151
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Scott W, McCracken LM. Psychological assessment to identify patients at risk of postsurgical pain: the need for theory and pragmatism. Br J Anaesth 2018; 117:546-548. [PMID: 27799167 DOI: 10.1093/bja/aew335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- W Scott
- Department of Psychology, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - L M McCracken
- Department of Psychology, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.,INPUT Pain Management, Guy's and St Thomas' NHS Foundation Trust, London, UK
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152
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Bjørnnes AK, Lie I, Parry M, Falk R, Leegaard M, Rustøen T, Valeberg BT. Association between self-perceived pain sensitivity and pain intensity after cardiac surgery. J Pain Res 2018; 11:1425-1432. [PMID: 30122973 PMCID: PMC6078187 DOI: 10.2147/jpr.s167524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and purpose Cardiac surgical pain remains a clinical challenge affecting about 40% of individuals in the first six months post-cardiac surgery, and continues up to two years after surgery for about 15–20%. Self-perceived sensitivity to pain may help to identify individuals at risk for persistent cardiac surgical pain to optimize health care responses. The purpose of this study was to assess the relationship between self-perceived pain sensitivity assessed by the Pain Sensitivity Questionnaire (PSQ) and postoperative worst pain intensity up to 12 months after cardiac surgery. Sex differences in baseline characteristics and the PSQ scores were also assessed. Methods This study was performed among 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery between March 2012 and September 2013. A secondary data-analysis was utilized to explore the relationship between preoperative PSQ scores and worst pain intensity rated preoperatively, across postoperative Days 1–4, at 2 weeks, and at 1, 3, 6, and 12 months post-surgery. Linear mixed model analyses were performed to estimate changes in pain intensity during 1-year follow-up. Results The mean (±standard deviation) PSQ-total score was 3.3±1.4, with similar scores in men and women. The PSQ-total score was significantly associated with higher worst pain intensity ratings adjusted for participant characteristics (p=0.001). Conclusion Use of the PSQ before surgery may predict cardiac surgical pain intensity. However, previous evidence is limited and not consistent, and more research is needed to substantiate our results.
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Affiliation(s)
- Ann Kristin Bjørnnes
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway, .,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada,
| | - Irene Lie
- Center for Patient Centered Heart and Lung Research, Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada,
| | - Ragnhild Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Marit Leegaard
- OsloMet - Oslo Metropolitan University, Faculty of Health Sciences, Institute of Nursing, Oslo, Norway
| | - Tone Rustøen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway, .,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Berit Taraldsen Valeberg
- OsloMet - Oslo Metropolitan University, Faculty of Health Sciences, Institute of Nursing, Oslo, Norway
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153
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[Persistent postsurgical pain in children and young people : Prediction, prevention, and management]. Schmerz 2018; 32:293-300. [PMID: 29992500 DOI: 10.1007/s00482-018-0308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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154
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155
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Kornilov N, Lindberg MF, Gay C, Saraev A, Kuliaba T, Rosseland LA, Lerdal A. Higher physical activity and lower pain levels before surgery predict non-improvement of knee pain 1 year after TKA. Knee Surg Sports Traumatol Arthrosc 2018; 26:1698-1708. [PMID: 28916991 DOI: 10.1007/s00167-017-4713-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/08/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to describe patterns of pain during the first year following total knee arthroplasty (TKA) and evaluate pre- and postoperative factors associated with pain and patient satisfaction at 1 year. It was hypothesized that more severe preoperative pain would be associated with more residual pain and lower patient satisfaction 1 year after surgery. METHODS A longitudinal cohort study was performed with repeated measures of pain (0-10 numeric rating scale) and evaluation of other self-reported symptoms (Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Score), daily functioning (Lawton Instrumental Activities of Daily Living Scale), quality of life (EQ-5D-3L), knee function (KSS Knee and Function Score), perioperative and clinical characteristics (e.g. surgery duration, brand of implant, comorbidities), biochemical parameters (haemoglobin, C-reactive protein, creatinine), and patient satisfaction (20-item scale). Post-surgical improvement was defined as at least a two-point decrease in the patient's rating of pain interference with walking from baseline to 1 year. Hundred patients (mean age 64 ± 8 years and 93% female) consecutively admitted for uncomplicated primary TKA participated, and 79 with complete data were included in this analysis. RESULTS Pain generally decreased during the first postoperative year, from an average rating of 6 (SD = 3) to 1 (SD = 2). However, 18 of the 79 patients experienced no improvement in pain from baseline to 1 year. Factors associated with non-improvement of pain interference with walking after TKA included lower preoperative ratings of pain interference with walking (p < 0.001) and lower preoperative ratings of average pain (p = 0.004), active or very active levels of preoperative physical activity (p = 0.017), and higher ratings of worst pain on the first three postoperative days (p = 0.028). Pain at 1 year was the only predictor of lower patient satisfaction at 1 year. CONCLUSIONS Patients with low preoperative pain ratings or high preoperative levels of physical activity are at increased risk of non-improvement in knee pain after TKA. This finding should be taken into consideration when selecting appropriate candidates for TKA surgery. Orthopaedic surgeons should pay particular attention to patients reporting low pain interference with walking and consider other conservative or surgical treatment options before TKA. Effective strategies for detection and treatment of TKA patients with high pain ratings at early follow-up visits also need to be developed. LEVEL OF EVIDENCE Prognostic study, Level II.
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Affiliation(s)
- Nikolai Kornilov
- Department of Knee Surgery N 17, Russian Research Institute of Traumatology and Orthopaedics n.a. R.R. Vreden, Saint-Petersburg, Russia, 195427.
| | - Maren Falch Lindberg
- Department of Surgery, Lovisenberg Diakonale Hospital, 0440, Oslo, Norway.,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318, Oslo, Norway
| | - Caryl Gay
- Department of Family Health Care Nursing, University of California, San Francisco, CA, 94143-0606, USA.,Department of Research and Development, Lovisenberg Diakonale Hospital, 0440, Oslo, Norway
| | - Alexander Saraev
- Department of Knee Surgery N 17, Russian Research Institute of Traumatology and Orthopaedics n.a. R.R. Vreden, Saint-Petersburg, Russia, 195427
| | - Taras Kuliaba
- Department of Knee Surgery N 10, Russian Research Institute of Traumatology and Orthopaedics n.a. R.R. Vreden, Saint-Petersburg, Russia, 195427
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, 0424, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Anners Lerdal
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318, Oslo, Norway.,Department of Research and Development, Lovisenberg Diakonale Hospital, 0440, Oslo, Norway
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Pang J, Tringale KR, Tapia VJ, Panuganti BA, Qualliotine JR, Jafari A, Haft SJ, Friedman LS, Furnish T, Brumund KT, Califano JA, Coffey CS. Opioid prescribing practices in patients undergoing surgery for oral cavity cancer. Laryngoscope 2018; 128:2361-2366. [DOI: 10.1002/lary.27215] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/15/2018] [Accepted: 03/13/2018] [Indexed: 02/02/2023]
Affiliation(s)
- John Pang
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Kathryn R. Tringale
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Viridiana J. Tapia
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Bharat A. Panuganti
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Jesse R. Qualliotine
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Aria Jafari
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Sunny J. Haft
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Lawrence S. Friedman
- Department of Medicine; UC San Diego School of Medicine; San Diego California U.S.A
| | - Timothy Furnish
- Department of Anesthesiology; UC San Diego School of Medicine; San Diego California U.S.A
| | - Kevin T. Brumund
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Joseph A. Califano
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
| | - Charles S. Coffey
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; UC San Diego School of Medicine; San Diego California U.S.A
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Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship. Curr Pain Headache Rep 2018; 22:40. [DOI: 10.1007/s11916-018-0694-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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158
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Nicholls JL, Azam MA, Burns LC, Englesakis M, Sutherland AM, Weinrib AZ, Katz J, Clarke H. Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials. Patient Relat Outcome Meas 2018; 9:49-64. [PMID: 29403322 PMCID: PMC5783145 DOI: 10.2147/prom.s121251] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. MATERIALS AND METHODS We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias. RESULTS Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2-3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding. CONCLUSION This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.
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Affiliation(s)
- Judith L Nicholls
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
| | - Muhammad A Azam
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
- Department of Psychology, York University
| | - Lindsay C Burns
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
- Department of Psychology, York University
| | | | - Ainsley M Sutherland
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
| | - Aliza Z Weinrib
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
- Department of Psychology, York University
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
- Department of Psychology, York University
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Stone AB, Wick EC, Wu CL, Grant MC. The US Opioid Crisis: A Role for Enhanced Recovery After Surgery. Anesth Analg 2018; 125:1803-1805. [PMID: 28678072 DOI: 10.1213/ane.0000000000002236] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alexander B Stone
- From the *Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland; and †Department of Surgery, The University of California San Francisco Medical Center, San Francisco, California
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Bjørnnes AK, Parry M, Lie I, Falk R, Leegaard M, Rustøen T. The association between hope, marital status, depression and persistent pain in men and women following cardiac surgery. BMC WOMENS HEALTH 2018; 18:2. [PMID: 29291728 PMCID: PMC5749023 DOI: 10.1186/s12905-017-0501-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 12/19/2017] [Indexed: 02/07/2023]
Abstract
Background Cardiac surgery is a major life event, and outcomes after surgery are associated with men’s and women’s ability to self-manage and cope with their cardiac condition in everyday life. Hope is suggested to impact cardiac health by having a positive effect on how adults cope with and adapt to illness and recommended lifestyle changes. Methods We did a secondary analysis of 416 individuals (23% women) undergoing elective coronary artery bypass graft and/or valve surgery between March 2012 and September 2013 enrolled in randomized controlled trial. Hope was assessed using The Herth Hope Index (HHI) at three, six and 12 months following cardiac surgery. Linear mixed model analyses were performed to explore associations after cardiac surgery between hope, marital status, depression, persistent pain, and surgical procedure. Results For the total sample, no statistically significant difference between global hope scores from 3 to 12 months was observed (ranging from 38.3 ± 5.1 at 3 months to 38.7 ± 5.1 at 12 months), and no differences between men and women were observed at any time points. However, 3 out of 12 individual items on the HHI were associated with significantly lower scores in women: #1) I have a positive outlook toward life, #3) I feel all alone, and #6) I feel scared about my future. Over the study period, diminished hope was associated with older age, lower education, depression prior to surgery, and persistent pain at all measurement points. Isolated valve surgery was positively associated with hope. While neither sex nor marital status, as main effects, demonstrated significant associations with hope, women who were divorced/widowed/single were significantly more likely to have lower hope scores over the study period. Conclusion Addressing pain and depression, and promoting hope, particularly for women living alone may be important targets for interventions to improve outcomes following cardiac surgery. Trial registration Clinical Trials gov Identifier: NCT01976403. Date of registration: November 28, 2011.
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Affiliation(s)
- Ann Kristin Bjørnnes
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Ullevål, P.O Box 4956, Nydalen, 0424, Oslo, Norway. .,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Irene Lie
- Center for patient centered heart- and lung research, Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, P.O Box 4956, Nydalen, 0424, Oslo, Norway
| | - Ragnhild Falk
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Ullevål, P.O Box 4956, Nydalen, 0424, Oslo, Norway
| | - Marit Leegaard
- Faculty of Health Sciences, Institute of Nursing, Oslo and Akershus University College of Applied Sciences, P.O Box 4, St. Olavs Plass, N-0130, Oslo, Norway
| | - Tone Rustøen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Ullevål, P.O Box 4956, Nydalen, 0424, Oslo, Norway.,Institute of Health and Society, Oslo University Hospital, Ullevål, P.O Box 4956, Nydalen, 0424, Oslo, Norway
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Abstract
This chapter describes the Manage My Pain digital pain management platform and its integration into the Transitional Pain Service at Toronto General Hospital. A collaboration between ManagingLife, the developer of Manage My Pain, and the Transitional Pain Service led to the creation of a patient-provider virtual community with the aim of managing complex pain after surgery so as to prevent the transition from acute post-surgical pain to chronic post-surgical pain. User engagement, motivation, and satisfaction are discussed with respect to the needs of (1) people living with pain and (2) health care providers. Challenges in implementation are described, along with new features developed for the digital platform as a result of the partnership between ManagingLife and the Transitional Pain Service.
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162
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Parry M, Bjørnnes AK, Clarke H, Cooper L, Gordon A, Harvey P, Lalloo C, Leegaard M, LeFort S, McFetridge-Durdle J, McGillion M, O’Keefe-McCarthy S, Price J, Stinson J, Victor JC, Watt-Watson J. Self-management of cardiac pain in women: an evidence map. BMJ Open 2017; 7:e018549. [PMID: 29175891 PMCID: PMC5719283 DOI: 10.1136/bmjopen-2017-018549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/10/2017] [Accepted: 11/02/2017] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping. DESIGN AND SETTING Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age. INTERVENTIONS Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain. PRIMARY AND SECONDARY OUTCOMES MEASURES Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life. RESULTS The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years. CONCLUSIONS Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain. PROSPERO REGISTRATION NUMBER CRD42016042806.
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Affiliation(s)
- Monica Parry
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Ann Kristin Bjørnnes
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Institute of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Hance Clarke
- Pain Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Lynn Cooper
- Canadian Pain Coalition, Toronto, Ontario, Canada
| | - Allan Gordon
- Wasser Pain Management Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Paula Harvey
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s College Hospital, Women’s College Research Institute, Toronto, Ontario, Canada
| | - Chitra Lalloo
- Hosp Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Marit Leegaard
- Institute of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Sandra LeFort
- School of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | | | | | - Sheila O’Keefe-McCarthy
- Department of Nursing, Faculty of Applied Sciences, BrockUniversity, Toronto, Ontario, Canada
| | - Jennifer Price
- Women’s College Hospital, Women’s College Research Institute, Toronto, Ontario, Canada
| | - Jennifer Stinson
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Hosp Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - J Charles Victor
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Judy Watt-Watson
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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163
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McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond) 2017; 6:19. [PMID: 29201359 PMCID: PMC5700757 DOI: 10.1186/s13741-017-0079-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/31/2017] [Indexed: 01/26/2023] Open
Abstract
The practice of chronic opioid prescription for chronic non-cancer pain has come under considerable scrutiny within the past several years as mounting evidence reveals a generally unfavorable risk to benefit ratio and the nation reels from the grim mortality statistics associated with the opioid epidemic. Patients struggling with chronic pain tend to use opioids and also seek out operative intervention for their complaints, which combination may be leading to increased postoperative "acute-on-chronic" pain and fueling worsened chronic pain and opioid dependence. Besides worsened postoperative pain, a growing body of literature, reviewed herein, indicates that preoperative opioid use is associated with significantly worsened surgical outcomes, and severely increased financial drain on an already severely overburdened healthcare budget. Conversely, there is evidence that preoperative opioid reduction may result in substantial improvements in outcome. In the era of accountable care, efforts such as the Enhanced Recovery After Surgery (ERAS) protocol have been introduced in an attempt to standardize and facilitate evidence-based perioperative interventions to optimize surgical outcomes. We propose that addressing preoperative opioid reduction as part of a targeted optimization approach for chronic pain patients seeking surgery is not only logical but mandatory given the stakes involved. Simple opioid reduction/abstinence however is not likely to occur in the absence of provision of viable and palatable alternatives to managing pain, which will require a strong focus upon reducing pain catastrophization and bolstering self-efficacy and resilience. In response to a call from our surgical community toward that end, we have developed a simple and easy-to-implement outpatient preoperative optimization program focusing on gentle opioid weaning/elimination as well as a few other high-yield areas of intervention, requiring a minimum of resources.
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Affiliation(s)
- Heath McAnally
- Northern Anesthesia & Pain Medicine, LLC, 10928 Eagle River Rd #240, Eagle River, AK 99577 USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Box 356540, Seattle, WA 98195-6540 USA
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164
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Schutzer-Weissmann J, Farquhar-Smith P. Post-herpetic neuralgia - a review of current management and future directions. Expert Opin Pharmacother 2017; 18:1739-1750. [PMID: 29025327 DOI: 10.1080/14656566.2017.1392508] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-herpetic neuralgia (PHN) is common and treatment is often suboptimal with less than half of patients achieving adequate 50% pain relief. As an area of unmet clinical need and as an archetype of neuropathic pain, it deserves the attention of clinicians and researchers. Areas covered: This review summarises the epidemiology, pathophysiology, risk factors and clinical features of varicella infection. It describes the current and possible future management strategies for preventing varicella infection and reactivation and for treating PHN. Expert opinion: A highly successful Varicella Zoster (VZV) vaccine has not been universally adopted due to fears that it may increase Herpes Zoster (HZ) incidence - and thus PHN - in older, unvaccinated generations. This is a controversial theory but advances in the efficacy of vaccines against HZ may allay these fears and encourage more widespread adoption of the VZV vaccine. Treatment of PHN, as for any neuropathic pain, must be multidisciplinary and multimodal. Advances in sensory phenotyping technology and genomics may allow more individualised treatment. Traditional research methodologies are ill-suited to assess the kind of complex interventions that are necessary to achieve better clinical outcomes in this challenging field.
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Affiliation(s)
- John Schutzer-Weissmann
- a Department of Anaesthesia , Critical Care and Pain Medicine, The Royal Marsden Hospital , London , UK
| | - Paul Farquhar-Smith
- a Department of Anaesthesia , Critical Care and Pain Medicine, The Royal Marsden Hospital , London , UK
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165
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Mu A, Weinberg E, Moulin DE, Clarke H. Pharmacologic management of chronic neuropathic pain: Review of the Canadian Pain Society consensus statement. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:844-852. [PMID: 29138154 PMCID: PMC5685445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To provide family physicians with a practical clinical summary of the Canadian Pain Society (CPS) revised consensus statement on the pharmacologic management of neuropathic pain. QUALITY OF EVIDENCE A multidisciplinary interest group within the CPS conducted a systematic review of the literature on the current treatments of neuropathic pain in drafting the revised consensus statement. MAIN MESSAGE Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are the first-line agents for treating neuropathic pain. Tramadol and other opioids are recommended as second-line agents, while cannabinoids are newly recommended as third-line agents. Other anticonvulsants, methadone, tapentadol, topical lidocaine, and botulinum toxin are recommended as fourth-line agents. CONCLUSION Many pharmacologic analgesics exist for the treatment of neuropathic pain. Through evidence-based recommendations, the CPS revised consensus statement helps guide family physicians in the management of patients with neuropathic pain.
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Affiliation(s)
- Alex Mu
- Anesthesiologist in the Pain Research Unit in the Department of Anesthesia at the Toronto General Hospital in Ontario.
| | | | - Dwight E Moulin
- Professor in the Department of Clinical Neurological Sciences and the Department of Oncology at Western University in London, Ont
| | - Hance Clarke
- Assistant Professor in the Department of Anesthesia and in the Transitional Pain Service of the Toronto General Hospital at the University of Toronto
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166
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Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids. Anesth Analg 2017; 125:1653-1657. [DOI: 10.1213/ane.0000000000002280] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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167
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Weinrib AZ, Azam MA, Birnie KA, Burns LC, Clarke H, Katz J. The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management. Br J Pain 2017; 11:169-177. [PMID: 29123661 PMCID: PMC5661689 DOI: 10.1177/2049463717720636] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major surgery continues to be problematic. This article briefly reviews the known psychological risk and protective factors associated with the development of chronic postsurgical pain (CPSP). We begin with a definition of CPSP and then explain what we mean by a risk/protective factor. Next, we summarize known psychological risk and protective factors for CPSP. Psychological interventions that target risk factors and may impact postsurgical pain are reviewed, including the acceptance and commitment therapy (ACT)-based approach to CPSP prevention and management we use in the Transitional Pain Service (TPS) at the Toronto General Hospital. Finally, we conclude with recommendations for research in risk factor identification and psychological interventions to prevent CPSP. Several pre-surgical psychological risk factors for CPSP have been consistently identified in recent years. These include negative affective constructs, such as anxiety symptoms, depressive symptoms, pain catastrophizing and general psychological distress. In contrast, relatively few studies have examined psychological protective factors for CPSP. Psychological interventions that target known psychological risk factors while enhancing protective psychological factors may reduce new incidence of CPSP. The primary goal of our ACT intervention is to teach patients a mindful way of responding to their postsurgical pain that empowers them to interrupt the negative cycle of pain, distress, behavioural avoidance and escalating opioid use that can limit functioning and quality of life while paradoxically amplifying pain over time. Early clinical outcome data suggest that patients who receive care from TPS physicians reduce their pain and opioid use, yet patients who also receive our ACT intervention have a larger decrease in daily opioid dose while reporting less pain interference and lower depression scores.
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Affiliation(s)
- Aliza Z Weinrib
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Muhammad A Azam
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Kathryn A Birnie
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
| | - Lindsay C Burns
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Hance Clarke
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
| | - Joel Katz
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
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168
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Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg 2017; 125:1704-1713. [DOI: 10.1213/ane.0000000000002433] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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169
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Demsey D, Carr NJ, Clarke H, Vipler S. Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period. Plast Reconstr Surg 2017; 140:613e-619e. [PMID: 28953743 PMCID: PMC5783634 DOI: 10.1097/prs.0000000000003742] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Opioid addiction is a public health crisis that affects all areas of medicine. Large numbers of the population across all racial and economic demographics misuse prescription opioids and use illicit opioids. The current understanding is that opioid misuse is a disease that requires treatment, and is not an issue of choice or character. Use of opioid medication is a necessary part of postoperative analgesia, but many physicians are unsure of how to do this safely given the risk of patients developing an opioid misuse disorder. This review gives an update of the current state of the opioid crisis, explains how current surgeons' prescribing practices are contributing to it, and gives recommendations on how to use opioid medication safely in the perioperative period.
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Affiliation(s)
- Daniel Demsey
- Vancouver, British Columbia; and Toronto, Ontario, Canada
- From the Division of Plastic Surgery and the Fraser Health Substance Use Services, University of British Columbia; and the Department of Anaesthesia and Pain Management, University of Toronto, Toronto General Hospital
| | - Nicholas J Carr
- Vancouver, British Columbia; and Toronto, Ontario, Canada
- From the Division of Plastic Surgery and the Fraser Health Substance Use Services, University of British Columbia; and the Department of Anaesthesia and Pain Management, University of Toronto, Toronto General Hospital
| | - Hance Clarke
- Vancouver, British Columbia; and Toronto, Ontario, Canada
- From the Division of Plastic Surgery and the Fraser Health Substance Use Services, University of British Columbia; and the Department of Anaesthesia and Pain Management, University of Toronto, Toronto General Hospital
| | - Sharon Vipler
- Vancouver, British Columbia; and Toronto, Ontario, Canada
- From the Division of Plastic Surgery and the Fraser Health Substance Use Services, University of British Columbia; and the Department of Anaesthesia and Pain Management, University of Toronto, Toronto General Hospital
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170
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Brown M, Farquhar-Smith P. Pain in cancer survivors; filling in the gaps. Br J Anaesth 2017; 119:723-736. [DOI: 10.1093/bja/aex202] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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171
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Breivik H, Skovlund E. More postoperative pain reported by women than by men - Again. Scand J Pain 2017; 12:96-97. [PMID: 28850503 DOI: 10.1016/j.sjpain.2016.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Harald Breivik
- Department of Pain Management and Research, Oslo University Hospital, Norway; Department of Anaesthesiology, Oslo University Hospital, Norway; University of Oslo, Faculty of Medicine, Oslo, Norway.
| | - Eva Skovlund
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
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172
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Persistent postsurgical pain in children and young people: prediction, prevention, and management. Pain Rep 2017; 2:e616. [PMID: 29392231 PMCID: PMC5777679 DOI: 10.1097/pr9.0000000000000616] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 12/03/2022] Open
Abstract
Ensuring optimum preoperative and postoperative pain management should always be a priority in children.
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173
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Abstract
Chronic postoperative pain is a poorly recognized potential outcome from surgery. It affects millions of patients every year, with pain lasting for months to years, resulting in patient suffering and ensuing economic consequences. The operations with the highest incidence of chronic postoperative pain are amputations, thoracotomies, cardiac surgery, and breast surgery. Other risk factors include preoperative pain, psychological factors, demographics, and the intensity of acute postoperative pain. Attempts to prevent chronic postoperative pain have often led to debatable results. This article presents data from recently published studies examining the incidence, risk factors, mechanisms, treatment options, and preventive strategies for chronic postoperative pain in adults. In summary, many of the previously identified risk factors for chronic postoperative pain have been confirmed and some novel ones discovered, such as the importance of the trajectory of acute pain and the fact that catastrophizing may not always be predictive. The incidence of chronic postoperative pain hasn’t changed over time, and there is limited new information regarding an effective preventive therapy. For example, pregabalin may actually cause more harm in certain surgeries. Further research is needed to demonstrate whether multimodal analgesic techniques have the best chance of significantly reducing the incidence of chronic postoperative pain and to determine which combination of agents is best for given surgical types and different patient populations.
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Affiliation(s)
- Darin Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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174
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Schug SA. Pain after Surgery—Acute Becomes Chronic: Might There be a Silver Rocket? Anaesth Intensive Care 2017; 45:439-440. [DOI: 10.1177/0310057x1704500404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S. A. Schug
- University of Western Australia, Perth, Western Australia
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175
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Rai A, Meng H, Weinrib A, Englesakis M, Kumbhare D, Grosman-Rimon L, Katz J, Clarke H. A Review of Adjunctive CNS Medications Used for the Treatment of Post-Surgical Pain. CNS Drugs 2017; 31:605-615. [PMID: 28577135 DOI: 10.1007/s40263-017-0440-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Inadequate post-operative pain management can have significant impacts on patients' quality of life. Effective management of acute pain after surgery is important for early mobilization and discharge from hospital, patient satisfaction, and overall well-being. Utilizing multimodal analgesic strategies has become the mainstay of acute post-operative pain management. A comprehensive search was performed, assessing the published or otherwise publically available literature on different central nervous system (CNS) drugs [excluding opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen] and their uses to treat acute post-surgical pain. Included among the drugs evaluated in this review are anticonvulsants, N-methyl-D-aspartic acid (NMDA) agonists, local anesthetics, α2-agonists, cannabinoids, serotonin-noradrenaline reuptake inhibitors (SNRIs), and serotonin-noradrenaline-dopamine reuptake inhibitors (SNDRIs). Timing, dosing, routes of administration, as well as mechanisms of action are discussed for these CNS drugs.
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Affiliation(s)
- Ajit Rai
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Howard Meng
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada
| | - Aliza Weinrib
- Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Marina Englesakis
- Library and Information Services, Toronto General HospitalUniversity Health Network, 1 EN-418, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Dinesh Kumbhare
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Liza Grosman-Rimon
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada.,Department of Psychology, York University, 4700, Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 3 EB-317, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. .,Department of Anesthesia, University of Toronto, RM 1200, 12th floor, 123 Edward St., Toronto, Ontario, M5G 1E2, Canada. .,Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
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176
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Impact of marital status and comorbid disorders on health-related quality of life after cardiac surgery. Qual Life Res 2017; 26:2421-2434. [PMID: 28484915 DOI: 10.1007/s11136-017-1589-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE To explore associations between HRQL, marital status, and comorbid disorders in men and women following cardiac surgery. METHOD A secondary analysis was completed using data from a randomized controlled trial in which 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery were recruited between March 2012 and September 2013. HRQL was assessed using the Health State Descriptive System (15D) preoperatively, then at 2 weeks, and at 3, 6, and 12 months following cardiac surgery. Linear mixed model analyses were performed to explore associations between HRQL, social support, and comorbid disorders. RESULTS The overall 15D scores for the total sample improved significantly from 2 weeks to 3 months post surgery, with only a gradual change observed from 3 to 12 months. Thirty percent (n = 92) of the total sample reported a lower 15D total score at 12 months compared to preoperative status, of whom 78% (n = 71) had a negative minimum important differences (MID), indicating a worse HRQL status. When adjusted for age and marital status, women had statistically significant lower 15D total scores compared to men at 3, 6, and 12 months post surgery. Compared to pre-surgery, improvement was demonstrated in 4 out of 15 dimensions of HRQL for women, and in 6 out of 15 dimensions for men at 12 months post surgery. Both men and women associated back/neck problems, depression, and persistent pain intensity with lower HRQL; for women, not living with a partner/spouse was associated with lower HRQL up to 12 months. CONCLUSION Women experienced decreased HRQL and a slower first-year recovery following cardiac surgery compared to men. This study demonstrates a need for follow-up and support to help women manage their symptoms and improve their function within the first year after cardiac surgery. This was particularly pronounced for those women living alone.
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177
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Systematic Review of Liposomal Bupivacaine (Exparel) for Postoperative Analgesia. Plast Reconstr Surg 2017; 138:748e-756e. [PMID: 27673545 DOI: 10.1097/prs.0000000000002547] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of postoperative pain often requires multimodal approaches. Suboptimal dosages of current therapies can leave patients experiencing periods of insufficient analgesia, often requiring rescue therapy. With absence of a validated and standardized approach to pain management, further refinement of treatment protocols and targeted therapeutics is needed. Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system. The effectiveness of liposomal bupivacaine has not been systematically analyzed relative to conventional treatments in plastic surgery. METHODS A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through October of 2015 with search terms related to liposomal bupivacaine and filtered for relevance to postoperative pain control in plastic surgery. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS A total of eight articles were selected and reviewed from 160 identified. Articles covered a variety of techniques using liposomal bupivacaine for postoperative pain management. Four hundred five patients underwent procedures (including breast reconstruction, augmentation mammaplasty, abdominal wall reconstruction, mastectomy, and abdominoplasty) where pain was managed with liposomal bupivacaine and compared with those receiving traditional pain management. Liposomal bupivacaine use showed adequate safety and tolerability and, compared to traditional protocols, was equivalent or more effective in postoperative pain management. CONCLUSION Liposomal bupivacaine is a safe method for postoperative pain control in the setting of plastic surgery and may represent an alternative to more invasive pain management systems such as patient-controlled analgesia, epidurals, peripheral nerve catheters, or intravenous narcotics.
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178
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Weinrib AZ, Burns LC, Mu A, Azam MA, Ladak SSJ, McRae K, Katznelson R, Azargive S, Tran C, Katz J, Clarke H. A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone. J Pain Res 2017; 10:747-755. [PMID: 28392713 PMCID: PMC5376151 DOI: 10.2147/jpr.s124566] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.
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Affiliation(s)
- Aliza Z Weinrib
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Psychology, York University
| | - Lindsay C Burns
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Psychology, York University
| | - Alex Mu
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
| | - Muhammad Abid Azam
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Psychology, York University
| | - Salima SJ Ladak
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
| | - Karen McRae
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rita Katznelson
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Saam Azargive
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
| | - Cieran Tran
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
| | - Joel Katz
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Psychology, York University
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
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179
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Rosenbloom BN, McCartney CJL, Canzian S, Kreder HJ, Katz J. Predictors of Prescription Opioid Use 4 Months After Traumatic Musculoskeletal Injury and Corrective Surgery: A Prospective Study. THE JOURNAL OF PAIN 2017; 18:956-963. [PMID: 28347798 DOI: 10.1016/j.jpain.2017.03.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/13/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
The aim of the present study was to examine the incidence and predictors of persistent prescription opioid use 4 months after traumatic injury. Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4 months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information. The sample consisted of 122 patients (66.4% male; mean age = 44.8 years, SD = 17.1), of whom 94.3% (n = 115) were using prescription opioids. At T2, 35.3% (n = 43) patients were using prescription opioids. After controlling for age, sex, injury severity, T1 pain severity, and T2 symptoms of depression, 2 factors emerged as significantly related to T2 prescription opioid use; namely, T2 pain severity (odds ratio = 1.248, 95% confidence interval, 1.071-1.742) and T2 pain self-efficacy (odds ratio = .943, 95% confidence interval, .903-.984). These results suggest that opioid use after traumatic musculoskeletal injury is related to pain severity and how well patients cope specifically with their pain, over and above other psychological factors, such as depression and anxiety. PERSPECTIVE This article identifies predictive factors for prescription opioid use after traumatic musculoskeletal injury, namely severe pain and a poor sense of control over the pain. These results highlight the importance of using prospective longitudinal study designs to understand why patients continue to use prescription opioids after major tissue-damaging events.
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Affiliation(s)
- Brittany N Rosenbloom
- Institute of Medical Science, Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada.
| | - Colin J L McCartney
- Institute of Medical Science, Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sonya Canzian
- Trauma and Neurosurgery Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hans J Kreder
- Division of Orthopedics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Joel Katz
- Institute of Medical Science, Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada
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180
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Wentlandt K, Dall'Osto A, Freeman N, Le LW, Kaya E, Ross H, Singer LG, Abbey S, Clarke H, Zimmermann C. The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant 2016; 30:1591-1596. [PMID: 27910190 DOI: 10.1111/ctr.12838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 12/20/2022]
Abstract
Although patients within a transplant program are awaiting or have received disease modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized palliative care services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing palliative care resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory palliative care for these patients and there have been no descriptions of programs delivering such care in the medical literature. We outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated palliative care to patients awaiting and receiving organ transplantation.
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Affiliation(s)
- Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Angela Dall'Osto
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Nicole Freeman
- Department of Family Medicine [Windsor Program], Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ebru Kaya
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Abbey
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Pain Research Unit and the Transitional Pain Service, Department of Anaesthesia, University Health Network, Toronto, ON, Canada.,Department of Anaesthesia, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Campbell Family Cancer Research Institute, Ontario Cancer Institute, Toronto, ON, Canada
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181
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Huang A, Azam A, Segal S, Pivovarov K, Katznelson G, Ladak SS, Mu A, Weinrib A, Katz J, Clarke H. Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service. Pain Manag 2016; 6:435-43. [PMID: 27381204 DOI: 10.2217/pmt-2016-0004] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital. METHODS 200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery. RESULTS 51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood. CONCLUSION Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.
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Affiliation(s)
- Alexander Huang
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
| | - Abid Azam
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Shira Segal
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Pivovarov
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gali Katznelson
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
| | - Salima Sj Ladak
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
| | - Alex Mu
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada
| | - Aliza Weinrib
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario Canada
| | - Hance Clarke
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario Canada
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Suffeda A, Meissner W, Rosendahl J, Guntinas-Lichius O. Influence of depression, catastrophizing, anxiety, and resilience on postoperative pain at the first day after otolaryngological surgery: A prospective single center cohort observational study. Medicine (Baltimore) 2016; 95:e4256. [PMID: 27428236 PMCID: PMC4956830 DOI: 10.1097/md.0000000000004256] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The aim was to assess the association between objectified preoperative psychological factors and postoperative pain at the first day after otolaryngological surgery in accordance with other predictors of postoperative pain. Eighty-two (82) patients (59% male, median age 56 years) were included between January and May 2015. The psychological assessment the day before surgery included the Patient Health Questionnaire (PHQ-9), pain catastrophizing scale (PCS), State-Trait Operation Anxiety (STOA) inventory, and the resilience scale (RS-13). On first postoperative day, patients were rated their pain using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's maximal pain. QUIPS allowed standardized assessment of patients' characteristics, pain parameters, and outcome. The influence of preoperative and postoperative parameters on patients' maximal postoperative pain was estimated by univariate and multivariate statistical analysis. The mean maximal pain was 3.2 ± 2.9. In univariate analysis, higher PHQ-9 score more than 4 (P = 0.010), higher STOA trait anxiety (P = 0.044), and higher STOA total score (P = 0.043) were associated to more postoperative pain. In multivariate analysis higher PHQ-9 score remained an independent predictor for severe pain (beta = 0.302; 95% confidence interval [CI]: 0.054-0.473; P = 0.014). When all parameters were included into multivariate analysis, 2 of all somatic, psychological, and treatment factors were associated with severe maximal pain: more depression (PHQ-9; beta = 0.256; 95% CI: 0.042-0.404; P = 0.017), and use of opioids in the recovery room (beta = 0.371; 95% CI: 0.108-0.481; P = 0.002). Otolaryngological surgery covers the spectrum from low to severe postoperative pain and is therefore a good model for pain management studies. A set of somatic and psychological parameters seems to allow the identification of patients with higher risk for more postoperative pain. This should help to individualize and improve the perioperative pain management.
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Affiliation(s)
| | | | - Jenny Rosendahl
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Germany
| | - Orlando Guntinas-Lichius
- Department of Otorhinolaryngology
- Correspondence: Orlando Guntinas-Lichius, Department of Otorhinolaryngology, Jena University Hospital, Lessingstrasse 2, D-07740 Jena, Germany (e-mail: )
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Tiippana E, Hamunen K, Heiskanen T, Nieminen T, Kalso E, Kontinen VK. New approach for treatment of prolonged postoperative pain: APS Out-Patient Clinic. Scand J Pain 2016; 12:19-24. [DOI: 10.1016/j.sjpain.2016.02.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/07/2016] [Accepted: 02/20/2016] [Indexed: 10/22/2022]
Abstract
Abstract
Background and aims
Persistent postoperative pain (PPP) is a significant clinical problem. Several patient-related risk factors for PPP have been identified, including a previous chronic pain problem, young age, female gender and psychological vulnerability. Intra- and postoperative risk factors include surgical complications such as infections, haematoma, nerve damage and repeated surgery. As the length of hospital stay has been shortened, some patients may be discharged despite ongoing pain and insufficient analgesic medication. The challenge is to identify patients at high risk of developing PPP and to create a targeted care pathway to ensure effective and safe pain treatment especially in the subacute postoperative phase at home. This observational study describes the first two years of the Acute Pain Service Out-Patient Clinic (APS-OPC) at the Helsinki University Hospital.
Methods
Patient characteristics, known risk factors, and details of treatment of PPP for the first 200 patients referred to our APS-OPC were retrospectively collected from the medical records. The APS-OPC clinic functions in close collaboration with the Multidisciplinary Pain Clinic (MPC), and the number of patients in need of physiotherapist, psychologist or psychiatrist counselling was recorded, as well as the number of patients referred to the MPC for further PPP management.
Results
Patients were referred to the APS-OPC from different surgical specialities, the two most common being thoracic and orthopaedic surgery. Seventy per cent of the patients (139/200) presented symptoms indicating neuropathic postsurgical pain. The patients had, on average, five risk factors for PPP. The median time from surgery to the first contact to the APS-OPC was two months, and the median duration of follow-up was 2.8 months (0–16 months). The median number of contacts with APS-OPC was 3 (range 1–14). Every fourth patient needed only one contact to the APS-OPC. Nineteen per cent of the patients had an appointment with the physiotherapist and 20% with a psychologist or psychiatrist. At discharge after surgery, 54% of the patients were using weak opioids, 32% strong opioids and 71% gabapentinoids; at discharge from the APS-OPC, these numbers were 20%, 6% and 43%, respectively. Twenty-two per cent of the patients were referred to the MPC for further pain management.
Conclusions
The APS-OPC provides a fluent fast-track method of ensuring effective multimodal analgesia in the subacute recovery phase after surgery. Even strong opioids can be safely used after discharge and then tapered off in close supervision of the APS-OPC anaesthesiologist. As the APS-OPC was implemented in close collaboration with the MPC, the multidisciplinary resources are easily available during the course of the APS-OPC treatment.
Implications
The first two years of the APS-OPC have shown that a significant number of surgical patients benefit from continuing active pain management after discharge from hospital. This fast-track service provides physician-supervised titration of analgesics to improve pain relief in the subacute phase. An important task of the APS-OPC is to ensure that strong opioids are not inappropriately continued after recovery. Another goal of the APS-OPC is to identify patients in need of multidisciplinary pain management services to prevent chronification.
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Affiliation(s)
- Elina Tiippana
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Katri Hamunen
- Division of Pain Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Tarja Heiskanen
- Division of Pain Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Teija Nieminen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Eija Kalso
- Division of Pain Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Vesa K. Kontinen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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184
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Important development: Extended Acute Pain Service for patients at high risk of chronic pain after surgery. Scand J Pain 2016; 12:58-59. [DOI: 10.1016/j.sjpain.2016.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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185
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Clarke H. Transitional Pain Medicine: novel pharmacological treatments for the management of moderate to severe postsurgical pain. Expert Rev Clin Pharmacol 2016; 9:345-9. [DOI: 10.1586/17512433.2016.1129896] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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