A world-first transitional pain program that aims to stop pain from becoming chronic after surgery is being pioneered at Toronto General Hospital, University Health Network.
The one-year pilot program is designed to treat complex pain patients who have had surgery by helping with pain control, monitoring and weaning patients off excessive amounts of opioid medications for pain, and providing much-needed support for patients after they are discharged from the hospital. Follow-up care is provided by a diverse team of clinicians who specialize in pain control. Program specialists are not aware of any other such program in scientific publications.
Poorly controlled postsurgical pain is a risk factor for hospital re-admission and increased use of health care resources.
Searching for answers
The program, which began in June 2014, also hopes to answer compelling questions of which risk factors cause chronic pain, what works best to stop or modify the "pain pathway" for patients, and how interventions can prevent hospital re-admissions of complex patients after surgery.
"We want to break the cycle of pain with multiple pain strategies," says Dr. Hance Clarke, Medical Director of the Pain Research Unit and Director of The Transitional Pain Service in the Anesthesia Department and Pain Management at Toronto General Hospital (TGH). He adds that after about three months, post-surgical pain can develop into chronic pain, therefore it is important to intervene before this happens. As many as 30 per cent of surgical patients develop chronic pain after surgery, and are at an increased risk for long-term opioid use. Half of patients after major surgery are discharged from hospital with a prescription for opioids.
One of the hottest topics in pain research is how to change this "pain pathway" so that it does not become a constant in a person's life, explains Dr. Rita Katznelson, Director of the Chronic Pain Program at TGH. "There's no blueprint out there on how we go about doing this. But we are determined that these patients who are struggling will not be abandoned. We will continue to treat their pain after they leave the hospital with clinic visits and education for the patient and family."
Chronic use of opioids for chronic pain
In assessing the problem of opioid use after surgery in all Ontario residents who had major surgery from 2003-2010, Dr. Clarke and team previously found that 3.1 per cent of those who had never taken opioids before surgery remained on this medication three months afterwards. Other researchers have estimated the one-year prevalence to be high as 10 per cent following low-risk surgery. Among these at-risk patients are those who have pre-existing pain, mental health issues, chronic use of opioids, and those who do not have access to teams who specialize in advanced and multiple techniques of pain management.
All surgical patients at Toronto General Hospital are eligible to be referred to this new program either by a "pain alert" triggered during the comprehensive assessment of patients before surgery (e.g. those who are on daily opioids or have chronic pain), or as a referral after surgery for those who continue to have intense pain. A follow-up plan, including pain clinic visits after discharge to the hospital, education and consults with family physicians, will be offered to these patients.
Every year, about 500 patients at TGH are identified before major surgery as having chronic pain, and taking opioid medication. Some of these patients remain in hospital for up to seven days longer than the usual stay, requiring specialized interventions to help them with their pain and opioid use.
The Transitional Pain Team uses a variety of methods to help and teach patients to manage their pain. These include prescribing non-opioid medications, use of psychological techniques such as mindfulness or moment-by-moment awareness of our thoughts, feelings, and sensations, as well as "exercise prescriptions" and acupuncture by a healthcare team of medical pain specialists, pain nurse practitioners, a psychologist and physiotherapists. Family physicians can use the Transitional Pain Team as a resource for their patients for up to a year after discharge.
Physiotherapist Bansi Shah calls this approach "ground-breaking" since a patient has access to a whole team of pain experts who use both traditional and complementary skills to help a patient. "We view our patients holistically, and treat what affects their mind, body and movement. This comprehensive approach gives us a greater chance of making a difference in their lives, of helping them back to the activities they enjoy."
Clinical psychologist Dr. Aliza Weinrib uses a novel approach to help patients coping with pain. She first spends about 30 minutes listening and speaking with patients, asking them about their values and what is important to them. "People feel understood and heard and that prepares us for the next question: 'What is getting in the way of you doing what you can and what you like?'" Dr. Weinrib then maps out a graduated, step-by-step plan with patients to help them with their mood, perception of their pain, coping strategies, and functioning.
"This program is unique in that it identifies patients before their surgery who are at increased risk for developing chronic pain, and then cares for them both throughout their hospital stay and after they are discharged," says Dr. Gerald O'Leary, Anesthetist-in-Chief at University Health Network. "A significant gap in patient care will be addressed by reaching out to many different caregivers and patients' families to help these patients."
Helping patients with pain
Bryan, 58, who requested that his last name not be used, had open-heart surgery on June 10, 2014. After not even drinking coffee for years, and training for gruelling triathlons, his opioid pain medication, received after surgery, affected him greatly. "I felt as if I fell into a deep, dark pit. I had night terrors, could not sleep and felt anxious. It was disconcerting," remembers Bryan. Easing off the opioid medication and having a psychologist to talk to about these side effects was reassuring, says Bryan, adding that he also learned many coping strategies, including staying "in the moment" rather than catastrophizing or ruminating excessively on the pain.
Sarah Slater, 35, had surgery in March 2013 to remove scar tissue from her small intestine. She experienced pain so crippling that she could not hold up her bow when teaching archery to high school students and aspiring Olympic athletes. She also wanted to find alternatives to opioid medication in keeping with the anti-doping philosophy endorsed by the International Olympic Committee.
The pain team was able to wean Sarah off opioids with medications that are alternatives to opioids, and help her cope with her continuing pain. Instead of being "on edge" with her pain, Sarah now practices deep breathing when it strikes, and is hoping to try acupuncture at the transitional pain clinic. "It's helpful and reassuring to have someone listen to you and be that voice of reason. I need someone to acknowledge my pain, teach me helpful tips and the program did that."