Prevention and Management of Chronic Postsurgical Pain and Persistent Opioid Use Following Solid Organ Transplantation: Experiences From the Toronto General Hospital Transitional Pain Service

Abstract

Background. With >700 transplant surgeries performed each year, Toronto General Hospital (TGH) is currently one of the largest adult transplant centers in North America. There is a lack of literature regarding both the identification and management of chronic postsurgical pain (CPSP) after organ transplantation. Since 2014, the TGH Transitional Pain Service (TPS) has helped manage patients who developed CPSP after solid organ transplantation (SOT), including heart, lung, liver, and renal transplants. Methods. In this retrospective cohort study, we describe the association between opioid consumption, psychological characteristics of pain, and demographic characteristics of 140 SOT patients who participated in the multidisciplinary treatment at the TGH TPS, incorporating psychology and physiotherapy as key parts of our multimodal pain management regimen. Results. Treatment by the multidisciplinary TPS team was associated with significant improvement in pain severity and a reduction in opioid consumption. Conclusions. Given the risk of CPSP after SOT, robust follow-up and management by a multidisciplinary team should be considered to prevent CPSP, help guide opioid weaning, and provide psychological support to these patients to improve their recovery trajectory and quality of life postoperatively.

Practical strategies for the prevention and management of chronic postsurgical pain

“…Some studies have indicated that TPS is effective in alleviating postoperative pain and in reducing opioid use after discharge [107,108]. Recent reports also suggest that implementing TPS for various surgical patients resulted in a substantial reduction in the severity of CPSP and opioid consumption after discharge [109][110][111][112]. Moreover, implementing TPSs is expected to be economically feasible by reducing the social costs associated with CPSP, such as loss of productivity and treatment expenses [113].…”

Pain management for liver transplant recipients

“…Yu et al also performed a retrospective cohort study that instituted a multidisciplinary team incorporating psychology and psychotherapy as key parts of the multimodal pain management regimen [24 ▪▪ ]. They identified two subsets of patients at risk of developing CPSP thought to benefit from the multidisciplinary approach: those identified with preoperative chronic pain/opioid use and those identified after transplant with pain or opioid requirements outside of the normal trajectory.…”

Chronic Postsurgical Pain After Solid Organ Transplantation: A Dreaded Complication in Recipients and Living Donors

“…Several reports evaluated chronic opioid consumption before and after transplantation and its impact on mortality. [4][5][6] Chuan et al 10 performed a retrospective analysis of 140 SOT patients followed by a transitional pain service (TPS) at the Toronto General Hospital that provides a multidisciplinary care pathway preoperatively and postoperatively. Opioid consumption calculated in milligram morphine equivalent (MME) per day was the main outcome measure.…”

“…The study by Chuan et al 10 has the merit to address the beneficial issue on transplant patients of a long follow-up by a specialized pain care service. Despite that, currently, some centers have a pain care referent or department, often run by an anesthesiologist or addictologist, and few are dedicated to long-term follow-up of SOT recipients.…”

“…12 Similar data were reported after a heart transplant. 11 In the study of Chuan et al, 10 34% of the patients were on an opioid dose prescription of >50 MME/d posttransplant, and the management by the TPS led to a significant reduction in the daily dose. Nevertheless, the tools used by the TPS in terms of management, interventions and medications, and the patient willingness to integrate such programs are not elucidated.…”