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Transitional Pain Clinic 179
Both hospitals describe the effect of the model in terms of dollars where the
savings from TPS outweighed its costs.
Unfortunately, most of the currently offered analgesic therapies are not routinely
continued into the discharge period. However, to prevent pain sensitization and
chronicity, a long-term therapeutic plan must be implemented and personalized for
a given patient. Even with excellent in-hospital pain management, patients may
be abruptly switched from an individual regimen to a standard oral regimen, then
discharged with a non-personalized care plan. Thereafter, subsequent pain manage-
ment is often inadequate. The result of this suboptimal care results in more pain,
stress, and a decrease in the patient’s quality of life. Patients who are discharged
prematurely and without an adequate plan will only drain more costs from the
healthcare system in the future if CPSP develops.
Duke Health succeeded in tackling patients at elevated risk for CPSP develop-
ment through a clinical care model designed to decrease perioperative opioids and
support the patient beyond the immediate perioperative period. This model consists
of 3 different categories related to -1-psychological (cognitive behavioral, relax-
ation, and patient’s favorite soft music therapy), -2- Medical (opioid weaning, multi-
modal approach) and -3-physical optimization (rehabilitation, anti-inflammatory,
plant-based diet), and pain clinic (morphine and opioid weaning).
At Duke, the staff managing the TPS is also in charge of inpatient care services,
thereby optimizing the continuum of care [71].
Vanderbilt has noticed that TPS can benefit patients through reinforcing ERAS
pathways in the perioperative period. Strict adherence to these protocols has improved
pain satisfaction on stratified high-risk patients (high-dose opioid (>60 MEDD)
and opioid-use disorder), decreased health care expenses, and improved outcomes
(pain control, opioid- dose adjustment, treatment of chronic conditions, and patient
education). [72][45].
Closing the Gap Between Acute and Chronic Pain: Practical
Solutions
Preventing CPSP is better for healthcare systems and patients and should be the
goal of perioperative analgesia. There are multiple pathways to CPSP prevention
that might be considered, and a tailored and combined approach is more likely to be
successful. Practical solutions could be achieved through the following:
Primary prevention of pain is defined as preventing acute pain with modeled
approaches for the general population and high-risk groups.
Secondary prevention is defined as prevention of the transition from acute to chronic
pain. Hence the many names of this period; subacute pain, persistent pain, and
transitional pain.
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180 M. Tanios et al.
Tertiary prevention is aimed at reducing the frequency, severity and disability
related to chronic pain [10].
Macrae et al. suggested that preventing pain is like any other disease states that
have a progression. As an example, controlling diabetes and smoking will prevent
limb amputation and the development of phantom pain [73].
Chronic pain after surgery is costly and may be substantially contributing to the
opioid epidemic. There are direct medical costs related to specialty evaluations,
radiographic diagnosis, surgeries, procedures, medications (opioids, neuromodula-
tors, antidepressants), and indirect costs related to job loss and disability. CPSP and
persistent opioid use following surgery are some of the main reasons that clinicians
and patients are voicing a need for “Transitional Pain Clinic” (TPC) [74].
The inclusion of healthcare experts from different specialties and business special-
ists is required to make the TPC sustainable. Education, fellowships, and the value of
dual fellowships in Acute Pain Management (APM) and Chronic Pain Management
(CPM) or dual staff coverage (acute and chronic) together should be encouraged.
Involving stakeholders like academic chairs to contribute to funding fellowships
for interested staff, special training, and electives may also reinforce participation.
Attending society, meetings and courses related to pain medicine and continued prac-
tice expansion through the incorporation of ultrasound, nerve and interfascial blocks,
X-ray,advanced procedures, neuromodulation, cryoanalgesia, and RFA will enhance
practitioners’ skills and improve confidence in applying new techniques.
Vital to the success of TPC is multidisciplinary collaboration and the creation of
personalized plans for each individual patient. These plans should include a psychi-
atric evaluation that focuses on changing a patient’s mentality on how to adapt to
adverse situations and manage pain. Communication among the members may be
enhanced through the establishment of regular meetings. Inclusion of substance use
disorder and perioperative medicine education can be an important component of
continued learning and practice expansion.
Expansion of funding for acute and chronic pain programs may help to shift the
treatment paradigm from identifying risk factors associated with pain into ways to
prevent the transition from acute to chronic pain earlier. These interventions may
result in saving health care costs and making the TPC financially feasible as well.
19 Cost-Effectiveness Enhancement of Transitional Pain
Clinic
At this point, optimizing the cost-effectiveness of the TPC dictates that utilization
should be prioritized for high-risk patients and matched to the anticipated volume of
major surgical procedures. Nesting the TPC within the perioperative surgical home
should improve the ability to implement pre-emptive pain management strategies and
plan postoperative TPC referral. Involving additional services related to preoperative
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Transitional Pain Clinic 181
preparation like psychiatry and addiction clinics will have a positive impact on the
patient’s behavior.
Machine learning algorithms can be useful tools for predicting patients at elevated
risk for CPSP. Telehealth communication is an easy and accessible way of communi-
cation between patients and their caregivers. Future composite biomarkers to detect
the underlying cause behind the transition of acute to chronic pain after surgery are
under investigationthrough ongoing multicenter control trials. Clarke et al. suggested
that analyzing a patient’s DNA sequencing, blood and salivary pain biomarkers and
their analgesic responses to medications will be a crucial step toward a personalized
pain medicine [75]. The concept of “Traditional Pain Management” needs to change
into “Transitional Pain Clinic” for treating acute pain before proceeding to chronic
pain.
20 Practice and Research Gaps
Unfortunately, there remain many gaps between patient care in the perioperative
period and the postoperative care needed to achieve long-term recovery. First and for
most, acceptance of the clinician team and restrictive/myopic business models remain
barriers to further TPC success. Second, discharging patients with interdisciplinary
team support can overwhelm patients. Third, the greatest obstacle is to wean patients
from opioids especially if they are dependents and reached the tolerance level. The
goal of decreasing dependance on opioids is a noble target worthy of pursuit. Fourth,
behavior and psychological support has a direct impact on the quality of recovery for
these patients. Communication, early planning, and focusing on closing the gap while
identifying patients with highly predisposing risk factors for CPSP are additional
assets that should be considered to ensure the success of TPC.
Finally, obtaining approval from institutional leadership and securing financial
investments required from hospitals and healthcare system represent critical steps in
crafting a business plan that will ensure program sustainability and enhance recovery
outcomes. CPSP mandates a comprehensive pain management strategy, hence the
necessity for TPC [17, 76].
21 Future Directions
The future role of TPC is focusing on identifying analgesic gaps, leveraging expertise,
and coordinating care to close gaps in pain care will help to ensure a place for this
patient care modality.
Alternative approaches that can be easily implemented in most healthcare systems
include the utilization of APM and CPM teams with enhanced collaboration and
earlier patient stratification, consultations, referral to multidisciplinary teams and
coordination with addiction, rehabilitation medicine, and psychiatry. Using existing
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182 M. Tanios et al.
resources represents an intriguing opportunity to enhance patient care without
needing to identify novel revenue streams. Ideally, any intervention will result in
decreasing length of stay, opioid weaning, reducing emotional distress, improving
quality of life, less surgical follow-up, and increasing postoperative satisfaction. In
a concurrent fashion, implementation of these workflows can be expected to reduce
the incidence and severity of persistent postsurgical pain to where it can be more
easily controlled.
22 Conclusion
Postoperative analgesic management continues to suffer from gaps in care that can
be improved through the incorporation of advances in pain science and the inclusion
of collaborative and multidisciplinary healthcare professionals.
While APM and CPM services play an essential role in perioperative pain manage-
ment, they generally lack the ability to follow patients at timepoints largely removed
from their surgical procedures. The inherent value of TPC is that they can continue
to follow patients as they recover and work to diminish or eliminate the need for
opioid analgesics. The value of this clinic may be difficult to measure, but decreased
opioid consumption, hospital admissions, improved patient satisfaction, and a dimin-
ished community-based opioid burden are all immeasurable attributes of the services
provided by TPC. As the field continue to evolve, future research should focus on
types of surgeries and patient characteristics that are most likely to benefit from TPC
and novel methodologies to improve the care provided to these patients.
23 Key Points
•
Chronic postsurgical pain (CPSP) is the one of the most common causes
of disability. Perioperative pain management should be proactive and utilize
comprehensive approaches rather than reactive or mono-focal care.
•
The TransitionalPain Clinic is designed to close the gap between acute and chronic
pain. It encompasses perioperative pain management and a post discharge pain
care plan.
•
The Transitional Pain Clinic represents an important modality for treating acute
pain before proceeding to chronic pain.
•
Transitional Pain Clinics leverage multimodal approaches to analgesic manage-
ment that strive to decrease opioid use, lower pain scores, improve quality of life,
and reduce health care costs.
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Transitional Pain Clinic 183
List of Abbreviations
TPC Transitional Pain Clinic
CPSP Chronic Post-Surgical Pain
ERAS Enhanced recovery After Surgery
ICD-11 International Classification of Diseases Eleventh Revision
IASP International Association for the study of Pain
CDC Centers for Disease Control and Prevention
TKR Total Knee Replacement
BMI Body Mass Index
PPPC Persistent Perioperative Pain Clinic
MEQ Morphine Equivalents
MEDD Morphine Equivalent Daily Dose
IV Intra-Venous
NMDA N-Methyl-D-Aspartate
COMT Catechol-O-Methyl Transferase
RCT Randomized-Control Trial
C2 nerve Cervical 2 nerve
OTC Over The Counter
PNS Peripheral Nerve Stimulation
RFA Radio Frequency Ablation
SCS Spinal Cord Stimulation
TPS Transitional Pain Services
APM Acute Pain Management
CPM Chronic Pain Management
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