101
|
The Analgesic Effects of Liposomal Bupivacaine versus Bupivacaine Hydrochloride Administered as a Transversus Abdominis Plane Block after Abdominally Based Autologous Microvascular Breast Reconstruction: A Prospective, Single-Blind, Randomized, Controlled Trial. Plast Reconstr Surg 2020; 145:997e-998e. [PMID: 32332564 DOI: 10.1097/prs.0000000000006782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
102
|
Clarke HA, Manoo V, Pearsall EA, Goel A, Feinberg A, Weinrib A, Chiu JC, Shah B, Ladak SSJ, Ward S, Srikandarajah S, Brar SS, McLeod RS. Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery. Can J Pain 2020; 4:67-85. [PMID: 33987487 PMCID: PMC7951150 DOI: 10.1080/24740527.2020.1724775] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 12/12/2022]
Abstract
This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.
Collapse
Affiliation(s)
- Hance A. Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, Ontario, Canada
| | - Varuna Manoo
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Emily A. Pearsall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Akash Goel
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Adina Feinberg
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aliza Weinrib
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jenny C. Chiu
- Department of Pharmacy, North York General Hospital, Toronto, Ontario, Canada
| | - Bansi Shah
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Salima S. J. Ladak
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Ward
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Sanjho Srikandarajah
- Department of Anaesthesia, North York General Hospital, Toronto, Ontario, Canada
| | - Savtaj S. Brar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Robin S. McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
103
|
Thomas JM. Pharmacotherapy for treating chronic pain in children: A need for pragmatic idealism. Paediatr Anaesth 2020; 30:86-88. [PMID: 32077564 DOI: 10.1111/pan.13781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/25/2019] [Accepted: 12/01/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Jane M Thomas
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.,The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand.,Anaesthesiology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
104
|
Jivraj NK, Scales DC, Gomes T, Bethell J, Hill A, Pinto R, Wijeysundera DN, Wunsch H. Evaluation of opioid discontinuation after non-orthopaedic surgery among chronic opioid users: a population-based cohort study. Br J Anaesth 2020; 124:281-291. [PMID: 32000975 DOI: 10.1016/j.bja.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.
Collapse
Affiliation(s)
- Naheed K Jivraj
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
| | - Damon C Scales
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Tara Gomes
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | | | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Department of Anaesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| |
Collapse
|
105
|
Goel A, Feinberg A, McGuiness B, Brar S, Srikandarajah S, Pearsall E, McLeod R, Clarke H. Postoperative opioid-prescribing patterns among surgeons and residents at university-affiliated hospitals: a survey study. Can J Surg 2020; 63:E1-E8. [PMID: 31916430 DOI: 10.1503/cjs.016518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Overprescribing of opioids to patients following surgery is a public health concern, as unused pills may be diverted and contribute to opioid misuse and dependence. The objectives of this study were to determine current opioid-prescribing patterns for common surgical procedures, factors that affect surgeons’ prescribing behaviour and their perceived ability to manage patients with opioid use disorder. Methods Survey participants included all consultant and trainee surgeons at the University of Toronto. The survey, which was administered electronically, included 52 multiple-choice, rank-order and open-text questions eliciting information on current prescribing patterns, prescribing of adjunct pain medications, and education and other factors related to opioid prescribing. Staff surgeons were also asked about how they manage patients with a suspected opioid issue. Results Eighty surgical trainees and 40 staff surgeons responded to the survey (response rate 32%). Five staff surgeons (12%) felt adequately educated to prescribe pain medications (including opioids) at discharge. Staff surgeons prescribed Tylenol 3 more frequently than other opioids. Twenty (51%) of 39 staff surgeons reported that they sought further help for their patients when an opioid use disorder was suspected. Conclusion Our results support existing studies showing a large degree of variability in postoperative opioid prescribing. Institutional guidelines have been shown to be effective in curbing excessive opioid prescribing without increasing unnecessary emergency department visits for uncontrolled pain. Thus, there is an opportunity to develop institutional guidelines to educate surgical teams in the prescribing of opioids and about services available for patients with a substance use disorder.
Collapse
Affiliation(s)
- Akash Goel
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Adina Feinberg
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Brandon McGuiness
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Sav Brar
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Sanjho Srikandarajah
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Emily Pearsall
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Robin McLeod
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| | - Hance Clarke
- From the Department of Anesthesia, University of Toronto, Toronto, Ont. (Goel); the Harvard T.H. Chan School of Public Health, Boston, Mass. (Goel, McGuiness); the Department of Surgery, University of Toronto, Toronto, Ont. (Feinberg, Brar, Pearsall, McLeod); the Department of Vascular Surgery, McMaster University, Hamilton, Ont. (McGuiness); the Department of Surgery, Mount Sinai Hospital, Toronto, Ont. (Brar); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Srikandarajah); and the Department of Anesthesia, University Health Network, Toronto, Ont. (Clarke)
| |
Collapse
|
106
|
Wolmeister AS, Schiavo CL, Nazário KCK, Castro SMDJ, de Souza A, Caetani RP, Caumo W, Stefani LC. The Brief Measure of Emotional Preoperative Stress (B-MEPS) as a new predictive tool for postoperative pain: A prospective observational cohort study. PLoS One 2020; 15:e0227441. [PMID: 31914146 PMCID: PMC6948814 DOI: 10.1371/journal.pone.0227441] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/18/2019] [Indexed: 01/01/2023] Open
Abstract
Background Preoperative patients’ vulnerabilities such as physical, social, and psychological are implicated in postoperative pain variability. Nevertheless, it is a challenge to analyze a patient's psychological profile in the preoperative period in a practical and consistent way. Thus, we sought to identify if high preoperative emotional stress, evaluated by the Brief Measure of Emotional Preoperative Stress (B-MEPS) scale is associated with higher postoperative pain levels and poor rehabilitation in patients submitted to intermediate or major surgery. Moreover, the possible neurobiological or neurophysiological mechanisms implicated in high preoperative emotional stress, evaluated through preoperative quantitative sensory pain tests and serum biomarkers BDNF and S100B were investigated. Methods We conducted a prospective, observational, cohort study of ASA 2 and 3 adult patients undergoing major urologic, gynecologic, proctologic and orthopedic surgeries from March 2017 to March 2018. B-MEPS and Central Sensitivity Inventory were evaluated preoperatively, followed by a sequence of experimental pain tests and serum biomarkers collection. Postoperative evaluation carried out within the first 48 hours after surgery comprehended pain at rest and movement-evoked pain, and the consumption of morphine. Quality-of-Recovery was also evaluated in the 3rd postoperative day. Results 23 (15%) out of 150 patients included in the study presented high emotional preoperative stress. Variables significantly related to preoperative stress were: previous psychiatric diagnosis and Central Sensitization Inventory result. Mean movement-evoked pain in the first 12 to 48 hours was 95–105% higher than pain at rest. A mixed model for repeated measures showed a sustainable effect of B-MEPS as a movement-evoked pain predictor. Previous pain, cancer surgery, and preoperative pressure pain tolerance were also independent predictors of postoperative pain. Moderate to severe postoperative movement-evoked pain was predictive of poor rehabilitation in 48 hours after surgery. Conclusion We confirmed that a brief screening method of preoperative emotional states could detect individuals prone to experience severe postoperative pain. Specific interventions considering the stress level may be planned in the future to improve perioperative outcomes.
Collapse
Affiliation(s)
- Anelise Schifino Wolmeister
- Postgraduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Carolina Lourenzon Schiavo
- Postgraduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Kahio César Kuntz Nazário
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | | | - Andressa de Souza
- Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rafael Poli Caetani
- School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Wolnei Caumo
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana Cadore Stefani
- Laboratory of Pain & Neuromodulation, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- * E-mail:
| |
Collapse
|
107
|
Tsedinova Y, Churuykanov M, Medvedeva L, Zagorulko O, Boltenkova V, Galeev N. Psychological characteristics of patients with chronic postsurgical pain. ACTA ACUST UNITED AC 2020. [DOI: 10.17116/pain20201802129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
108
|
Akbar N, Teo SP, Artini Hj-Abdul-Rahman HN, Hj-Husaini HA, Venkatasalu MR. Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative. Ann Geriatr Med Res 2019; 23:190-196. [PMID: 32743311 PMCID: PMC7370760 DOI: 10.4235/agmr.19.0037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 11/30/2022] Open
Abstract
Background Effective pain management is a fundamental human right. However, global disparities in pain management practices exist across health settings. This study explored healthcare practitioners’ views on pain management in the acute care hospital setting. Methods The focus groups included clinical specialties most likely to encounter patients with ‘difficult to manage pain’, namely those in the Geriatrics and Palliative Care Unit (2 doctors and 3 nurses), Critical Care Unit (7 doctors), and the Pain Management Team (3 doctors and 2 nurses). The transcripts were analyzed using a qualitative thematic analysis. Results The data analysis revealed four themes. Theme 1, ‘Being too safe’ described the presence of apprehensive attitudes among patients and healthcare practitioners that limits the appropriate use of diverse and tailored pain medications in acute care hospital settings. Theme 2, ‘Working as a team’ described the need for collaborative approaches to achieve hospital-wide evidence-based pain management. Theme 3, ‘Adaptation for local and cultural preferences’ explored how pain was perceived through cultural lenses and suggested strategies to tailor pain management to local and cultural preferences. Finally, Theme 4, ‘Driving acute pain management forward’ listed clinician solutions for improving pain management in acute care hospital settings toward a pain-free hospital initiative. Conclusion Despite advances in pain medicine and pain teaching strategies, effective pain management is proportionate to both clinical and cultural preferences. Future studies should investigate the standardization of global pain management tools and guidelines to fit the local culture and context.
Collapse
Affiliation(s)
- Nuraqilah Akbar
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
| | - Shyh Poh Teo
- Geriatrics and Palliative Unit, Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
| | - Hjh Noor Artini Hj-Abdul-Rahman
- Geriatrics and Palliative Unit, Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
| | - Hjh Asmah Hj-Husaini
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam
| | | |
Collapse
|
109
|
Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
110
|
Freys SM, Pogatzki-Zahn E. Pain therapy to reduce perioperative complications. Innov Surg Sci 2019; 4:158-166. [PMID: 33977126 PMCID: PMC8059349 DOI: 10.1515/iss-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
Collapse
Affiliation(s)
- Stephan M. Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
| |
Collapse
|
111
|
Rosenbloom BN, Pagé MG, Isaac L, Campbell F, Stinson JN, Wright JG, Katz J. Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery. J Pain Res 2019; 12:3079-3098. [PMID: 31814752 PMCID: PMC6858804 DOI: 10.2147/jpr.s210594] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 10/07/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability. METHODS This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy. RESULTS AND DISCUSSION The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability. CONCLUSION Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.
Collapse
Affiliation(s)
| | - M Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l’Université de Montréal and Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Jennifer N Stinson
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, and Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - James G Wright
- Department of Surgery, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
112
|
Bai JW, Bao J, Bhatia A, Chan VWS. A perioperative approach to the opioid crisis. CMAJ 2019; 190:E1151-E1152. [PMID: 30274991 DOI: 10.1503/cmaj.180801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Johnny-Wei Bai
- Department of Anesthesia and Pain Management, Toronto Western Hospital (University Health Network), Toronto, Ont.
| | - James Bao
- Department of Anesthesia and Pain Management, Toronto Western Hospital (University Health Network), Toronto, Ont
| | - Anuj Bhatia
- Department of Anesthesia and Pain Management, Toronto Western Hospital (University Health Network), Toronto, Ont
| | - Vincent W S Chan
- Department of Anesthesia and Pain Management, Toronto Western Hospital (University Health Network), Toronto, Ont
| |
Collapse
|
113
|
Opioid-free anaesthesia: Con: it is too early to adopt opioid-free anaesthesia today. Eur J Anaesthesiol 2019; 36:250-254. [PMID: 30817360 DOI: 10.1097/eja.0000000000000965] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
114
|
Montbriand JJ, Weinrib AZ, Azam MA, Ladak SSJ, Shah BR, Jiang J, McRae K, Tamir D, Lyn S, Katznelson R, Clarke HA, Katz J. Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service. Nicotine Tob Res 2019; 20:1144-1151. [PMID: 28472423 DOI: 10.1093/ntr/ntx094] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/01/2017] [Indexed: 12/25/2022]
Abstract
Introduction The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.
Collapse
Affiliation(s)
- Janice J Montbriand
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Aliza Z Weinrib
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Muhammad A Azam
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Salima S J Ladak
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - B R Shah
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Jiao Jiang
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Diana Tamir
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Sheldon Lyn
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Hance A Clarke
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Joel Katz
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, University of Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| |
Collapse
|
115
|
Bicket MC, Brat GA, Hutfless S, Wu CL, Nesbit SA, Alexander GC. Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework. Am J Health Syst Pharm 2019; 76:1403-1412. [DOI: 10.1093/ajhp/zxz146] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AbstractPurposeMillions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.MethodsWe reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.ResultsOpioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.ConclusionsThe severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.
Collapse
Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, and Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gabriel A Brat
- Harvard Medical School, Boston, MA, and Division of Acute Care Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Hutfless
- Gastrointestinal Epidemiology Research Center, Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, and Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Suzanne A Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, and Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, MD
| | - G Caleb Alexander
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
116
|
Clarke H, Bao J, Weinrib A, Dubin RE, Kahan M. Canada's hidden opioid crisis: the health care system's inability to manage high-dose opioid patients: Fallout from the 2017 Canadian opioid guidelines. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:612-614. [PMID: 31515308 PMCID: PMC6741787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Hance Clarke
- Staff anesthesiologist and Director of Pain Services in the Department of Anesthesia and Pain Management in the Pain Research Unit at Toronto General Hospital in Ontario.
| | - James Bao
- Anesthesiology resident in the Department of Anesthesia and Pain Management at Toronto General Hospital
| | - Aliza Weinrib
- Clinical psychologist in the Transitional Pain Service in the Department of Anesthesia and Pain Management at Toronto General Hospital
| | - Ruth E Dubin
- Family physician with a special interest in pain and addiction practising in Kingston, Ont, Associate Professor in the Department of Family Medicine at Queen's University, and Co-chair of ECHO Ontario Pain and Opioid Stewardship
| | - Meldon Kahan
- Professor in the Department of Family and Community Medicine at the University of Toronto, and Medical Director of Substance Use Service/Addictions Medicine and Project Lead of META:PHI (Mentoring, Education and Clinical Tools for Addiction: Primary Care-Hospital Integration), both at Women's College Hospital
| |
Collapse
|
117
|
Clarke H, Bao J, Weinrib A, Dubin RE, Kahan M. La crise cachée des opioïdes au Canada : l’incapacité du système de santé de gérer les patients prenant de fortes doses d’opioïdes. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e376-e378. [PMID: 31515322 PMCID: PMC6741786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Hance Clarke
- Anesthésiologiste membre du personnel et directeur des Services de gestion de la douleur au Département d'anesthésie et de gestion de la douleur à l'Unité de recherche sur la douleur de l'Hôpital Toronto General (Ontario).
| | - James Bao
- Résident en anesthésiologie au Département d'anesthésie et de gestion de la douleur de l'Hôpital Toronto General
| | - Aliza Weinrib
- Psychologue clinicienne au Service de la gestion de la douleur transitionnelle au Département d'anesthésie et de contrôle de la douleur à l'Hôpital Toronto General
| | - Ruth E Dubin
- Médecin de famille ayant un intérêt spécial en gestion de la douleur et en dépendances à Kingston (Ontario), professeure agrégée au Département de médecine familiale de l'Université Queen's et coprésidente du projet ECHO Ontario Pain and Opioid Stewardship
| | - Meldon Kahan
- Professeur au Département de médecine familiale et communautaire de l'Université de Toronto, directeur médical du Service de lutte contre la toxicomanie et de médecine des dépendances, et directeur du projet META:PHI (Mentoring, Education and Clinical Tools for Addiction: Primary Care-Hospital Integration), les 2 à l'Hôpital Women's College
| |
Collapse
|
118
|
Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
Collapse
Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
119
|
Wu CL, King AB, Geiger TM, Grant MC, Grocott MPW, Gupta R, Hah JM, Miller TE, Shaw AD, Gan TJ, Thacker JKM, Mythen MG, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients. Anesth Analg 2019; 129:567-577. [PMID: 31082966 PMCID: PMC7261519 DOI: 10.1213/ane.0000000000004194] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
Collapse
Affiliation(s)
- Christopher L. Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Adam B. King
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
| | - Timothy M. Geiger
- Department of Surgery, Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael P. W. Grocott
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Southampton National Institute of Health Research Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust/University of Southampton, Southampton, United Kingdom
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Jennifer M. Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D. Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K. M. Thacker
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt, Vanderbilt University School of Medicine and University Medical Center, Nashville, Tennessee
| |
Collapse
|
120
|
Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St-Jean M, Rashiq S, Van Camp K, Flamer D, Satok-Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth 2019; 123:e333-e342. [PMID: 31153631 PMCID: PMC6676043 DOI: 10.1016/j.bja.2019.03.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/09/2019] [Accepted: 03/21/2019] [Indexed: 01/09/2023] Open
Abstract
Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.
Collapse
Affiliation(s)
- Akash Goel
- Department of Anaesthesia, University of Toronto, Canada; T.H. Chan School of Public Health, Harvard University, USA
| | - Saam Azargive
- Department of Anaesthesia, University of Toronto, Canada; Department of Anaesthesia, Queen's University School of Medicine, Canada
| | - Joel S Weissman
- T.H. Chan School of Public Health, Harvard University, USA; Department of Surgery, Brigham and Women's Institute, USA
| | | | - John G Hanlon
- Department of Anaesthesia, University of Toronto, Canada
| | - Bana Samman
- Department of Anaesthesia, University of Toronto, Canada
| | - Mary Dominicis
- Department of Anaesthesia, University of Toronto, Canada
| | - Karim S Ladha
- Department of Anaesthesia, University of Toronto, Canada
| | - Wiplove Lamba
- Department of Psychiatry, University of Toronto, Canada
| | - Scott Duggan
- Department of Anaesthesia, Queen's University School of Medicine, Canada
| | - Tania Di Renna
- Department of Anaesthesia, University of Toronto, Canada
| | - Philip Peng
- Department of Anaesthesia, University of Toronto, Canada
| | - Clinton Wong
- Department of Anaesthesia, University of British Columbia, Canada
| | - Avinash Sinha
- Department of Anaesthesia, McGill University, Canada
| | - Naveen Eipe
- Department of Anaesthesia, University of Ottawa, Canada
| | - David Martell
- Department of Family Medicine, Dalhousie University, Canada
| | | | | | - Kwesi Kwofie
- Department of Anaesthesia, Dalhousie University, Canada
| | | | - Saifee Rashiq
- Department of Anaesthesia, University of Alberta, Canada
| | - Kari Van Camp
- Pain Research Unit, Toronto General Hospital, University of Toronto, Canada
| | - David Flamer
- Department of Anaesthesia, University of Toronto, Canada
| | | | - Hance Clarke
- Department of Anaesthesia, University of Toronto, Canada; Pain Research Unit, Toronto General Hospital, University of Toronto, Canada.
| |
Collapse
|
121
|
Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD, Geiger TM, Gordon DB, Grant MC, Grocott M, Gupta R, Hah JM, Hurley RW, Kent ML, King AB, Oderda GM, Sun E, Wu CL. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129:553-566. [DOI: 10.1213/ane.0000000000004018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
122
|
Nowakowski ME, McCabe RE, Busse JW. Cognitive behavioral therapy to reduce persistent postsurgical pain following internal fixation of extremity fractures (COPE): Rationale for a randomized controlled trial. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2019; 3:59-68. [PMID: 35005420 PMCID: PMC8730643 DOI: 10.1080/24740527.2019.1615370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Approximately half of all patients who undergo surgical repair of extremity fractures report persistent postsurgical pain (PPSP) at 1-year post-surgery. Psychological factors such as anxiety, depression, catastrophization, poor coping, high somatic complaints, and pessimism about recovery are risk factors for the development of PPSP. It is possible that interventions such as cognitive behavior therapy (CBT) that target psychological factors may reduce the incidence of PPSP in this population. Aims: The current report reviews the role of psychological factors in the development of PPSP and discusses the rationale and protocol development for a multi-site randomized-controlled trial investigating the effectiveness of CBT in reducing PPSP in patients with surgically treated extremity fractures.
Collapse
Affiliation(s)
- Matilda E. Nowakowski
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Chronic Pain Clinic, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Randi E. McCabe
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Anxiety Treatment and Research Clinic, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Jason W. Busse
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
123
|
Ouellette C, Henry S, Turner A, Clyne W, Furze G, Bird M, Sanchez K, Watt-Watson J, Carroll S, Devereaux PJ, McGillion M. The need for novel strategies to address postoperative pain associated with cardiac surgery: A commentary and introduction to "SMArTVIEW". Can J Pain 2019; 3:26-35. [PMID: 35005416 PMCID: PMC8730666 DOI: 10.1080/24740527.2019.1603076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/24/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Abstract
Background: With coronary heart disease affecting over 2.4 million Canadians, annual cardiac and major vascular surgery rates are on the rise. Unrelieved postoperative pain is among the top five causes of hospital readmission following surgery; little is done to address this postoperative complication. Barriers to effective pain assessment and management following cardiac and major vascular surgery have been conceptualized on patient, health care provider, and system levels. Purpose: In this commentary, we review common patient, health care provider, and system-level barriers to effective postoperative pain assessment and management following cardiac and major vascular surgery. We then outline the SMArTVIEW intervention, with particular attention to components designed to optimize postoperative pain assessment and management. Methods: In conceptualizing the SMArTVIEW intervention design, we sought to address a number of these barriers by meeting the following design objectives: (1) orchestrating a structured process for regular postoperative pain assessment and management; (2) ensuring adequate clinician preparation for postoperative pain assessment and management in the context of virtual care; and (3) enfranchising patients to become active self-managers and to work with their health care providers to manage their pain postoperatively. Conclusions: Innovative approaches to address these barriers are a current challenge to health care providers and researchers alike. SMArTVIEW is spearheading this paradigm shift within clinical research to address barriers that impair effective postoperative pain management by actively engaging health care providers and patients in an accessible format (i.e., digital health solution) to give primacy to the need of postoperative pain assessment and management following cardiac and major vascular surgery.
Collapse
Affiliation(s)
- Carley Ouellette
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shaunattonie Henry
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andy Turner
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | | | - Gill Furze
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Marissa Bird
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Karla Sanchez
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Judy Watt-Watson
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Carroll
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| | - PJ Devereaux
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Michael McGillion
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Perioperative & Digital Health Department, Population Health Research Institute, Hamilton, Ontario, Canada
| |
Collapse
|
124
|
Katz J, Weinrib AZ, Clarke H. Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service. Can J Pain 2019; 3:49-58. [PMID: 35005419 PMCID: PMC8730596 DOI: 10.1080/24740527.2019.1574537] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/14/2019] [Accepted: 01/22/2019] [Indexed: 12/16/2022]
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.
Collapse
Affiliation(s)
- Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Aliza Z. Weinrib
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
125
|
Anderson TA, Ahmad S. Defining and Reducing the Risk of Persistent Postoperative Opioid Use. Anesth Analg 2019; 129:324-326. [PMID: 31313668 DOI: 10.1213/ane.0000000000004193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T Anthony Anderson
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Shireen Ahmad
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
126
|
Stulberg JJ, Schäfer WLA, Shallcross ML, Lambert BL, Huang R, Holl JL, Bilimoria KY, Johnson JK. Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design. BMJ Open 2019; 9:e030404. [PMID: 31164370 PMCID: PMC6561445 DOI: 10.1136/bmjopen-2019-030404] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies. METHODS AND ANALYSIS The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site. ETHICS AND DISSEMINATION The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).
Collapse
Affiliation(s)
- Jonah J Stulberg
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Willemijn L A Schäfer
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Meagan L Shallcross
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bruce L Lambert
- Centre for Communication and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Reiping Huang
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane L Holl
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Karl Y Bilimoria
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Julie K Johnson
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
127
|
Opioid Prescribing In-Hospital: Time for Innovative Approaches to Help Combat the Opioid Crisis. CANADIAN JOURNAL OF ADDICTION 2019. [DOI: 10.1097/cxa.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
128
|
Soffin EM, Lee BH, Kumar KK, Wu CL. The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse. Br J Anaesth 2019; 122:e198-e208. [PMID: 30915988 PMCID: PMC8176648 DOI: 10.1016/j.bja.2018.11.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.
Collapse
Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Bradley H Lee
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Kanupriya K Kumar
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
129
|
Shechter R, Speed TJ, Blume E, Singh S, Williams K, Koch CG, Hanna MN. Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program. Am J Med Qual 2019; 35:5-15. [DOI: 10.1177/1062860619851170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.
Collapse
|
130
|
Abstract
Severe chronic pain is often devastating for the affected individuals causing substantial suffering, health impairment, and a very low quality of life, including significant negative consequences for the patient and for society. Patients with complex pain disorders are seen often in relation to anaesthesia. They deserve special attention and require long time hospitalization and multiple contacts with health-care providers after discharge from hospital. A wider adoption of best perioperative and intraoperative pain management practice is required. This paper reviews current knowledge of perioperative and intraoperative pain management and anaesthetic care of the chronic pain patient. The individual topics covered include the magnitude of the problem created by chronic pain, the management of the patients taking various types of opioids, tolerance and opioid induced hyperalgesia and the multidisciplinary approach to pain management. The preventive and preemptive strategies for reducing the opioid needs and chronic pain after surgery are reviewed. The last section includes the role of acute pain services and an example of the implementation of a transitional pain service with the various benefits it offers; for example, the decrease of the opioid dose after discharge from the hospital. Patients also receive the continuity of care, with not only pain relief but also improvements in physical functioning, quality of life and emotional stress.
Collapse
|
131
|
Hollmann MW, Rathmell JP, Lirk P. Optimal postoperative pain management: redefining the role for opioids. Lancet 2019; 393:1483-1485. [PMID: 30983573 DOI: 10.1016/s0140-6736(19)30854-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Markus W Hollmann
- Department of Anaesthesiology, University Medical Center Amsterdam, Amsterdam 1105AZ, Netherlands.
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
132
|
Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet 2019; 393:1537-1546. [PMID: 30983589 DOI: 10.1016/s0140-6736(19)30352-6] [Citation(s) in RCA: 429] [Impact Index Per Article: 85.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/20/2018] [Accepted: 02/07/2019] [Indexed: 12/14/2022]
Abstract
Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.
Collapse
Affiliation(s)
- Paul Glare
- Pain Management Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Karin R Aubrey
- Pain Management Research Institute, University of Sydney, Sydney, NSW, Australia; Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC.
| |
Collapse
|
133
|
Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019; 393:1547-1557. [PMID: 30983590 PMCID: PMC6556783 DOI: 10.1016/s0140-6736(19)30428-3] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.
Collapse
Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Bateman
- Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
134
|
Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
Collapse
Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| |
Collapse
|
135
|
Bjurström MF, Irwin MR. Perioperative Pharmacological Sleep‐Promotion and Pain Control: A Systematic Review. Pain Pract 2019; 19:552-569. [DOI: 10.1111/papr.12776] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/21/2019] [Accepted: 02/07/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Martin F. Bjurström
- Department of Anesthesiology and Intensive Care Skåne University Hospital LundSweden
- Department of Clinical Sciences Lund University Lund Sweden
- Cousins Center for Psychoneuroimmunology University of California, Los Angeles (UCLA) Los Angeles California U.S.A
| | - Michael R. Irwin
- Cousins Center for Psychoneuroimmunology University of California, Los Angeles (UCLA) Los Angeles California U.S.A
| |
Collapse
|
136
|
Okifuji A, Neikrug A. Update and future perspective of behavioral medicine in the treatment for chronic pain. Pain Manag 2019; 9:161-173. [PMID: 30785366 DOI: 10.2217/pmt-2017-0055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Chronic pain is a biopsychosocial condition, and behavioral medicine has made significant contributions to the understanding of the phenomenon and optimization of therapeutic outcomes. The objective of this article is to provide future perspectives of behavioral medicine in pain management based upon recent development in the field. We will briefly review the mainstream approach of cognitive-behavioral therapy, its variations and new and innovative approaches that are on the horizon. We also review strategies that address potential barriers to pain management. Behavioral medicine is a promising field in pain medicine. The future growth is likely to come from addressing how we incorporate the patient heterogeneity into our treatment approaches and a better understanding of its role in a multimodal treatment.
Collapse
Affiliation(s)
- Akiko Okifuji
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA 84108
| | - Ariel Neikrug
- Department of Psychiatry, University of California Irvine, CA 92868, USA 92868
| |
Collapse
|
137
|
Bayman EO, Parekh KR, Keech J, Larson N, Vander Weg M, Brennan TJ. Preoperative Patient Expectations of Postoperative Pain Are Associated with Moderate to Severe Acute Pain After VATS. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:543-554. [PMID: 29878248 PMCID: PMC6657569 DOI: 10.1093/pm/pny096] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The goal of this post hoc analysis of subjects from a prospective observational study was to identify the predictors of patients developing moderate to severe acute pain (mean numerical rating scale [NRS] ≥4, 0-10) during the first three days after video-assisted thoracoscopic surgery (VATS) from a comprehensive evaluation of demographic, psychosocial, and surgical factors. METHODS Results from 82 patients who were enrolled one week before VATS and evaluated during the first three postoperative days are presented. The primary outcome variable of the current study was the presence of moderate to severe acute pain after VATS. RESULTS Fifty-nine percent (95% confidence interval, 47-69%) of study subjects developed moderate to severe acute pain after VATS. Factors univariately associated with the presence of moderate to severe acute pain were greater average expected postoperative pain, greater pain to a suprathreshold cold stimulus, and longer durations of surgery and hospital stay (P < 0.05). When considered in the multiple logistic regression models, the patients' preoperative average intensity of expected postoperative pain (NRS, 0-10) was the only measure associated with the moderate to severe acute pain. Average intensity of postoperative pain expected by patients when questioned preoperatively mediated the effect of reported intensity of pain to the suprathreshold cold stimulus for moderate to severe acute pain levels. Preoperative patient expectations had greater predictive value than other assessed variables including psychosocial factors such as catastrophizing or anxiety assessed one week before surgery. CONCLUSIONS None of the preoperative psychosocial measures were associated with the moderate to severe acute pain after VATS. Average expected postoperative pain was the only measure associated with the development of moderate to severe acute pain after VATS.
Collapse
Affiliation(s)
| | | | | | | | | | - Timothy J Brennan
- Departments of Anesthesia
- Department of Pharmacology, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
138
|
Rieder TN. Opioids and Ethics: Is Opioid-Free the Only Responsible Arthroplasty? HSS J 2019; 15:12-16. [PMID: 30863226 PMCID: PMC6384204 DOI: 10.1007/s11420-018-9651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/08/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Travis N. Rieder
- 0000 0001 2171 9311grid.21107.35Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Ave, Baltimore, MD 21205 USA
| |
Collapse
|
139
|
Singleton MN, Hannafin JA, Liguori GA, Soffin EM. The Role of Peripheral Nerve Catheters in Buprenorphine/Naloxone Management in Elective Orthopedic Surgery: A Case Report. HSS J 2019; 15:93-95. [PMID: 30863239 PMCID: PMC6384208 DOI: 10.1007/s11420-018-9648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/15/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Michael N. Singleton
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jo A. Hannafin
- Department of Sports Medicine, Hospital for Special Surgery, New York, NY USA
| | - Gregory A. Liguori
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| |
Collapse
|
140
|
Al Hroub A, Obaid A, Yaseen R, El-Aqoul A, Zghool N, Abu-Khudair H, Al Kakani D, Alloubani A. Improving the Workflow Efficiency of An Outpatient Pain Clinic at A Specialized Oncology Center by Implementing Lean Principles. Asia Pac J Oncol Nurs 2019; 6:381-388. [PMID: 31572758 PMCID: PMC6696806 DOI: 10.4103/apjon.apjon_21_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objective Adult outpatient oncology pain clinics face many challenges due to the increased number of patients, the restriction of electronic appointment systems, overcrowding, waiting time, and patient dissatisfaction. This project aimed to improve clinic time efficiency, decrease clinic waiting time, and improve patient satisfaction. Methods Lean thinking concepts and their tools, for example, value-stream mapping and value added (VA)/non-VA (NVA) analysis were used. Electronic appointment system slots were stratified based on patient visit type. A total of 187 patients were included in a time-motion survey at three different occasions: preintervention (n = 67) and two consecutive quarter postintervention time points (n = 64, n = 56). Simultaneously, patient satisfaction was reported quarterly by a quality management office. Results The pain clinic workflow became more efficient; the mean clinic waiting time decreased from 72.5 min at preintervention to 19.5 and 21 min at the two postintervention quarters, respectively. Moreover, patient satisfaction improved from 75% at the preintervention to 100% and 96.7% at the two postintervention quarters. Conclusions Redesigning the process of an electronic appointment system using lean thinking considerably decreases patients' waiting time, improves patient satisfaction, improves resource utilization, allows proper scheduling based on patient visit types, eliminates unnecessary waste processes, and reallocates health-care providers' time toward direct, individualized patient care.
Collapse
|
141
|
|
142
|
Abstract
Increasing numbers of those living with and beyond cancer presents a clinical challenge for pain specialists. A large proportion of these patients experience pain secondary to their disease or its treatment, impeding rehabilitation and significantly impacting upon their quality of life. The successful management of this pain presents a considerable challenge. This review aims to outline current concepts and treatment options, while considering nuances within pain assessment and the use of large-scale data to help guide further advances.
Collapse
Affiliation(s)
- David Magee
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Sabina Bachtold
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Matthew Brown
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.,Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Paul Farquhar-Smith
- Department of Pain Medicine, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| |
Collapse
|
143
|
Martorella G, Graven L, Schluck G, Bérubé M, Gélinas C. Nurses' Perception of a Tailored Web-Based Intervention for the Self-Management of Pain After Cardiac Surgery. SAGE Open Nurs 2018; 4:2377960818806270. [PMID: 33415209 PMCID: PMC7774353 DOI: 10.1177/2377960818806270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023] Open
Abstract
Background Cardiac surgeries rank among the most frequent surgical procedures and present a risk of chronic postsurgical pain (CPSP). A continuum approach is required to prevent the development of CPSP. As a first step, a tailored web-based intervention was developed and successfully tested to tackle pain management during hospitalization. Before proceeding to further development, preliminary acceptability of the intervention including the postdischarge phase must be evaluated. Purpose The purpose of this study was to examine nurses’ perception of a tailored Web-based intervention for pain management in the early recovery phase. The objectives were to evaluate intervention’s acceptability and to identify ways to enhance its acceptability. Methods A parallel mixed methods approach was used to assess the acceptability of the intervention in the early recovery phase (first month after surgery). Results In total, 249 participants completed the online survey and 10 participants were individually interviewed. Overall, the intervention was rated as acceptable. No difference was found in acceptability ratings by demographics. The intervention was rated as appropriate to very much appropriate by 79% of participants. Although nurses seemingly would recommend it to their patients, they did not perceive that their patients would be as highly willing to use it. Interviews highlighted several strengths of the intervention, such as postoperative pain awareness, customization of content, and flexible dosage and schedule. However, the main weakness was related to patient adherence. Opting for a hybrid format and integrating individual preferences could enhance the coaching experience. Conclusion The innovative intervention was judged as acceptable for pain management in the early recovery phase. Considering that the intervention has demonstrated positive effects on the pain experience in the first week after cardiac surgery, it seems logical to explore its potential impact after discharge on the transition to CPSP.
Collapse
Affiliation(s)
- Geraldine Martorella
- TMH Center for Research and Evidence-Based Practice, College of Nursing, Florida State University, FL, USA
| | - Lucinda Graven
- College of Nursing, Florida State University, Tallahassee, FL, USA
| | - Glenna Schluck
- College of Nursing, Florida State University, Tallahassee, FL, USA
| | - Mélanie Bérubé
- Ingram School of Nursing, McGill University, Montreal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, Canada.,Centre for Nursing Research, Jewish General Hospital, Montreal, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Alan Edwards Centre for Research on Pain, McGill University, Montreal, Canada
| |
Collapse
|
144
|
Pagé MG, Karanicolas PJ, Cleary S, Wei AC, McHardy P, Ladak SSJ, Ayach N, Sawyer J, McCluskey SA, Srinivas C, Katz J, Coburn N, Hallet J, Law C, Greig P, Clarke H. In-hospital opioid consumption, but not pain intensity scores, predicts 6-month levels of pain catastrophizing following hepatic resection: A trajectory analysis. Eur J Pain 2018; 23:503-514. [PMID: 30298685 DOI: 10.1002/ejp.1324] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND The study aims were to model acute pain intensity and opioid consumption trajectories up to 72 hr after open hepatic resection, identify predictors of trajectory membership and examine the association between trajectory memberships and 6-month pain and psychological outcomes. This is a long-term analysis of a published randomized controlled trial on the impact of medial open transversus abdominis plane catheters on post-operative outcomes. METHODS A total of 152 patients (89 males; mean age 63.0 [range: 54-72]) completed questionnaires on pain and related characteristics pre-operatively and 6 months post-operatively. Total opioid use was recorded several times over a 72-hr period while self-reported pain intensity scores were collected multiple times until hospital discharge. Analyses were carried out using growth mixture modelling, logistic regression and general linear models. RESULTS Both pain intensity and opioid consumption showed that a four-trajectory model best fits the data. Patients in the lowest opioid consumption trajectory were more likely to be classified in the constant mild pain intensity trajectory. Age and baseline levels of anxiety significantly predicted opioid trajectory membership while baseline depressive symptoms significantly predicted pain intensity trajectory membership. Patients in the two highest opioid consumption trajectories reported significantly higher levels of pain catastrophizing at 6 months compared to patients in the other 3 trajectories (all p < 0.05). CONCLUSION High consumption of opioids after surgery is associated with higher levels of pain catastrophizing 6 months later. Identification of patients within these trajectories may lead to the development of early interventions targeted to high risk individuals. SIGNIFICANCE Differences in initial levels of opioid consumption and rates of change in opioid consumption shortly after surgery can help predict long-term psychological responses to pain. Identifying key characteristics associated with initial opioid consumption can lead to the development of cost-effective early interventions targeted to high risk individuals.
Collapse
Affiliation(s)
- M Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l' Université de Montréal (CRCHUM), Montreal, Québec, Canada.,Department of anesthesiology and pain medicine, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sean Cleary
- Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic - Rochester, Rochester, Minnesota
| | - Alice C Wei
- Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paul McHardy
- Department of Anaesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Salima S J Ladak
- Department of Anaesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Nour Ayach
- Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jason Sawyer
- Department of Anaesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Coimbatore Srinivas
- Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Anaesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of psychology, Faculty of Arts, York University, Toronto, Ontario, Canada
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Calvin Law
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Greig
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anaesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
145
|
Amaya F. A good beginning makes a good ending: association between acute pain trajectory and chronic postsurgical pain. J Anesth 2018; 32:789-791. [PMID: 30367240 DOI: 10.1007/s00540-018-2570-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/18/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Fumimasa Amaya
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto, 6028566, Japan.
| |
Collapse
|
146
|
Schnabel A. Acute neuropathic pain and the transition to chronic postsurgical pain. Pain Manag 2018; 8:317-319. [PMID: 30280642 DOI: 10.2217/pmt-2018-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1A, 48149 Muenster, Germany.,Department of Anaesthesiology, University Hospital of Wuerzburg, Oberdürrbacherstr. 6, 97080 Würzburg, Germany
| |
Collapse
|
147
|
Gibson E, Sabo MT. Can pain catastrophizing be changed in surgical patients? A scoping review. Can J Surg 2018; 61:311-318. [PMID: 30246983 PMCID: PMC6153100 DOI: 10.1503/cjs.015417] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2018] [Indexed: 12/12/2022] Open
Abstract
Background Catastrophizing, a coping style characterized by an exaggerated negative affect when experiencing or anticipating pain, is an important factor that adversely affects surgical outcomes. Various interventions have been attempted with the goal of reducing catastrophizing and, by extension, improving treatment outcomes. We performed a systematic review to determine whether catastrophizing can be altered in surgical patients and to present evidence for interventions aimed at reducing catastrophizing in this population. Methods Using a scoping design, we performed a systematic search of MEDLINE and Embase. Studies reporting original research measuring catastrophizing, before and after an intervention, on the Pain Catastrophizing Scale (PCS) or Coping Strategies Questionnaire (CSQ) were selected. Studies were assessed for quality, the nature of the intervention and the magnitude of the effect observed. Results We identified 47 studies that measured the change in catastrophizing score following a broad range of interventions in surgical patients, including surgery, patient education, physiotherapy, cognitive behavioural therapy, psychologist-directed therapy, nursing-directed therapy and pharmacological treatments. The mean change in catastrophizing score as assessed with the PCS ranged from 0 to –19, and that with the CSQ, from +0.07 to –13. Clinically important changes in catastrophizing were observed in 7 studies (15%). Conclusion Catastrophizing was observed to be modifiable with an intervention in a variety of surgical patient populations. Some interventions produced greater reductions than others, which will help direct future research in the improvement of surgical outcomes.
Collapse
Affiliation(s)
- Eric Gibson
- From the Faculty of Kinesiology (Gibson), the Section of Orthopaedic Surgery, Department of Surgery (Sabo) and the South Campus Research Unit for Bone & Soft Tissue (Gibson, Sabo), University of Calgary, Calgary, Alta
| | - Marlis T. Sabo
- From the Faculty of Kinesiology (Gibson), the Section of Orthopaedic Surgery, Department of Surgery (Sabo) and the South Campus Research Unit for Bone & Soft Tissue (Gibson, Sabo), University of Calgary, Calgary, Alta
| |
Collapse
|
148
|
Dindo L, Zimmerman MB, Hadlandsmyth K, StMarie B, Embree J, Marchman J, Tripp-Reimer T, Rakel B. Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study. THE JOURNAL OF PAIN 2018; 19:1211-1221. [PMID: 29777950 PMCID: PMC6163061 DOI: 10.1016/j.jpain.2018.04.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/18/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022]
Abstract
High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in "at-risk" veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. PERSPECTIVE This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.
Collapse
Affiliation(s)
- Lilian Dindo
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas; Center for Innovations, Quality, and Effectiveness, Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas.
| | | | | | | | - Jennie Embree
- College of Nursing, University of Iowa, Iowa City, Iowa
| | - James Marchman
- Department of Psychology, University of Iowa, Iowa City, Iowa
| | | | - Barbara Rakel
- College of Nursing, University of Iowa, Iowa City, Iowa
| |
Collapse
|
149
|
Giummarra MJ, Black O, Smith P, Collie A, Hassani-Mahmooei B, Arnold CA, Gong J, Gabbe BJ. A population-based study of treated mental health and persistent pain conditions after transport injury. Injury 2018; 49:1787-1795. [PMID: 30154021 DOI: 10.1016/j.injury.2018.08.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Persistent pain and mental health conditions often co-occur after injury, cause enormous disability, reduce social and economic participation, and increase long-term healthcare costs. This study aimed to characterise the incidence, profile and healthcare cost implications for people who have a treated mental health condition, persistent pain, or both conditions, after compensable transport injury. METHODS The study comprised a population cohort of people who sustained a transport injury (n = 74,217) between 2008 to 2013 and had an accepted claim in the no-fault transport compensation system in Victoria, Australia. Data included demographic and injury characteristics, and payments for treatment and income replacement from the Compensation Research Database. Treated conditions were identified from 3 to 24-months postinjury using payment-based criteria developed with clinical and compensation system experts. Criteria included medications for pain, anxiety, depression or psychosis, and services from physiotherapists, psychologists, psychiatrists, and pain specialists. The data were analysed with Cox Proportional Hazards regression to examine rates of treated conditions, and general linear regression to estimate 24 month healthcare costs. RESULTS Overall, the incidence of treated mental health conditions (n = 2459, 3.3%) and persistent pain (n = 4708, 6.3%) was low, but rates were higher in those who were female, middle aged (35-64 years), living in metropolitan areas or neighbourhoods with high socioeconomic disadvantage, and for people who had a more severe injury. Healthcare costs totalled more than $A707 M, and people with one or both conditions (7.7%) had healthcare costs up to 7-fold higher (adjusting for demographic and injury characteristics) in the first 24 months postinjury than those with neither condition. CONCLUSIONS The incidence of treated mental health and persistent pain conditions was low, but the total healthcare costs for people with treated conditions were markedly higher than for people without either treated condition. While linkage with other public records of treatment was not possible, the true incidence of treated conditions is likely to be even higher than that found in this study. The present findings can be used to prioritise the implementation of timely access to treatment to prevent or attenuate the severity of pain and mental health conditions after transport injury.
Collapse
Affiliation(s)
- Melita J Giummarra
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Caulfield Pain Management and Research Centre, Caulfield Hospital, Caulfield, Victoria, Australia; Institute for Safety, Compensation and Recovery Research, Monash University, Melbourne, Victoria, Australia.
| | - Oliver Black
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Smith
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Institute for Work and Health, Toronto, Ontario, Canada
| | - Alex Collie
- Insurance, Work and Health Group, Monash University, Melbourne, Victoria, Australia
| | | | - Carolyn A Arnold
- Caulfield Pain Management and Research Centre, Caulfield Hospital, Caulfield, Victoria, Australia; Academic Board of Anaesthesia & Perioperative Medicine, School of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Jennifer Gong
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Farr Institute, Swansea University Medical School, Swansea University, Wales, UK
| |
Collapse
|
150
|
Clarke H, Azargive S, Montbriand J, Nicholls J, Sutherland A, Valeeva L, Boulis S, McMillan K, Ladak SSJ, Ladha K, Katznelson R, McRae K, Tamir D, Lyn S, Huang A, Weinrib A, Katz J. Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service. Can J Pain 2018; 2:236-247. [PMID: 35005382 PMCID: PMC8730554 DOI: 10.1080/24740527.2018.1501669] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 12/19/2022]
Abstract
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. Opioid-naïve 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 opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.
Collapse
Affiliation(s)
- Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Saam Azargive
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Queen’s School of Medicine, Faculty of Health Sciences, Queen’s University, Kingston, Canada
| | - Janice Montbriand
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Judith Nicholls
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Hospital, Bridgetown, Barbados
- Cave Hill Campus, University of the West Indies, Wanstead, Barbados
| | - Ainsley Sutherland
- Department of Anesthesiology, St. Paul’s Hospital, Providence Health Care, Vancouver, Canada
| | - Liliya Valeeva
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | | | | | - Salima S. J. Ladak
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Karim Ladha
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Rita Katznelson
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Karen McRae
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Diana Tamir
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sheldon Lyn
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Alexander Huang
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Aliza Weinrib
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anesthesia, University of Toronto, Toronto, Canada
- Canada Research Chair in Health Psychology, Department of Psychology, York University, Toronto, Canada
| |
Collapse
|