Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service

Abstract

Background: Chronic postsurgical pain is a highly prevalent public health problem associated with substantial emotional, social, and economic costs. Aims: (1) To review the major risk factors for chronic postsurgical pain (CPSP); (2) to describe the implementation of the Transitional Pain Service (TPS) at the Toronto General Hospital, a multiprofessional, multimodal preventive approach to CPSP involving intensive, perioperative psychological, physical, and pharmacological management aimed at preventing and treating the factors that increase the risk of CPSP and related disability; and (3) to present recent empirical evidence for the efficacy of the TPS. Methods: The Toronto General Hospital TPS was specifically developed to target patients at high risk of developing CPSP. The major known risk factors for CPSP are perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. At-risk patients are identified early and provided comprehensive care by a multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physical therapists. Results: Preliminary results from two nonrandomized, clinical practice-based trials indicate that TPS treatment is associated with improvements in pain, pain interference, pain catastrophizing, symptoms of anxiety and depression, and opioid use. Almost half of opioid-naïve patients and one in four opioid-experienced patients were opioid free by the 6-month point. Conclusions: These promising results suggest that the TPS benefits patients at risk of CPSP. A multicenter randomized controlled trial of the TPS in several Ontario hospitals is currently underway.

Multidisciplinary Transitional Pain Service for the Veteran Population

“…This type of Transitional Pain Service (TPS) has been described previously. [15][16][17] Our service differs from those described previously by enrolling all patients before surgery rather than select postsurgical enrollment of only patients with a history of opioid use or SUD or patients who struggle with persistent postsurgical pain.…”

Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom

“…Secondary-care outpatient pain services or transitional pain services may be able to assist if difficulties arise. 57,58 Post-discharge management Action: surgeons, general practitioners, and other healthcare professionals (i) Patients must be guided and informed to dispose of unused opioid medicines safely to avoid both diversion and subsequent inappropriate use. Safe disposal must involve taking excess supplies of medicines to the community or hospital pharmacy.…”

Surgery and opioids: some cracks in an enduring romance

“…physicians, nurses, physical therapists, pharmacists, mental health professionals, among others) that identifies high-risk patients and provides a suite of perioperative supportive services aimed, in part, at preventing development of opioid misuse long-term. 25 A recent study from the USA demonstrates the utility of a perioperative transitional pain service in producing a 40% decrease in opioid use after orthopaedic surgery. 26 The document also encourages a closer and more integrated working model between the inpatient (acute) and community pain (chronic) teams.…”

“…A perioperative plan with collaborative multidisciplinary care is likely to improve inpatient pain management, decrease length of stay, and increase the potential for opioid tapering both before and after surgery. 25,26 However, opioid tapering is not without significant risks including suicidal ideation and behaviours and transitioning to heroin use, and hence should be attempted with proper institutional governance mechanisms in place. 27e29 There has been a trend toward limiting use of opioids intraoperatively to reduce intraoperative nociception and postoperative pain.…”