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Transitional Pain Clinic 169
The inclusion of CPSP in the new classification of ICD-11 highlights how this
condition is now considered a disease rather than a symptom and that identification
and diagnosis of pain needs to be addressed with a more specific long-term treatment
plan [9].
3 Incidence of CPSP
According to the Center for Disease and Control (CDC), Chronic pain is the leading
cause of disability in the USA [10]. The incidence of CPSP varies widely between
3 and up to 85% according to the type of surgery [8]. The exponential increase in
surgical procedures worldwide and a conservative median incidence of CPSP around
20–30% at 6–12 months is anticipated to substantially increase new cases of CPSP
[11].
A literature review that considered many study designs and variable assessments
of perioperative pain outlined the incidence of CPSP according to the type of surgery.
This reviewfound that CPSP is very common after amputation (30–85%), craniotomy
(7–65%), inguinal hernia (5–63%), cholecystectomy (3–56%), caesarean section (6–
55%), total knee arthroplasty (TKA) (13–44%), thoracotomy (5–71%), mastectomy
(11–57%), sternotomy (7–50%), vasectomy (0–37%), and less common among hip
replacement (7–23%), and abdominal surgery (17–21%) [11].
4 Mechanisms of CPSP
The pathophysiological theory behind CPSP is thought to be related to peripheral
(injury site) and central (spinal and supraspinal) sensitization after tissue/nerve injury.
This sensitization stimulates inflammatory and immune mediators which in turn
activates the peripheral and dormant nociceptive receptors leading to activation of
the central pathway via pain signaling at N-methyl-D-aspartate (NMDA) receptors
and glial cells [12].
The sustained release of this inflammatory cascade leads to pain symptoms such
as hyperalgesia (increased pain sensitivity to noxious stimuli), allodynia (painful
stimulation caused by non-painful stimuli), dysesthesia (unpleasant touch perception
and tingling) and pain chronicity. Therefore, CPSP is a combination of somatic,
inflammatory and neuropathic pain [13, 14].
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170 M. Tanios et al.
5RiskFactors
Evidence shows that CPSP could be related to perioperative pain levels and stimu-
lation of nociceptive pathways [1]. Early identification of risk factors for CPSP can
improve postsurgical outcomes and pain trajectories. CPSP is complex and can be
attributed to many factors that include, but are not limited to:
•
Demographic risk factors: Age (young), sex (female), high body mass index
(BMI), pain sensitivity, lower educational level and socioeconomic status [15].
•
Preoperative chronic pain: Patients with preexisting pain, poorly controlled
acute pain, comorbidities, chronic pain diagnoses (e.g., fibromyalgia, migraine,
low back pain), any coexisting psychological disorders are liable to experience
CPSP [16].
Preoperative pain is a strong predictor of CPSP [17].
•
Intraoperative related pain: Surgical trauma, types of surgical procedures,
(major, laparoscopic), surgical duration, incision site, nerve injury, ischemia,
complications, anesthetic techniques (halogenated anesthesia, remifentanil) may
result in opioid-induced hyperalgesia [18–20].
•
Postoperative acute pain: Exacerbated from any complication related to electro-
cautery, re-operation, infection, bleeding, hematoma, organ rupture, compartment
syndrome, radiation and chemotherapy [13].
Approximately 70% of patients suffer from hyperalgesia (neuropathic pain)
during the transition period between acute and chronic pain and consequently develop
an increased opioid requirement, tolerance and decreased pain control [21, 22].
•
Psychological factors: Stress-related to surgery and accompanying fear, anxiety,
diminished ability to cope with pain, lack of social support, depression and
preexisting psychological disorders.
A prospective study predicted that CPSP after colorectal surgery is related to age,
anxiety, depression, pain with movement 24 h after surgery, as well as the length of
surgery. These are all factors that must be addressed in a post care plan that aims
to mitigate CPSP development [2]. In the pediatric population, perioperative pain is
related to anxiety, coping, and parental catastrophizing [23].
•
Genetic factors: Identifying patients with polymorphisms that can lead to variable
pain sensitivity and opioid use. Examples would be Catechol-O-Methyl Trans-
ferase (COMT) and melanocortin-1-gene expressed in women with red hair are
associated with higher opioid use [20].
Montes et al. completed a study on 500 patients with CPSP and concluded that
a gene-related encoding protein that mediates peripheral and central inflammatory
response to tissue or nerve injury was unlikely but can’t be completely excluded and
more research is needed in the future [24].
The biopsychological model of pain related to social, behavioral and biological
factors can modify pain experience [25].
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Transitional Pain Clinic 171
6 Pediatric CPSP
Chronic Post-Surgical Pain (CPSP) in the pediatric population has been poorly
described in the literature, related to its lower prevalence [26].
CPSP in pediatrics is defined as pain affecting the surgical area for more than
3 months postoperatively. Recent studies evaluating CPSP account for pain severity,
frequency, social, physical, and functional limitations. The literature omits impor-
tant data points like school days missed, social isolation and pain related anxiety
(Fig. 1)[27].
A recent study reported that the prevalence of CPSP was 10.9% in children aged
6–18 years, after observing 258 patients [28]. In other studies, the prevalence of
CPSP was found to be 22% with mixed surgical procedures and 13.5% with inguinal
hernia repairs [29, 30].
Major orthopedic procedures, thoracotomies, and inguinal hernia repairs have a
propensity for CPSP development in pediatric patients. As per Dugan et al. of those
who reported pain, 28% missed some school days due to pain, 30% had trouble
sleeping, and 42% reported that they sometimes missed time spent with friends due
to pain [31].
Fig. 1 Risk factors. Adapted from Rosenberger et al.[11] and Robins et al. [23]
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172 M. Tanios et al.
7 Preoperative Pain Assessment
Presurgical risk modeling includes a consideration of risk factors including mental
health and preoperative pain[32]. Schreiber et al. reported that a personalized pain
plan was more effective than protocolization for controlling pain and preventing
CPSP [33].
To aid in pain plan personalization efforts, utilization of the Patient Heath Ques-
tionnaire (PHQ-9) and General Anxiety Disorder Questionnaire (GAD-7) could
assist in identifying patients at elevated for CPSP related to their preexisting anxiety
and depression symptomology [20]. A systematic review on Quantitative Sensory
Testing (QST) found a correlation of 4–54% between preoperative pain and CPSP
development depending on experimental stimulation methods (heat, cold, pressure
algometry, electrical, punctate mechanical stimulation, and induction of inflamma-
tory injury). Although this approach reported positive results in a research setting, it
is impractical in clinical settings [34, 35].
8 Prevention of CPSP and the Need for Post Discharge Pain
Care
CPSP is a complex biopsychological phenomenon that, once initiated, is difficult
to treat. The gap between acute and chronic pain is defined as the subacute pain
period. This analgesic period, the “gray zone”, generally extends between 10 days
to 3 months into the postoperative period and is often following hospital discharge.
This period is considered critical for identifying patients at increased risk and imple-
menting strategies aimed at preventing CPSP. Strategic models focus on this time
frame and may be referred to as “Transitional Pain Clinic” (TPC) and/or post
discharge personalized pain care. In this timeframe, multimodal preemptive anal-
gesics, nerve block, and cognitive behavior therapy represent a sampling of the
multidisciplinary approaches that may be needed [21, 36, 37].
9 Persistent Perioperative Pain Clinic (PPPC)
and Transitional Pain Clinic (TPC)
Many long-term physical, psychological, social, and economic effects can be seen
due to chronic pain. They become more complex over time and may even become
irreversible and refractory to treatment [38]. Evidence demonstrates that the develop-
ment of chronic pain can be limited by proactively preventing peripheral and central
sensitization to noxious stimulation by using multimodal analgesia[39]. Utilization
of comprehensive multi- or interdisciplinary biopsychosocial approaches are needed
to improve functioning after surgery and for prevention and treatment of CPSP [40].
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Transitional Pain Clinic 173
Fig. 2 Classification model of transitional pain clinic ERAS: Enhanced recovery after surgery PT/
OT: Physical therapy/occupational therapy
Therefore, TPC, which can include psychological assessment and behavioral
interventions, should be utilized to identify patients at risk for CPSP. The goals
of the TPC are to adequately manage and monitor long-term pain with multimodal
interventions, maintain function and activities of daily living, and reduce opioid
consumption. TPC provides multidisciplinary pain management during inpatient
stays and up to six months after hospital discharge [41–43].
The interdisciplinary team consists of nurse practitioners, physicians, psychol-
ogists and other allied health professionals, such as physiotherapists. Anesthesiol-
ogists and addictionologists tailor a patient’s care plan to utilize multimodal anal-
gesia and reduce opioid use when possible. Psychologists provide behavior interven-
tions for pain and addiction. An important aspect to the success of the TPC is the
patient’s participation in understanding and showing commitment towards weaning
from opioid-based pain management. Intensive follow-up with patients immediately
post-discharge, bimonthly visits for two months after discharge and then monthly
visits for three to six months have demonstrated a positive impact on pain outcomes
and reducing opioid consumption (Fig. 2)[43].
10 Referral Criteria to TPC
The process should start with identifying risk factors for new persistent opioid use
after surgery including tobacco use, alcohol and substance use disorders, mood disor-
ders, anxiety and pain diagnosis prior to surgery. For example, the odds of chronic
opioid therapy after lumbar fusion are increased in patients with clinically diagnosed
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174 M. Tanios et al.
depression, with 77% of those patients receiving chronic opioids versus 50% without
a diagnosis of depression[42].
Other patients that would benefit from a referral to the TPC include patients
consuming more than 90 mg/day of oral morphine equivalents (MEQ) on postop-
erative day 1, patients followed by the acute pain service for more than 3 days
postoperatively for poorly controlled postoperative pain or complex pain patients
requiring multiple pain consultations prior to hospital discharge, and patients being
discharged on long-acting opioids [43].
11 Flow of Patients
The anesthesia team develops a pain management plan for the preoperative, intra-
operative and immediately postoperative periods. Postoperatively, while the patient
is in the hospital, physical and occupational therapy referrals should be attempted.
Patients and family engagement are paramount. Necessary home healthcare refer-
rals should be arranged. In-hospital opioid consumption should be monitored and
weaned, if possible, with the aid of nonopioid medications and nonpharmacologic
strategies.
On discharge, appointments should be made for the patient with the TPC to
continue the opioid weaning process. Physical therapy/ occupational therapy (PT/
OT), social workers, home health care, and psychiatry referrals may also be required
if not already involved.
Life-style modification including massage, acupuncture, music therapy, relaxation
techniques, social support and other integrative medicine practices are useful tools
in managing pain. These modalities offer temporary pain relief, likely by distracting
the patient from thinking about their own pain s ymptoms [44].
Hypnosis is another alternative technique for stress reduction [45]. A large meta-
analysis on pediatric and adult populations undergoing diverse surgical procedures
found that hypnosis has a positive impact on emotional feelings related to stress.
Shnur et al. documented that 15 min of hypnosis improved the patient’s emotional
state, mood, and anxiety compared to placebo [46].
Finally, the patient’s primary care provider should be a critical component of the
postoperative pain management transition team and should ultimately be comfortable
managing the prescribed analgesic regimen.
12 Pre-emptive and Preventative Analgesic Regimen
Pre-emptive analgesia techniques are interventions that seek to block peripheral and
central pain transmission before a noxious stimulus occurs. This would include local
anesthesia given into the skin before an incision is made, ongoing IV (opioid, anes-
thesia) or regional/neuraxial local anesthesia during the noxious insult (surgery) and
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Transitional Pain Clinic 175
after the injury/throughout the recovery period. The goal of preventative analgesia is
to enable early mobilization and to decrease the stress response perioperatively while
minimizing side effects from any one analgesic technique. Preventative analgesia
includes a combination of interventional techniques (nerve or fascial plane blocks)
and pharmacologic therapies. A multimodal approach can allow for a reduction in
opioid use, lower pain scores and decrease the length of hospital stay [47].
The use of perioperative regional anesthesia may or may not prevent CPSP. It
has not been proven that regional anesthesia prevents CPSP after thoracotomy. Nor
does perioperative regional anesthesia or preoperative genicular nerve neuroabla-
tion prevent CPSP in knee arthroplasty. However, after breast cancer surgery, in
highly catastrophizing patients, paravertebral blocks may prevent CPSP intensity
and diminish the surgical impact on daily life for up to a year [48].
13 Pharmacological Interventions of CPSP
The application of Enhanced Recovery after Surgery (ERAS) protocols using multi-
modal approaches to pain management could assist in mitigating postoperative pain
and the development of CPSP. Medications used to treat pain include ketamine,
gabapentinoids, anti-inflammatory, corticosteroids, intravenous lidocaine, alpha-2
agonists (clonidine, dexmedetomidine), and topical treatments (low-concentration
capsaicin, 5% lidocaine patch, nitroglycerin transdermal patch, 5% amitriptyline
cream, 0.5% ketamine, 2% amitriptyline/1% ketamine combination cream).
Although these medications are frequently used to treat acute postoperative pain,
a recent meta-analysis pointed out that many pharmacological medications proved
to be inefficient in reducing CPSP [49].
Ketamine
Current studies found that ketamine’s effect on CPSP development is not promising.
Although it was previously thought that ketamine use preoperatively can decrease
postoperative opioid use, this may not be true. When taking a closer look at the
availableevidence, factors such as small sample size studied, ketamine dosage, timing
and duration of use with different types of surgery, gave results that are inconclusive
[49].
Gabapentinoids
Gabapentinoids are used preoperatively to reduce neuropathic pain especially when
nerve damage is suspected during surgery. Unfortunately, a recent comprehensive
study found that gabapentin is not useful for the prevention of CPSP. Although, it
was effective for 3 months after total knee arthroplasty and cardiac surgery, more
studies with larger sample sizes are needed to prove its effect on CPSP [49].
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Non-steroid anti-inflammatory drugs (NSAIDs)
NSAIDs are beneficial in reducing secondary hyperalgesia and central sensitization
but have no effect on CPSP. NSAID use may be limited in patients with impaired
kidney functions, bleeding tendencies, and allergic reactions [50].
Acetaminophen
Acetaminophen is frequently used in perioperative management for its analgesic
effect, but no study found an effect on CPSP [50].
Corticosteroids
A Cochrane review on 3 studies found that corticosteroids contributed to decreasing
central sensitization to pain and had a positive effect on decreasing CPSP. In contrast,
De Oliveira et al. reported that dexamethasone use did not decrease the incidence of
CPSP in mastectomy patients [51].
IV Lidocaine
Based on the limited duration of IV lidocaine administration, it is not terribly
surprising that reports of sustained pain control remain inconclusive. For example,
the prevalence of pain at 6 months when the IV lidocaine infusion was given for
24 h or less showed statistically significant reductions in pain after breast surgery in
2 trials. However, no pain benefit was found at 3 months for the same procedure and
the same infusion duration in other trials. Two recent reviews supported the use of
IV lidocaine in treating CPSP in different types of surgery, but a larger multicenter
clinical trial will be more beneficial in confirming the use of IV lidocaine [49, 52, 53].
14 Opioid Weaning and Pain Management
Opioid-induced hyperalgesia, a paradoxical increase in the patient’s pain severity and
decrease in pain tolerance may develop after short-term administration of opioids in
the peri-operative period. While hyperalgesia is a clinically relevant issue, especially
for patients with chronic pain, it can be overcome in the acute postoperative setting
by a concurrent infusion of low-dose ketamine, for example. While intra-operative
opioids should be used judicially, the difference in the operating room is unlikely to
make a significant difference in patients’ lives [54].
This elucidates a need for an institutional effort lead by a variety of services to
wean patients from opioids. To do so, this should include educating providers who
prescribe discharge analgesics about alternative options for pain management that
include multimodal analgesic regimens.
For patients who cannot be immediately weaned off opioids, follow-up in a chronic
pain or TPC should be arranged [54].
A patient-specific approach starting from preoperative risk assessment (risk
factors are discussed earlier in this chapter), education, and setting realistic and
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Transitional Pain Clinic 177
achievable goals and expectations for postoperative pain could help decrease opioid
use. Determining the need for discharge opioid prescriptions should also be based
on inpatient opioid consumption.
It may be beneficial to give patients written prescriptions for over the counter
(OTC) medications, as patients may perceive the medication as having greater
efficacy than when dispensed OTC [55].
Treatment of acute pain with opioids for greater than 8 days can lead approxi-
mately 1 in 7 patients to continue to use opioids for up to 1 year.The rate for long-term
opioid use increases to 30% for patients who use opioids for 31 days or more. [56].
As attention to opioid prescribing has increased, legislative bodies in certain states
have started to limit the duration of initial opioid prescriptions for acute pain and
professional guidelines are also recommending opioid tapers by 6 weeks after most
major surgeries. However, the recommendations for opioid weaning are largely based
on anecdotal experience [42].
15 The Role of Peripheral Nerve Stimulation
A variety of beneficial interventional CPSP treatment modalities have been described
and implemented in clinical practice. Neuromodulation with peripheral nerve stim-
ulation (PNS) for up to 60 days is commonly used with better outcomes on pain
control. Over the last decade, there has been a growing interest in evaluating the effi-
cacy and duration of pain relief with PNS for difficult to treat pain cases like CPSP
and post amputation phantom limb pain. PNS placement can be achieved with ultra-
sound guidance and/or fluoroscopy. PNS is a proven technique that is safe, effective,
and minimally invasive while still treating chronic, intractable post-surgical pain
targeting different nerve locations [57].
Wilson et al. reported a significant reduction of pain scores with the use of
PNS in a randomized-controlled t rial (RCT) evaluating the impact of this tech-
nique on shoulder pain management[58]. Deer et al. reviewed 14 RCTs on patients
with chronic refractory pain that included chronic migraine sufferers (occipital
nerve), cluster headache (sphenopalatine ganglion), headache with fibromyalgia (C2
nerve), hemiplegic shoulder pain, failed back pain syndrome, extremity, trunk, and
pelvic pain (tibial nerve). These patients were successfully treated with PNS and
demonstrated the efficacy of percutaneously implanted stimulators in pain intensity
reduction over multiple nerve locations [59]. Bouche et al. presented a case series
describing the use of ultrasound-guided percutaneous PNS of the brachial plexus as
well as supra-scapular nerve and reported pain reduction of more than 50% after one
year in patients with CPSP and peripheral nerve injury [60].
Spinal cord stimulation (SCS) has been successfully used for phantom limb pain,
chronic post thoracotomy pain, neuropathic pain of upper and lower limbs, cervical
and spinal surgeries and complex regional pain syndrome [13, 61, 62].
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16 Cryoanalgesia
Cryoneurolysis involves cooling targeted nerves to reversibly decrease their function
and provides sustained pain relief that can last for weeks to months [44, 63].
24 RCTs examined the efficacy of cryoanalgesia for thoracotomy, herniotomy,
nephrectomy and tonsillectomy and found positive outcomes in decreasing CPSP,
post-operative opioid use and consequently nausea and constipation when compared
to opioid analgesia only. This opioid-sparing technique can last beyond a patient’s
hospital discharge, and persistent pain control will hopefully translate into reduc-
tions in health care costs via a decreased incidence of readmission and emergency
room visits. Furthermore, cryoanalgesia is inexpensive and is associated with less
maintenance requirements compared to nerve blocks where there is a risk of local
anesthetic toxicity and the burden to carry an infusion pump [64].
17 Radiofrequency Ablation
As a minimally invasive technique, Radio Frequency Ablation (RFA) has been
widely accepted for treating chronic refractory post-surgical pain. Radiofrequency
on targeted nerves alters pain pathways with thermal coagulation.
Two case reports documenting chronic chest pain after surgery noticed long-term
pain relief with RFA [65]. Another case series focusing on intercostal neuralgia
reported promising results in pain reduction with RFA [66]. Case series for hip pain
with avascular necrosis used cooled RFA under fluoroscopic guidance and found a
significant decrease in opioid use and pain scores [67].
18 Business Models of Transitional Pain Clinic
Toronto General hospital developed an innovative multidisciplinary approach for
CPSP. It consists of a combination of opioid weaning with non-opioid medica-
tions, when possible, along with psychological assessment with Acceptance and
Commitment Therapy (ACT).
The concept of ACT is based on behavioral interventions and stress reduction
that can lead to reductions in pain-related complications. Implementation of this
ACT behavioral management program was associated with a significant decrease in
pain characteristics, opioid use, and depression compared to groups with no ACT
intervention [68].
The Salt Lake City Veteran Affairs hospital established a multidisciplinary Transi-
tional Pain Services (TPS) for patients undergoing orthopedic surgery, which resulted
in reductions in opioid use. These pain services were financially supported by their
hospitals [69, 70].
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