How We Do It: Salt Lake City Veterans Affairs Medical Center Transitional Pain Service

Feb 1, 2021, 00:55 AM by Michael J. Buys, MD

Program Design and Implementation:

In January of 2018, we developed and implemented a Transitional Pain Service (TPS)¹ at the Salt Lake City Veterans Administration Medical Center. The multidisciplinary team consists of an anesthesiologist with specialization in acute pain management, two nurse practitioners with experience in both acute and chronic pain management, four nurse care coordinators, and a psychologist (Figure 1).

Figure 1. Transitional Pain Service Workflow

We enroll all patients who are at high risk for persistent postoperative pain,² as well as all patients who have a history of substance abuse disorder or chronic opioid use. Once identified, the patients are contacted by one of our TPS team members and invited to attend a one-time presurgical expectations class that includes topics on expectations for postoperative pain,^3,4 available analgesic therapies, appropriate use of opioids, and the impact of psychological factors on pain.^5,6 Pain coping strategies are introduced using a Mindfulness-Based Intervention and Acceptance and Commitment Therapy matrix.⁷ In addition, the nurse practitioner and/or anesthesiologist meets individually with patients to develop a personalized plan that may include preoperative opioid taper, a buprenorphine use strategy, or opioid-free strategies.

Chronic opioid use patients have been more likely to stop opioid use altogether or decrease their dose from baseline compared to prior to TPS implementation and are less likely to increase their opioid use after surgery.

In-Hospital: The TPS team rounds on patients daily and provides recommendations for analgesic therapies. Patients are offered daily sessions with the psychologist in their hospital room to reinforce and practice pain coping strategies such as mindful meditation. Prior to discharge, the TPS team provides recommendations for discharge medications and an opioid taper plan.

Post-Surgery: After discharge, patients are called by the nurse care coordinators at post discharge days 2, 7, 10, 14, 21, 28, and then monthly for at least 3 months. Nurses notify the anesthesiologist and nurse practitioner when patients are struggling with pain control or opioid taper. The TPS team prescribes alternative analgesic therapies, coordinates continued opioid therapy with the surgical and primary care providers, and develops opioid taper plans. Individual sessions with the psychologist are available to patients after discharge. Close care coordination is maintained with the surgical team, the primary care provider, and other providers such as mental health or chronic pain. For patients who require longer term care for their chronic pain condition and help with long opioid tapers, we developed a combined clinic with the TPS and our Anesthesia Chronic Pain group. This clinic allows patients to be seen by both services in the same setting where TPS can provide a warm handoff to the chronic pain team.

Figure 2: Percent of Preoperative Opioid Naïve Patients with New Chronic Opioid Use 90-Days after Surgery before and after TPS implementation⁸

Conclusion

Since implementation in 2018, we have enrolled more than 850 patients. Of the opioid-naïve patients, only one (first quarter of 2018) had persistent opioid use at 90-days post discharge (Figure 2). Chronic opioid use patients have been more likely to stop opioid use altogether or decrease their dose from baseline compared to prior to TPS implementation and are less likely to increase their opioid use after surgery.⁸ After demonstrating our outcomes along with overwhelming positive patient and provider experiences, the TPS is now financially supported by the hospital.

Michael J. Buys, MD, is an anesthesiologist at Salt Lake City Veterans Administration Medical Center and an associate professor in the department of Anesthesiology at the University of Utah in Salt Lake City.

References:

Huang A, Azam A, Segal S, et al. Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service. Pain Manag. 2016;6:435-43.
Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet. 2019;393:1537-46.
Lee BH, Wu CL. Educating patients regarding pain management and safe opioid use after surgery: a narrative review. Anesth Analg. 2020;130:574-81.
Rucinski K, Cook JL. Effects of preoperative opioid education on postoperative opioid use and pain management in orthopaedics: A systematic review. J Orthop. 2020;20:154-9.
Dunn LK, Sun EC. Mind over matter: reducing perioperative opioid use through patient education. Anesth Analg. 2020;130:556-8.
Horn A, Kaneshiro K, Tsui BCH. Preemptive and preventive pain psychoeducation and its potential application as a multimodal perioperative pain control option: a systematic review. Anesth Analg. 2020;130:559-73.
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. Can J Pain. 2017;1(1). https://doi.org/10.1080/24740527.2017.1325317
Buys MJ, Bayless K, Romesser J, et al. Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service. Reg Anesth Pain Med. 2020;6:rapm–2020–101797–852.

ASRA Pain Medicine Update