ASRA Pain Medicine Update

Opioid use in the United States is widespread for both acute and chronic pain conditions. Given the potential negative effects of opioid analgesics, the Centers for Disease Control and Prevention (CDC) issued guidelines for best practices in opioid prescribing.^[1] Transition clinics in pain medicine are designed to help patients prevent the transition from acute opioid use to chronicity. Meeting that challenge requires a multidisciplinary approach, including pharmacologic and interventional pain management, physical therapy, and rehabilitation medicine, as well as pain psychology and behavioral support. 

Transitional clinics in pain medicine are designed to prevent the transition of acute opioid use to chronicity and exist in various states of comprehensiveness.

Chronic Opioid Use

Although opioids were initially developed for the treatment of acute pain states, their use in the setting of chronic pain is extensive. According to CDC, 259 million prescriptions for opioid analgesics were written in 2012.^[2] Nearly 20% of ambulatory patients seen in 2012 with the chief complaint of pain were prescribed opioid analgesics.³

The list enumerating all possible adverse effects of opioids is extensive, but perhaps most concerning is the potential for misuse, addiction, and death. Annual costs associated with misuse and abuse of prescription opioids are estimated at $53.4 billion for nonmedical uses, $55.7 billion for abuse and dependence, and $20.4 billion for overdose.^[1] Their pervasive use and potential for severe consequences has led to the United States declaring the opioid use epidemic a public health emergency.^[4]

Risk Factors for Transition to Chronicity

In March 2017, CDC published a Morbidity and Mortality Weekly Report describing the development of chronic opioid use among nearly 1.3 million opioid-naïve non-cancer patients who received a first prescription for opioid analgesics.^[5] The report identified several risk factors for transition to chronicity of opioid use, including number of supplied days of opioid analgesics, provision of refills, use of long-acting opioids, and cumulative opioid dose. Each additional day of supplied opioid analgesics beyond three days was associated with a marginal increase in risk for transition to chronicity as measured by continued use at one and three years after the initial episode. Opioid use at one year from first episode was 6.0% for those with at least one day of prescribed opioid therapy, 13.5% for those with at least eight days, and 29.9% for those with at least 31 days. The provision of a second prescription or refill doubled the risk of transition to chronicity: approximately one patient in seven still used opioids one year following the initial episode. The authors also emphasized that the greatest incremental increases in transition to chronicity were associated with the initial prescription exceeding ten or thirty days, provision of a third prescription, or cumulative dose exceeding 700 morphine milligram equivalents.

The CDC data are illuminating, but one important caveat is that the analysis does not account for the etiology of pain. In the transition to chronic opioid use following surgery, the concept of chronic postsurgical pain (CPSP) takes center stage. Defined as pain for at least two months following surgery that is attributed to surgery itself and not related to pre-existing or other medical conditions, CPSP is thought to be based on a variety of demographic as well as biopsychosocial factors.^[6]Patients at increased risk for development of CPSP often have high intensity of perioperative pain, perioperative opioid consumption, or the presence of certain psychological states, including depression, anxiety, and post-traumatic stress disorder.^[7]

Transitional Clinics in Pain Medicine

Transitional clinics in pain medicine are designed to prevent the transition of acute opioid use to chronicity and exist in various states of comprehensiveness. One of the more thorough programs that have been chronicled in the literature, the Transitional Pain Service (TPS) at Toronto General Hospital provides a continuum of services, including identification of high-risk individuals through preoperative consultation, provision of guidance for perioperative pain management, meticulous education for patients and family members, and postoperative clinic follow-up that coordinates pharmacologic management, psychotherapy, and rehabilitation medicine in a multidisciplinary effort guiding patients toward a full recovery.^[7]

 Applications to Practice

The perioperative home framework augments anesthesiologists’ role in patient recovery following surgery, which affords an opportunity to target modifiable risk factors for transition to chronicity of opioid use. Enhanced recovery after surgery protocols designed to minimize perioperative opioid use may be successful in the inpatient setting, but it may not extend to the outpatient setting in the absence of a cultural change related to opioid prescribing at discharge.^[8]

Working with surgical colleagues, pharmacists, patients, and their families to discuss optimal duration of opioid prescriptions as well as choices for opioid formulation can help mitigate those risks. Leveraging nonopioid analgesics and nonpharmacologic modalities is another part of a comprehensive approach to multimodal analgesia and requires the involvement of multiple specialties, including physical therapy, rehabilitation medicine, and pain psychology.

Recommendations:

• Patients going for surgery should be evaluated for the presence of risk factors for CPSP.
• Patients at risk for developing CPSP should be evaluated by the TPS for perioperative pain control. Their perioperative care should focus on using a multidisciplinary approach for treating pain in the perioperative period using non-opioid analgesics, physical therapy, education, psychological support and regional anesthesia.
• Patients should be followed in the post-operative period for evaluation of the continuous need of pain control, use of non-opioid approaches, weaning down opioids if used after surgery, and functional restoration.
• Some patients may develop CPSP and those may need to be referred at an early stage to a chronic pain clinic to provide multidisciplinary pain management without the need for high dose opioids for a prolonged duration post-operatively.

References:

1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic [ain—United States, 2016. MMWR Recomm Rep. 2016;65(RR-1):1–49. http://dx.doi.org/10.15585/mmwr.rr6501e1
2. Centers for Disease Control and Prevention. Opioid painkiller prescribing: where you live makes a difference. http://www.cdc.gov/vitalsigns/opioid-prescribing. Accessed April 27, 2018.
3. Daubresse M, Chang H, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care. 2013;51:870–878. https://doi.org/10.1097/MLR.0b013e3182a95d86
4. White House. The opioid crisis. http://www.whitehouse.gov/opioids. Accessed April 27, 2018.
5. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66:265–269. http://dx.doi.org/10.15585/mmwr.mm6610a1
6. Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008;101:77–86. https://doi.org/10.1093/bja/aen099
7. Katz J, Weinrib A, Fashler SR. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695–702. https://doi.org/10.2147/JPR.S91924
8. Brandal D, Keller MS, Lee C, et al. Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study. Anesth Analg. 2017;125:1784–1792. https://doi.org/10.1213/ANE.0000000000002510