ASRA Pain Medicine Update

In 2014, the Toronto General Hospital opened its doors to the Transitional Pain Service (TPS). This service enables targeted, mechanism-based treatments for patients who are at risk for the development of chronic postsurgical pain and disability while enabling safe opioid prescribing and weaning after major surgery. Over the years, we have had our share of ups and downs. However, today we are an entrenched and respected service within the University of Toronto’s University Health Network and have secured long-term funding by our provincial government. We are partnered at both the provincial and federal level to identify and treat the coexisting issues of mental health problems, opioid misuse, and chronic pain.

The benefits to patients who struggle with opioid and pain issues in the postoperative period are profound, and the sense of satisfaction equally profound for the healthcare provider when an individual’s life trajectory is changed for the better.

In Canada, the TPS model of care has been replicated by the University of British Columbia and the University of Calgary, and it is being considered as a model of care at Dalhousie University, where it would represent coast-to-coast adoption of this service. There also has been outstanding work in the United States that has focused on the topic of opioid prescribing related to surgery and postdischarge care. The programs in Salt Lake City, UT (by Dr. Michael Buys), and Duke Health (by Dr. Padma Gulur) are other great examples of similar services with their own unique properties that have changed practice patterns for patients within their institutions. In other areas of the world, the University of Oslo in Norway and Monash University in Melbourne, Australia, have begun transitional pain programs associated with injuries caused by trauma.

Intuitively, there is little doubt that a TPS, in the context of the opioid crisis, makes sense. However, as these programs continue to be built, we want to bolster their development with the clinical and research evidence needed to support this innovation in care during the perioperative period and post-discharge. The TPS’s multidisciplinary approach to post-discharge care is not without added cost, nor is it easy; however, the benefits to patients who struggle with opioid and pain issues in the postoperative period are profound, and the sense of satisfaction equally profound for the healthcare provider when an individual’s life trajectory is changed for the better.

My colleagues at the University of Toronto, Drs. Aliza Weinrib, Joel Katz, Paul Tumber, Duminda Wijeysundera, Karim Ladha, and I have embarked upon the completion of the REdu Ction in Opioid Use for Pain (RECOUP) trial, which is a multisite pragmatic randomized study across five hospitals in Ontario focused on evaluating the model of care delivered by the TPS (mental health and pain medication optimization). In addition to this multisite trial, we are using Ontario’s Provincial Health database to determine whether or not there has been an economic impact for patients who have been seen by the TPS using longitudinal data over the past 5 years. In the past weeks, our newest partner has become the Health Canada Substance Use and Addictions Program, which has given us funding to finalize the RECOUP trial (circa. 2024) and develop knowledge translation resources for others to utilize. The TPS is involved in other exciting randomized controlled trials, including an evaluation of the psychological, psychophysiological, pain-related, and opioid-sparing effects of clinical hypnosis for patients undergoing major surgery; an examination of the efficacy of hatha yoga for postsurgical oncology patients; and a study of opioid-sparing and pain-relieving effects of battlefield acupuncture administered to patients immediately after surgery.

As the TPS has evolved, it has also become the hub for the intersection of pain and addiction medicine for inpatients on medicine wards struggling with opioid-related problems. Initiating buprenorphine therapy on currently hospitalized patients is commonplace for our TPS physicians, nurse practitioners, and psychologists. The years ahead are exciting. It has been an honor to be a founding member of the ASRA Persistent Perioperative Pain Special Interest Group, led by Dr. Hesham Elsharkawy. Further excitement abounds with respect to future discussions, research collaborations, and, ultimately, improvements in perioperative patient care that will evolve out of our concerted efforts to reduce the incidence and better treat chronic postsurgical pain.

Hance Clarke, MD, PhD, FRCPC, is the director of Pain Services and medical director of the Pain Research Unit in the department of Anesthesia and Pain Management at Toronto General Hospital and an associate professor in the department of Anesthesia at the University of Toronto in Canada.