October 17, 2016

Consider these statistics:

• Between 10 and 30 percent of surgical patients report persistent pain one year after surgery,¹ with rates of up to 40 percent among patients who have undergone major thoracic procedures.²
• Up to five percent of all surgical patients report severe, disabling pain one year following surgery.³
• Nearly eight percent of patients who have never previously taken opioids continue taking opioids one year after undergoing low-risk surgery.⁴
• One in 15 of the more than 95 percent of patients who receive opioids following the approximately 53 million inpatient and 57 million outpatient procedures performed in the United States each year will become long-term opioid users.⁵

The substantial burden of chronic postsurgical pain (CPSP) and the epidemic of opioid use and abuse in the U.S. are not unrelated.  These two daunting and closely interwoven issues require diligence, innovation and collaboration across healthcare. 

Anesthesiologists are ideally positioned to play a leading role in this regard.  Their ability as perioperativists and pain management experts to identify patients at risk of CPSP and opioid addiction preoperatively through risk stratification, and to tailor multifaceted care plans for vulnerable patients before, during and after surgery, provide an opportunity to help mitigate serious public health problems and make a difference in practices and institutions.

A Canadian hospital has blazed trails in this regard with a novel anesthesiologist-driven program that could give anesthesia providers a powerful tool for preventing and treating CPSP and protecting surgical patients from the costly and debilitating impact of opioid dependence.  The program echoes the multidisciplinary, prevention-based approach to integrated care before, during and after surgery of the perioperative surgical home (PSH) put forth by the American Society of Anesthesiologists (ASA).

We review the highlights of Toronto General Hospital’s (TGH) transitional pain service (TPS) here and invite you to consider how this successful program’s tactics and strategies might be applied in your own practices and facilities.

Who is At Risk?

TGH created the TPS in 2014 to provide tailored, individualized, multidisciplinary perioperative care for surgical patients with a focus on CPSP prevention and treatment.  The program draws on expertise from anesthesiology, psychology, physiotherapy and advanced practice nursing to closely monitor the presurgical pain, opioid consumption and psychological factors, such as anxiety and depression, that put some individuals at increased risk for CPSP. 

Other risk factors associated with CPSP include intraoperative nerve handling, acute postoperative pain, genetic predisposition, type of anesthesia and postoperative management.  “The TPS is designed to target and manage these known risks pre- and post surgery in an effort to reduce pain, disability and opioid misuse, while also benefiting the health care system by facilitating earlier discharge and reducing costs,” states Hance Clarke, MD, FRCPC, PhD, director of pain services and medical director of the Pain Research Unit at TGH in a 2015 article in the Journal of Pain Research.

TGH estimates its total expenditures for all-cause chronic pain after major surgery to be between CAD$2.5 and CAD$4.1 million per year.

The program uses a variety of treatment modalities to reduce the likelihood that acute postsurgical pain will become a chronic condition.  These include psychological counseling, non-opioid medications, structured opioid weaning, and complementary therapies such as acupuncture and physiotherapy.  Originally developed for postsurgical patients, the TPS has expanded into “peri-hospital” settings, including addiction treatment settings, to help return patients to baseline or better levels of functioning and transition safely back into the community. 

The TPS is the first known program to address CPSP at the preoperative, postoperative inpatient and postoperative outpatient stages.  It is specifically designed to enable clinicians to intervene earlier and spare patients the longer wait times they might face to receive care in a chronic pain clinic after discharge.

The TPS has three primary goals: 1) provide seamless pre- and postoperative pain management for patients at increased risk of CPSP; 2) manage opioid therapy for medically complex patients following discharge; and 3) help patients improve coping skills to ensure as high a quality of life as possible following surgery. 

The staff includes five anesthesiologists with advanced training in acute and/or chronic interventional pain management, two clinical psychologists, three acute pain nurse practitioners, two physical therapists skilled in acupuncture, a palliative care specialist, an exercise physiologist and a patient care coordinator.

Patient Flow

Patients for the TPS are identified during preadmission with a comprehensive medical assessment.  The charts of patients with existing pain problems requiring the daily use of opioid medication are flagged with a “pain alert.”  This subset represents approximately 12.5 percent of surgical patients at TGH. 

A perioperative pain management plan is created for medically complex patients.  One patient, for example, was a lung transplant candidate with chronic degenerative lung disease, chronic back pain, a history of street drug abuse, depression and anxiety, and high daily opioid consumption.  The TPS reduced his opioids in preparation for surgery with multimodal opioid-sparing surgery, which also decreased his pain.

Care plans also include education for patients and family members on analgesia management by a nurse practitioner and, if needed, a referral by one of the anesthesiologists to a psychologist or physiotherapist during the hospital stay.  The goals of these interventions are to reduce pain, distress and decrease the likelihood of a prolonged hospitalization.

Earlier intervention by a psychologist serves as a preventive strategy.  Although psychological intervention is used widely in the treatment of chronic pain, it has rarely been used as a strategy to treat postsurgical pain, despite findings that depression, anxiety and catastrophizing can predict CPSP.  “There is a growing call for integration of psychological services from the earliest time point, rather than waiting for CPSP to be entrenched before such services are offered,” Dr. Clark states.

Follow-up visits at the TPS outpatient clinic emphasize assessing the patient for opioid addiction risk and an opioid agreement contract.  A team psychologist also sees patients who are high opioid users.  Patients are assessed every two to three weeks, their opioids and other analgesics are adjusted until they reach a safe level and their pain is well controlled.  The service aims to transition patients to their primary care physicians after three to six visits at the TPS outpatient clinic—approximately six weeks to six months following hospital discharge.

Limited Coverage

Although the multidisciplinary, multimodal model of the TPS shows potential for the prevention and management of CPSP and, by extension, a strategy for addressing the opioid abuse epidemic, anesthesiologists remain somewhat hindered by inconsistent coverage for multimodal services.  As Lynne R. Webster, MD, a past president of the American Academy of Pain Medicine, writes in an editorial in the July 21st issue of Anesthesiology News:

One major party that must open its ears is the payer community, which routinely fails to cover many safer and more effective therapies recommended by the [Centers for Disease Control and Prevention in its 2016 Guideline for Prescribing Opioids for Chronic Pain].  Instead, the insurance system has forced a simple solution, reinforcing cookie-cutter, minimally monitored, drug-only therapy for complex medical and psychological problems in a highly diverse population.  Unfortunately, the CDC guidelines fail to challenge payers’ interests, choosing instead to push for opioid supply reduction measures that include dosing limits without regard for the necessity of individualized therapy and with very little consideration of the needs of people in pain.

Dr. Webster calls for the implementation of the National Pain Strategy for population health-level pain prevention, management and research, in which he believes patients’ needs “have been urgently set forth and thoughtfully analyzed” and “proposes a population-based approach to meeting the comprehensive, complicated care needs of people with chronic pain.”  He also advocates mandates to payers “demanding a minimum level of benefits for patients in pain to increase coverage for evidence-based alternatives to opioids.” 

With best wishes,

Tony Mira
President and CEO

References
¹Macrae W, Bruce J. Chronic pain after surgery. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, editors. (eds) Clinical pain management: chronic pain. London: Hodder Arnold, 2008:405–14.
²Steegers MAH, Snik DM, Verhagen AF, van der Drift MA, Wilder-Smith OHG. Only half of the chronic pain after thoracic surgery shows a neuropathic component J Pain 2008;9(10):955–61. [PubMed]
³Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, et al. (Groin Pain Trial Group). Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg 2006;243(4):553–8.[PMC free article] [PubMed] and Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, et al. Chronic pain and quality of life following open inguinal hernia repair. Brit J Surg 2001;88(8):1122–6. [PubMed]
⁴Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med 2012;172:425-30.
⁵Ibid.