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Giummarra MJ, Reeder S, Williams S, Devlin A, Knol R, Ponsford J, Arnold CA, Konstantatos A, Gabbe BJ, Clarke H, Katz J, Mitchell F, Robinson E, Zatzick D. Stepped collaborative care for pain and posttraumatic stress disorder after major trauma: a randomized controlled feasibility trial. Disabil Rehabil 2024; 46:3643-3659. [PMID: 37706486 PMCID: PMC10937328 DOI: 10.1080/09638288.2023.2254235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 06/29/2023] [Accepted: 08/27/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE To examine feasibility and acceptability of providing stepped collaborative care case management targeting posttraumatic stress disorder (PTSD) and pain symptoms after major traumatic injury. MATERIALS AND METHODS Participants were major trauma survivors in Victoria, Australia, at risk of persistent pain or PTSD with high baseline symptoms. Participants were block-randomized, stratified by compensation-status, to the usual care (n = 15) or intervention (n = 17) group (46% of eligible patients). The intervention was adapted from existing stepped collaborative care interventions with input from interdisciplinary experts and people with lived experience in trauma and disability. The proactive case management intervention targeted PTSD and pain management for 6-months using motivational interviewing, cognitive behavioral therapy strategies, and collaborative care. Qualitative interviews explored intervention acceptability. RESULTS Intervention participants received a median of 7 h case manager contact and reported that they valued the supportive and non-judgmental listening, and timely access to effective strategies, resources, and treatments post-injury from the case manager. Participants reported few disadvantages from participation, and positive impacts on symptoms and recovery outcomes consistent with the reduction in PTSD and pain symptoms measured at 1-, 3- and 6-months. CONCLUSIONS Stepped collaborative care was low-cost, feasible, and acceptable to people at risk of PTSD or pain after major trauma.IMPLICATIONS FOR REHABILITATIONAfter hospitalization for injury, people can experience difficulty accessing timely support to manage posttraumatic stress, pain and other concerns.Stepped case management-based interventions that provide individualized support and collaborative care have reduced posttraumatic stress symptom severity for patients admitted to American trauma centers.We showed that this model of care could be adapted to target pain and mental health in the trauma system in Victoria, Australia.The intervention was low cost, acceptable and highly valued by most participants who perceived that it helped them use strategies to better manage post-traumatic symptoms, and to access clinicians and treatments relevant to their needs.
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Affiliation(s)
- Melita J. Giummarra
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Caulfield Pain Management and Research Centre, Caulfield Hospital, Alfred Health, Caulfield, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Sandra Reeder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Scott Williams
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Caulfield Pain Management and Research Centre, Caulfield Hospital, Alfred Health, Caulfield, Australia
| | - Anna Devlin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rose Knol
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Social Work, Alfred Health, Melbourne, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Clayton, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Australia
| | - Carolyn A. Arnold
- Caulfield Pain Management and Research Centre, Caulfield Hospital, Alfred Health, Caulfield, Australia
- Academic Board of Anaesthesia & Perioperative Medicine, School of Medicine Nursing & Health Sciences, Monash University, Clayton, Australia
| | - Alex Konstantatos
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
| | - Belinda J. Gabbe
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Health Data Research UK, Swansea University Medical School, Singleton Park, Swansea University, Swansea, UK
| | - Hance Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Transitional Pain Service, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joel Katz
- Department of Anaesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Transitional Pain Service, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Psychology, York University, Toronto, Canada
| | - Fiona Mitchell
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Patient and Carer Coinvestigators with Lived Experience of Trauma, Australia
| | - Elizabeth Robinson
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Patient and Carer Coinvestigators with Lived Experience of Trauma, Australia
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of WA School of Medicine, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA, USA
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Pagé MG, Katz J, Darville R, Gabriel G, Ladha KS, Huang A, Ganty P, Katznelson R, Tamir D, Fiorellino J, Kahn M, Tao L, Slepian M, Wieskopf J, Clarke H. One-year opioid consumption trajectories among individuals receiving multidisciplinary postsurgical care: a single-center observational study from the Toronto General Hospital Transitional Pain Service. Reg Anesth Pain Med 2024:rapm-2024-105344. [PMID: 39084703 DOI: 10.1136/rapm-2024-105344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/19/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION The Transitional Pain Service (TPS) is an innovative, personalized approach to postsurgical opioid consumption and pain management. The objectives of this study were to identify trajectories of opioid consumption and pain intensity within 12 months after initiating treatment through the TPS, identify biopsychosocial factors associated with trajectory membership, and examine the relationship between trajectory membership and other outcomes of interest over the same 12-month period. METHODS Consecutive patients referred to the TPS were included in the present study (n=466). After providing informed consent, they completed self-report questionnaires at the initial visit at the TPS (either pre surgery or post surgery) and at every TPS visit until 12 months. Growth mixture modeling was used to derive trajectories and identify associated factors. RESULTS Results showed three distinct opioid consumption trajectories for both presurgical opioid consumers and opioid-naïve patients. These trajectories all decreased over time and among those who were consuming opioids before surgery that returned to presurgical levels. Being man, having a substance use disorder, or reporting higher levels of pain interference were associated with higher daily opioid consumption for presurgical opioid consumers. For presurgical opioid-naïve individuals, higher opioid consumption trajectories were associated with higher levels of psychological distress. Five pain intensity trajectories were identified, and there were no significant association between opioid consumption and pain intensity trajectories. CONCLUSIONS Results suggest that opioid consumption and pain intensity trajectories mostly decrease after surgery in a high-risk population enrolled in a TPS. Results also show heterogeneity in postsurgical recovery and highlight the importance of using personalized interventions to optimize individual trajectories.
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Affiliation(s)
- M Gabrielle Pagé
- Research Center, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Joel Katz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Rasheeda Darville
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Gretchen Gabriel
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Huang
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Praveen Ganty
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Diana Tamir
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joseph Fiorellino
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Michael Kahn
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Leeping Tao
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Maxwell Slepian
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | | | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontaio, Canada
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Sullivan MD, Katers L, Wang J, Arbabi S, Tauben D, Baldwin LM. A randomized trial of collaborative support for opioid taper after trauma hospitalization. Subst Abuse Treat Prev Policy 2024; 19:33. [PMID: 38915106 PMCID: PMC11197264 DOI: 10.1186/s13011-024-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024] Open
Abstract
The COTAT (Collaborative Opioid Taper After Trauma) Study was a randomized trial of an opioid taper support program using a physician assistant (PA) to provide pain and opioid treatment guidance to primary care providers assuming care for adult patients with moderate to severe trauma discharged from a Level I trauma center on opioid therapy. Patients were recruited, assessed, and randomized individually by a surgery research recruitment team one to two days prior to discharge to home. Participants randomized to the opioid taper support program were contacted by phone within a few days of discharge by the PA interventionist to confirm enrollment and their primary care provider (PCP). The intervention consisted of PA support as needed to the PCP concerning pain and opioid care at weeks 1, 2, 4, 8, 12, 16, and 20 after discharge or until the PCP office indicated they no longer needed support or the patient had tapered off opioids. The PA was supervised by a pain physician-psychiatrist, a family physician, and a trauma surgeon. Patients randomized to usual care received standard hospital discharge instructions and written information on managing opioid medications after discharge. Trial results were analyzed using repeated measures analysis. 37 participants were randomized to the intervention and 36 were randomized to usual care. The primary outcomes of the trial were pain, enjoyment, general activity (PEG score) and mean daily opioid dose at 3 and 6 months after hospital discharge. Treatment was unblinded but assessment was blinded. No significant differences in PEG or opioid outcomes were noted at either time point. Physical function at 3 and 6 months and pain interference at 6 months were significantly better in the usual care group. No significant harms of the intervention were noted. COVID-19 (corona virus 2019) limited recruitment of high-risk opioid tolerant subjects, and limited contact between the PA interventionist and the participants and the PCPs. Our opioid taper support program failed to improve opioid and pain outcomes, since both control and intervention groups tapered opioids and improved PEG scores after discharge. Future trials of post-trauma opioid taper support with populations at higher risk of persistent opioid use are needed. This trial is registered at clinicaltrials.gov under NCT04275258 19/02/2020. This trial was funded by a grant from the Centers for Disease Control and Prevention to the University of Washington Harborview Injury Prevention & Research Center (R49 CE003087, PI: Monica S. Vavilala, MD). The funder had no role in the analysis or interpretation of the data.
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Affiliation(s)
- Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, 98195, USA.
| | - Laura Katers
- Internal Medicine, Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
| | - Sam Arbabi
- Harborview Trauma Surgery, University of Washington, Seattle, WA, USA
| | - David Tauben
- Internal Medicine, Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Tong L, Solla C, Staack JB, May K, Tran B. Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach. Semin Cardiothorac Vasc Anesth 2024:10892532241235750. [PMID: 38506340 DOI: 10.1177/10892532241235750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.
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Affiliation(s)
- Larry Tong
- Virginia Commonwealth University, Richmond, VA, USA
| | - Che Solla
- University of Tennessee, Knoxville, TN, USA
| | | | - Keith May
- University of Tennessee, Knoxville, TN, USA
| | - Bryant Tran
- Virginia Commonwealth University, Richmond, VA, USA
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Al-Saidi I, Russell A, Dizdarevic A. The Acute Perioperative Pain Service: Impact, Organization, and Future Directions. Curr Pain Headache Rep 2023; 27:399-405. [PMID: 37354296 DOI: 10.1007/s11916-023-01133-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE OF REVIEW The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS). RECENT FINDINGS There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.
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Affiliation(s)
- Ibrahim Al-Saidi
- Columbia University Irving Medical Center, New York, USA.
- NewYork-Presbyterian/Columbia Univ Med Ctr, 622 W 168th St, NY, PH5-133 10032, New York, USA.
| | - Alex Russell
- Columbia University Irving Medical Center, New York, USA
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