulus is consciously experienced by a person [1]. They demonstrate how positive and negative expectations mobilize potent mental mechanisms. Their study took place in a psychology laboratory with exactly controlled stimulus-intensities, and they exposed the subjects to well-defined positive or negative expectations of what they would experience.

1 Important implications for clinical practice

These observations have clear implications for our daily clinical pain practice: There are always context sensitive therapeutic effects in patient-carer therapeutic relationships; the patient’s expectations of effects are strongly influenced by the contextual or environmental cues that surround any medical intervention, the therapeutic milieu in which therapy takes place.

2 The predictions we make about a therapy are part of the therapy

Importantly: we cannot avoid influencing our patients’ expectations of what we are administering: if the patients understand that we are convinced that a drug or another intervention will help, this will boost the positive effect. By neglecting this we may miss a possibility to improve the outcome. And this is not a transient “placebo-effect”: A 6-months long, truly blinded placebo-controlled study on osteoarthritis pain had a positive effect also from placebo throughout this half-year when the patients had extra attention and care from the research nurses and physicians involved [3].

3 Daily challenge: avoid negative expectations; give truthful information about the intervention

If we feel obliged to mention all possible adverse effects of the pain-modifying drug/intervention, this can have potent negative effects (nocebo-effect). The challenge is how to give a correct and truthful description of our own expectations [2,4,5]. These are influenced by so called “evidence-based” knowledge from randomized-controlled-trials (RCTs) and meta-analysis of such RCTs. Both can be biased, a fact that is not always evident.

A glaring example is randomized “controlled” studies on the effect of regional sympathetic blockade with guanethidine that was given to patients with various chronic pain conditions without selecting patients with sympathetically maintained pain: They administered test drug in a solution with lidocaine with or without guanethidine:lidocaine can have a potent pain-modulating effect on its own, and lidocaine can reduce the noradrenaline-releasing and blocking effect of guanethidine. These negative studies with serious flaws "killed" intravenous regional sympathetic block as a therapy for patients with sympathetically maintained pain. The drug is no longer available.

4 Informed consent

Thus, it is not always possible to prevent clinicians from reducing the effectiveness of a truly effective treatment through “nocebo” effects, by unintentionally inducing negative expectations. We need to be conscious about finding a balance between full disclosure of potential adverse effects of the interventions we administer to patients with complex chronic pain conditions with the need to avoid inducing nocebo effects [4,5].

5 We cannot avoid expectations and placebo/nocebo effects in clinical pain medicine

Benedetti and co-workers have documented how placebo effects of pain interventions are created by complex neurobiological mechanisms with neurotransmitters such as endorphins, cannabinoids, and dopamine causing activation of specific areas of the brain, particularly the prefrontal cortex, anterior insula, rostral anterior cingulate cortex, and amygdala [6]. These are real and potentially strong, positive or negative effects; we have to be aware of the fact that we cannot avoid these effects in our encounters with our pain patients. They are important aspects of what makes medicine a healing profession [4,5].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.09.013

Oslo University Hospital, Department of Pain Management and Research, Pbox 4950 Nydalen, 0424 Oslo, Norway

  1. Conflict of interest: None declared.

References

[1] Ružić V, Ivanec D, Stanke KM. Effect of expectation on pain assessment of lower- and higher-intensity stimuli. Scand J Pain 2017;14:9–14.Search in Google Scholar

[2] Chretien J-P. Expectation management. N Engl J Med 2014;371:1936–9, http://dx.doi.org/10.1056/NEJMms1406844.Search in Google Scholar

[3] Breivik H, Ljosaa TM, Stengaard-Pedersen K, Persson J, Arod H, Villumsen J, Tvinnerose D. A 6-months, randomised, placebo-controlled evaluation of efficacy and tolerability of a low-dose 7-day buprenorphine transdermal patch in osteoarthritis patients naïve to potent opioids. Scand J Pain 2010;1:122–41.Search in Google Scholar

[4] Bingel U. Avoiding nocebo effects to optimize treatment outcome. JAMA 2014;312:693.Search in Google Scholar

[5] Kaptchuk TJ, Miller FG. Placebo effects in medicine. N Engl J Med 2015;373:8–9, http://dx.doi.org/10.1056/NEJMp1504023.Search in Google Scholar

[6] Finniss DG, Kaptchuk TJ, Miller F, Benedetti F. Biological, clinical, and ethical advances of placebo effects. Lancet 2010;375:686–95.Search in Google Scholar
Published Online: 2017-01-01
Published in Print: 2017-01-01

© 2016 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2016.11.016

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Patients with chronic neck-pain after trauma do not differ in type of symptoms and signs, but suffer more than patients with chronic neck pain without a traumatic onset
  5. Observational study
  6. Chronic neck pain patients with traumatic or non-traumatic onset: Differences in characteristics. A cross-sectional study
  7. Editorial Comment
  8. Re-enforcing therapeutic effect by positive expectations of pain-relief from our interventions
  9. Original experimental
  10. Effect of expectation on pain assessment of lower- and higher-intensity stimuli
  11. Editorial comment
  12. Objective methods for the assessment of the spinal and supraspinal effects of opioids
  13. Topical review
  14. Objective methods for the assessment of the spinal and supraspinal effects of opioids
  15. Editorial Comment
  16. Multi-target treatment of bone cancer pain using synergistic combinations of pharmacological compounds in experimental animals
  17. Original experimental
  18. Synergistic combinations of the dual enkephalinase inhibitor PL265 given orally with various analgesic compounds acting on different targets, in a murine model of cancer-induced bone pain
  19. Editorial comment
  20. Terminal cancer pain intractable by conventional pain management can be effectively relieved by intrathecal administration of a local anaesthetic plus an opioid and an alfa2-agonist into the cerebro-spinal-fluid
  21. Observational study
  22. Multimodal intrathecal analgesia in refractory cancer pain
  23. Editorial comment
  24. Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables
  25. Observational study
  26. Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables
  27. Editorial comment
  28. Why are some patients with chronic pain from anterior abdominal nerve entrapment syndrome (ACNES) refractory to peripheral treatment with neurectomy?
  29. Clinical pain research
  30. Treatment response and central pain processing in Anterior Cutaneous Nerve Entrapment Syndrome: An explorative study
  31. Editorial comment
  32. Gain in functions before pain reduction during intensive multidisciplinary paediatric pain rehabilitation programme
  33. Clinical pain research
  34. Physical and occupational therapy outcomes: Adolescents’ change in functional abilities using objective measures and self-report
  35. Editorial comment
  36. Complex Regional Pain Syndrome (CRPS): High risk of CRPS after trauma in another limb in patients who already have CRPS in one hand or foot: Lasting changes in neural pain modulating systems?
  37. Clinical pain research
  38. The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndrome
  39. Editorial Comment
  40. Positive affect could reduce the impact of pain
  41. Original experimental
  42. The buffering role of positive affect on the association between pain intensity and pain related outcomes
  43. Editorial comment
  44. The meaning and consequences of amputation and mastectomy from the perspective of pain and suffering – Lessons to be learned and relearned
  45. Clinical pain research
  46. The meaning and consequences of amputation and mastectomy from the perspective of pain and suffering
  47. Editorial comment
  48. Invasive intervention for “intractable” Complex Regional Pain Syndromes (CRPS)?
  49. Educational case report
  50. Intrathecal management of complex regional pain syndrome: A case report and literature
  51. Observational study
  52. Item response theory analysis of the Pain Self-Efficacy Questionnaire
  53. Announcement
  54. Scandinavian Association for the Study of Pain (SASP): Annual Meeting 2017
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