opioid use
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Doctors at the Toronto General Hospital have developed a revolutionary Transitional Pain Service, bridging the gap between post-surgical care and long-term pain management. Their study shows that these services are effective at reducing long-term opioid use in those with risk factors.

Opioids are frequently used to treat persistent pain, including chronic post-surgical pain. However, concerns around opioid prescriptions and opioid use are mounting.  This is in part due to the risk of drug diversion (selling prescription drugs for recreational use), harmful side effects, addictions, and fatal overdoses.

A Standard Treatment

High-dose pharmacotherapy for pain after surgery is the standard treatment and patients are generally not offered any interventions targeting the psychological factors that make certain patients vulnerable to pain chronicity. Pain chronicity can include pain catastrophizing, sensitivity to pain traumatization, anxiety, and depressive symptoms.  In addition, although studies have shown that there are behavioural interventions that can reduce the impact of persistent pain by reducing pain interference (i.e., the impact of pain on work, sleep, relationships, enjoyment of life, etc.) post-surgical patients are not typically offered these interventions.

In fact, post-surgical patients are given very little guidance to support opioid weaning given the expectation that post-surgical pain will naturally resolve with time and so pain medication use will naturally taper off.  Unfortunately, depending on the type of surgery between 5% and 70% of post-surgical patients will continue to experience chronic post-surgical pain (CPSP).  In fact, as many as four patients out of every thousand who had never used opioids before surgery will continue opioid use as long as one year after surgery.

Recently, the U.S. national guidelines for managing post-surgical pain have emphasized that opioids should not be used alone to treat postoperative pain, but should instead be combined with nonpharmacological approaches.  In addition, patients who are taking medications to treat anxiety and depression pre-surgery are at the highest risk of persisting on opioids following a major surgery.  A concerted effort must be made to address anxiety and depression in the months after surgery, as the combined psychological symptoms and chronic pain can be overwhelming for these patients.

Transitional Pain Service (TPS)

The Toronto General Hospital has developed a unique and innovative Transitional Pain Service (TPS) that uses multidisciplinary methods to prevent and manage CPSP. This program provides physician-guided opioid medication management and tapering, as well as nonopioid medications. The TPS also offers behavioral interventions found in Acceptance and Commitment Therapy (ACT).  These interventions are tailored to the postsurgical population and address pain education, pain coping, pain interference, as well as mood and anxiety concerns.

The Transition Pain Service may be the first hospital-integrated, comprehensive, long-term postsurgical pain management program of its kind.  Because this program is new, there is no evidence on the clinical outcomes of postsurgical patients who receive psychological support to help them manage complex and persistent postsurgical pain, opioid use, and psychosocial symptoms.

Evaluating the Efficacy of the Transitional Pain Service

This study, published in The Canadian Journal of Pain, analyzed preliminary data of the TPS, looking specifically at changes in pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety and depression, and opioid use throughout TPS treatment.  Researchers then compared the results to those who received no psychological treatment.  They hypothesized significant decreases in pain, pain interference, sensitivity to pain, pain traumatization, pain catastrophizing, anxiety and depression, and opioid use in patients who received psychology services.

Ninety-one patients received one or more ACT intervention sessions after postsurgical hospital discharge (the ACT group) and 252 patients who did not (the no ACT group). All patients were treated at the TPS clinic.  Treatments were typically one-hour one sessions with a registered clinical psychologist. The ACT protocol is designed to reduce the struggle against inner experiences (such as pain) while simultaneously encouraging long-term patterns of behaviour that build a rewarding life.

The ACT matrix is a visual diagram that guides participants through their experiences in a way that is designed to help participants to be mindful of their experiences and behaviours.  They were also encouraged to practice mindfulness at home for 10 minutes every day.

The researchers used measures such as the Brief Pain Inventory-Short Form, the Sensitivity to Pain Traumatization Scale–12, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale to measure psychological and physical health.  The amount of opioids used in a 24-hour period was recorded in the medical charts by TPS physicians at each patient visit (including deviations from prescribed amounts) and abstracted from the medical record.

Improvement in Both Groups

The results indicate that both groups improved over the course of the study, showing significant decreases in pain intensity, pain interference, pain catastrophizing, anxiety symptoms, and opioid use by the time of the last TPS visit.

The patients who participated in approximately five ACT-based pain psychology sessions in addition to medication management by pain specialist physicians demonstrated significantly greater reductions in opioid use, pain interference, and depressed mood than patients who received physician-guided treatment alone. Keeping in mind that the patients who received the ACT-based therapy were referred due higher risk/need, and who also received more physician-guided care it is impossible to attribute the entire difference to the ACT therapy alone.

Study Limitations

It is important to note that this was not a randomized, blinded controlled study.  All of the participants received TPS, and those who were referred to the ACT group were those who were identified as having a higher risk of chronic opioid use.  These were patients accessing routine care a busy metropolitan hospital which makes the results generalizable to any similar large healthcare institution.

In addition to being observational in nature, another limitation was the relatively small sample size which limited the statistical analysis.  This study also did not differentiate between different types of surgeries, which is important because different types of surgeries typically have different outcomes in terms of long-term pain management and opioid use.

Another important limitation to this study is that the participation end-date was determined as the day that patients were transferred back to their primary care physicians.  This was notably later in the ACT treatment group meaning that they received treatment for a longer period of time.  There remains much research to do to understand the complex relationship between surgical procedures, pre-surgical mental health, post-surgical pain, and opioid use.

Bridging the Gap

This study is extremely relevant to those treating patients living with chronic pain after surgery, especially considering that there is a serious lack of research in this area. Specialized care for chronic pain is difficult to access and is often delayed.  The Transitional Pain Service at the Toronto General Hospital bridges the gap between post-surgical care and specialized long-term chronic pain care for those who are at risk of long-term opioid use. Preventing opioid-naïve patients from becoming chronic opioid users is an important objective in addressing the public health crisis that is opioid addiction.

Written by Lisa Borsellino, BSc

Reference:

Azam MA, Weinrib AZ, Montbriand J, et al. Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service. Canadian Journal of Pain. 2017 June 28.

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