J Pain Res. 2015 Oct 12;8:695-702. doi: 10.2147/JPR.S91924.

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

Katz J1, Weinrib A2, Fashler SR3, Katznelzon R4, Shah BR5, Ladak SS5, Jiang J5, Li Q5, McMillan K5, Mina DS6, Wentlandt K7, McRae K4, Tamir D4, Lyn S4, de Perrot M8, Rao V9, Grant D10, Roche-Nagle G11, Cleary SP12, Hofer SO13, Gilbert R14, Wijeysundera D4, Ritvo P15, Janmohamed T16, O’Leary G4, Clarke H4.
  • 1Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Psychology, York University, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
  • 2Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Psychology, York University, Toronto, ON, Canada.
  • 3Department of Psychology, York University, Toronto, ON, Canada.
  • 4Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
  • 5Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
  • 6Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada ; Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.
  • 7Palliative Care, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
  • 8Division of Thoracic Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 9Division of Cardiovascular Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 10Multiorgan Transplant Program, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 11Division of Vascular Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 12Division of General Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 13Division of Plastic Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 14Division of Otolaryngology – Head and Neck Surgery, Toronto General Hospital, York University, Toronto, ON, Canada.
  • 15Department of Kinesiology and Health Science, York University, Toronto, ON, Canada.
  • 16ManagingLife, Toronto, ON, Canada.

 

Abstract

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5-10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.

KEYWORDS: Transitional Pain Service; chronic postsurgical pain; multidisciplinary treatment; opioid use; transition to chronic pain

PMID: 26508886

 

The Transitional Pain Service – Supplemental information

Chronic pain drains the world’s economy of hundreds of billions of dollars annually. Chronic postsurgical pain (CPSP) is a significant driver of this cost, with annual direct and indirect per patient estimates of $41,000 USD. Between 5% and 10% of patients who undergo surgery each year develop moderate-to-severe chronic post-surgical pain. More than 230 million people undergo surgery annually worldwide. The global annual cost of new cases of CPSP is in the hundreds of billions of dollars. Equally concerning is the human cost of CPSP; it deprives the individual of vital energy and productivity and leads to many negative secondary, downstream effects, including job loss, marital and family problems, social isolation, anxiety and worry, depression, and even suicide.

Research, across a range of surgical procedures, has identified several risk factors for CPSP (see Fig 1). These include perioperative pain (e.g., presence and intensity of preoperative pain, high intensity acute postoperative pain),  perioperative opioid use, preoperative negative affective states including posttraumatic stress disorder (PTSD)-like symptoms, depression, anxiety, and pain catastrophizing.  Negative affect and pain catastrophizing are also risk factors for intense, acute postoperative pain and excessive opioid analgesic use.  Poorly controlled postoperative pain and excessive analgesic use delay recovery and hospital discharge. Importantly, intense pain, negative affect, and pain catastrophizing are all risk factors for opioid abuse in patients with chronic pain. The Transitional Pain Service is designed to target and manage these known risks before and after surgery in order to lessen pain intensity, pain-related disability, and opioid misuse, while also serving the health care system by enabling earlier discharge and reducing costs.

 

*Table 1. Transitional Pain Service (TPS) referral criteria

table 1

*Reproduced with permission from Katz et al. J Pain Research 2015:8;695–702.1

 

The Transitional Pain Service 1 (TPS) is designed to identify and manage patients who are at risk for transitioning from acute to chronic postsurgical pain (see Table 1).  We accomplish this through multidisciplinary, coordinated care beginning before surgery, extending into the acute postoperative period while in hospital, and continuing after the patients have been discharged from hospital and have returned home.  The three main goals of the TPS are to: (1) provide a novel, seamless approach to pre-and postoperative pain management for patients who are at increased risk for developing chronic post-surgical pain and pain disability, (2) manage opioid medication for medically complex patients after hospital discharge, and (3) improve patient coping and functioning in order to ensure as high a quality of life as possible after surgery.

At present, the TPS comprises five anesthesiologists with advanced training in acute and/or chronic interventional pain management, two clinical psychologists and several trainees, three acute pain nurse practitioners, two physical therapists with expertise in acupuncture, a palliative care specialist/family physician, an exercise physiologist, a patient-care coordinator, and an administrative assistant.

One of the most novel aspects of the TPS is the psychological intervention offered to all patients, the goals of which are to 1) help patients develop a personalized pain management plan, 2) address emotional distress and associated mental health issues that can amplify pain and increase opioid use, 3) facilitate opioid weaning using behavioral pain management strategies, and 4) decrease pain-related disability. These key areas are addressed in a brief behavioral intervention that is acceptable to medical patients who are not seeking traditional psychotherapy.

Preliminary analyses of TPS outcomes show reduced pain intensity over time.2 Pain scores from TPS-treated patients show lower numeric pain rating (NRS) scores at hospital discharge (mean NRS ± sd: 5.1 ± 2.7) and 2 months later (mean NRS ± sd: 2.7 ± 2.9) in comparison with a control cohort of non-TPS treated patients at discharge (mean NRS ± sd 7.7 ± 1.6) and at a 3 month follow-up (mean NRS ± sd: 4.8 ± 1.5). The data also show TPS-treated patients have less intense pain while in-hospital and their trajectory to mild pain is steeper.

In summary, the TPS addresses gaps in pain and opioid management for patients who have undergone surgery and are at high risk for developing chronic pain. The TPS transforms how postsurgical patients are managed by providing seamless care beginning before surgery continuing throughout the hospital stay and after patients return home.  Important next steps are (1) to evaluate the efficacy of the TPS in preventing CPSP using a more rigorous randomized, controlled design and (2) to determine the extent to which the TPS reduces hospital length of stay, re-admission rates and costs to the health care system.

 

fig1

Figure 1. Schematic illustration of the risk and protective factors associated with the transition of acute, time-limited, postsurgical pain to chronic postsurgical pain and pain-related disability. Factors are depicted for the preoperative, intraoperative, acute postoperative, and long-term postoperative phases. Lines with double arrows between variables show associative relationships reported in the literature. Lines with a single arrow show causal relationships based on randomized controlled trials of preventive analgesia.  Reproduced with permission from Katz et al. J Pain Research 2015:8;695–702.1

 

References

  1. Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, Jiang J, Li Q, McMillan K, Mina DS, Wentlandt K, McRae K, Tamir D, Lyn S, de Perrot M, Rao V, Grant D, Roche-Nagle G, Cleary SP, Hofer SO, Gilbert R, Wijeysundera D, Ritvo P, Janmohamed T, O’Leary G, Clarke H. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. Journal of pain research. 2015;8:695-702.
  2. Clarke H, Poon M, Weinrib A, Katznelson R, Wentlandt K, Katz J. Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain. Drugs. Mar 2015;75(4):339-351.

 

 

 

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