Implications of nocebo in anaesthesia care

Abstract

Nocebo refers to non-pharmacological adverse effects of an intervention. Well-intended procedural warnings frequently function as a nocebo. Both nocebo and placebo are integral to the generation of 'real' treatment effects and their associated 'real' side-effects. They are induced or exacerbated by: context; negative expectancy; and negative conditioning surrounding treatment. Since the late 1990s, the neuroscience literature has repeatedly demonstrated that the nocebo effect is mediated by discrete neurobiological mechanisms and specific physiological modulations. Although no single biological mechanism has been found to explain the nocebo effect, nocebo hyperalgesia is thought to initiate from the dorsal lateral prefrontal cortex subsequently triggering the brain's descending pain modulatory system and other pain regulation pathways. Functional magnetic resonance imaging shows that expectation of increased pain is accompanied by increased neural activity in the hippocampus and midcingulate cortex which is not observed when analgesia is expected. Functional magnetic resonance imaging studies have shown that the anterior cingulate cortex is pivotal in the perception of affective pain evoked by nocebo words. Research has also explored neurotransmitters which mediate the nocebo effect. The neuropeptide cholecystokinin appears to play a key role in the modulation of pain by nocebo. Hyperalgesia generated by nocebo also increases the activity of the hypothalamic-pituitaryadrenal axis as indicated by increases in plasma cortisol. The avoidance or mitigation of nocebo needs to be recognised as a core clinical skill in optimising anaesthesia care. Embracing the evidence around nocebo will allow for phrases such as 'bee sting' and 'sharp scratch' to be thought of as clumsy verbal relics of the past. Anaesthesia as a profession has always prided itself on practicing evidence-based medicine, yet for decades anaesthetists and other healthcare staff have communicated in ways counter to the evidence. The premise of every interaction should be 'primum non nocere' (first, do no harm). Whether the context is research or clinical anaesthesia practice, the nocebo can be ignored no longer.

Identification of Requirements for a Postoperative Pediatric Pain Risk Communication Tool: Focus Group Study With Clinicians and Family Members

“…Finally, pain risk communication may have significant nocebo effects (ie, where unintended negative suggestions/phrasing about a treatment/procedure result in increased adverse events) [ 39 ], such as loss of appetite, nausea, itching, and stomach pain [ 40 ]. Phraseology is important [ 39 ], and framing an opportunity to improve future patient comfort by identifying relevant and modifiable risk factors, instead of highlighting risks of pain and unmodifiable risk factors, might reduce these potential nocebo effects.…”

“…Finally, pain risk communication may have significant nocebo effects (ie, where unintended negative suggestions/phrasing about a treatment/procedure result in increased adverse events) [ 39 ], such as loss of appetite, nausea, itching, and stomach pain [ 40 ]. Phraseology is important [ 39 ], and framing an opportunity to improve future patient comfort by identifying relevant and modifiable risk factors, instead of highlighting risks of pain and unmodifiable risk factors, might reduce these potential nocebo effects. As 1 of the design requirements of our prototype is to present risk in a nonthreatening manner, we may wish to limit the use of the initial prototype to clinicians, while developing a version that focuses on “optimizing comfort” rather than “reducing pain” for sharing with family members.…”

Nocebo language in anaesthetic patient written information

“…While providing honest and accurate information is important, studies have shown how the impact of the words may be mitigated or altered in the way they are presented [17] and how possible therapeutic reframing [16, 18] may help. Arrow et al.…”

“…There were statements with evidence of nocebo communication for example `you will need strong painkillers´may suggest that `strong pain´will inevitably occur postoperatively. Such phrases increase negative expectancy and evidence suggests [16] are associated with the pain experience [4,8,17]. A minority of leaflets had sentences which focused on comfort, healing, benefit of surgery and the role of the medical staff to assist the patient in their recovery.…”

Implications of nocebo in anaesthesia care

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We read with interest the article by Arrow et al [1]. It raises a number of interesting points related to the impact of language used by anaesthetists and the potentially negative impact this may have on the patient's experience and perception of their care.

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