The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain

Abstract

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.

Transitional Pain Medicine: novel pharmacological treatments for the management of moderate to severe postsurgical pain

“…Our pain research unit has published a roadmap to the implementation of a world first Transitional Pain Service (TPS) dedicated to comprehensively addressing the problem of CPSP at three stages: (1) preoperatively, (2) postoperatively in the acute pain setting in-hospital, and (3) postoperatively in an outpatient setting for up to 6 months after surgery. [8] The priorities of the TPS are to comprehensively treat pain and improve patient functioning for patients at increased risk for developing chronic postsurgical pain, and manage/ wean opioid-based medication for medically challenging patients back to baseline or completely off post-discharge. A comparison will be made by analyzing the effectiveness for the TPS interventions for patients that have been involved with our program versus those that have declined within our institution and plan a linked analysis to other Ontario-based academic centers.…”

“…[8] The goal of our transitional pain program is twofold: (1) to modify the pain trajectories of patients who are at increased risk of developing chronic postsurgical pain and (2) to reduce opioid consumption long term, which is often overlooked in our typical course of current perioperative care. [13,14] There exists two subsets of patients that are treated by our service:…”

“…This population ranges from 10% to 20% depending on the institution (12.5% at the TGH). [8] These patients must also deal with their 'acute on chronic' postsurgical pain. Typically they leave the hospital after extended lengths of stay on significantly more opioid medications than they were taking during their preadmission visits.…”

“…[29] A similar trend in patient trajectories was found within the TPS at TGH. [8] For this reason, we utilize the revised Canadian chronic neuropathic pain guidelines [30] for patients who have significant acute neuropathic pain in the immediate postoperative time period. Once complex pain patients are discharged from hospital with follow-up to the TPS, their first outpatient visit is often within 2-3 weeks.…”

“…We aim to make significant in-roads with respect to the reduction of CPSP and persistent opioid use using our novel approach to perioperative care. [8] Although significant advances in pain genetics are more than 5 years away, it is hoped that a worldwide consortium focused on studying chronic postsurgical pain and collecting the DNA of patients that transition to chronic postsurgical pain will lead to the development of novel therapeutics to improve the treatment of CPSP and other chronic neuropathic pain conditions. [35] CPSP can result from essential, life-saving surgery and it would never be suggested that surgery not be performed in these situations.…”