What is the problem
Patients with significant pain issues may be at risk of debility and impaired ability to participate in prehabilitation. Consequently, they risk suffering worse postoperative outcomes in comparison to patients who are able to participate in prehabilitation.
In addition, these patients may be at higher risk of developing chronic post-surgical pain (CPP) which can cause ongoing reduction in function and quality of life, even after cancer treatment is completed. This is increasingly recognised as a major public health problem1,2.
Transitional Pain Services (TPS) are designed to help patients to maintain function, reduce opioid use, polypharmacy and reduce the incidence of CPP. They are involved in managing patients throughout the perioperative period: preoperatively, through the acute postoperative phase within the hospital setting, and postoperatively in the outpatient setting.
The TPS consists of pain specialist physicians and acute pain nurse practitioners, and can also include or involve liaison with anaesthetists, clinical psychologists, palliative care specialists, physiotherapists, addiction medicine services, mental health services, chronic pain service, and a patient care coordinator.
Screening
Referral criteria to Transitional Pain Service:
Patients undergoing high-risk surgery (e.g. laparotomy, oesophagectomy, thoracic surgery, mastectomy) and one or more of the following factors (with relevant screening questions):
- On opioids >90mg Oral Morphine Equivalent Daily Dosing (OMED)
- “What pain medications are you currently taking?”
- On methadone or Suboxone/Subutex or opioid replacement therapy
- “Are you on an opioid replacement program?”
- Uncontrolled cancer pain
- “Do you have uncontrolled pain related to your cancer?”
- History of substance abuse
- Psychological factors: pain catastrophising, depression, anxiety, post traumatic symptoms.
Assessment
Validated self-report measures
Further assessment should include a comprehensive pain assessment including pain history, impact of the pain and background information on the patient (psychosocial history).
Intervention
TPS interventions aim to maintain or improve function in order to facilitate prehabilitation. Patients are assisted to develop a personalised pain management plan.
Analgesia is optimised with multimodal analgesia strategies. This may involve the use of paracetamol, anti-inflammatories, antineuropathic agents, alpha-2 agonists, local anaesthetics, nerve blocks. Importantly, patients are supported in opioid and polypharmacy weaning.
Non-pharmacological interventions are carried out and may include cognitive behavioural therapy and pain education. This requires multidisciplinary input and can include physiotherapists and psychologists.
An anaesthesia/analgesia plan is formulated for the perioperative period.
Evaluation of the service
- Rate of referral to the TPS
- Compliance with TPS interventions
- Improved Quality of Life scores
- Decrease in disability
- Decrease in unplanned readmissions
- Reduction in polypharmacy and persistent opioid use post surgery.