Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.
Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.
Background: The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. Aims: To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. Methods: Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. Results: Six months postoperatively, pain and function were significantly improved. Opioidnaïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. Conclusions: The TPS enabled almost half of opioid-naïve patients and one in four opioidexperienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients. RÉSUMÉ Contexte: La période périopératoire constitue un créneau déterminant pour s'attaquer à la consommation d'opioïdes, en particulier chez les patients qui ont une histoire de douleur chronique et de consommation préopératoire d'opioïdes. Le Service de la douleur transitionnelle de l'Hôpital général de Toronto a été mis sur pied pour s'attaquer au problème de la douleur et de la consommation d'opioïdes après une chirurgie. But: Présenter les résultats de l'évaluation du programme du Service de la douleur transitionnelle à l'Hôpital général de Toronto en mettant l'accent sur les taux de sevrage des opioïdes ainsi que sur la prise en charge de la douleur chez les patients n'ayant jamais consommé d'opioïdes et ceux qui en avaient déjà consommé. Méthodes: Avant d'être opérés, 251 patients à haut risque du Service de la douleur transitionnelle ont été séparés en deux groupes, l'un réunissant les patients n'ayant jamais consommé d'opioïdes et l'autres réunissant ceux qui en avaient déjà consommé. Les résultats portaient sur la douleur, la consommation d'opiodes, les taux de sevrage, ainsi que les comorbidités psychosociales et médicales. Résultats: Six mois après l'opération, la douleur et le fonctionnement s'étaient améliorés de manière significative. Les patients qui n'avaient jamais consommé d'opioïdes et ceux qui en avaient déjà consommé avaient réduit leur consommation de 69 % et 44 % respectivement, et 46% et 26 % d'entre eux étaient complètement sevrés. La consommation au moment du congé de l'hôpital prédisait le sevrage chez les patients qui n'avaient jamais consommé ARTICLE HISTORY
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