Patients on high-dose opioids, those treated for substance use disorder, and those with uncontrolled psychological comorbidities often remain hospitalized for longer periods of time and experience higher rates of hospital readmission. Changing guidelines on opioid prescribing have also complicated care for surgical services. 

---

Transitional pain services (TPS) that take the positive results of enhanced recovery after surgery (ERAS) pathways and extend them upstream to the clinic and postoperatively have the potential to further lower risks and improve outcomes. 

Transitional pain services (TPS) that take the positive results of enhanced recovery after surgery (ERAS) pathways and extend them upstream to the clinic and postoperatively have the potential to further lower risks and improve outcomes. The following is a description of the early implementation of the Vanderbilt TPS.

Concept Design

At Vanderbilt, we recognized, like those before us, that if we were to have a chance at impacting the development of chronic postsurgical pain and opioid use disorder (OUD), we needed to get to patients early enough to assess personal and surgical risk factors and implement preventive treatment. We conceptualized our TPS by reviewing other early TPSs at the University of Toronto, Duke, and Johns Hopkins.^1-4

The TPS clinic consultation results in a plan that reduces risk by optimizing health (eg, controlling pain, adjusting medications, treating comorbid conditions, and providing education).

Service Creation

We created our TPS incrementally by rearranging personnel and resources to support new pathways of care. Our consulting faculty are pain medicine-boarded, buprenorphine-waivered anesthesiologists, physiatrists, and rehabilitation physicians. Our advanced practice nurses (APRNs) are experts in the clinical management of chronic pain and were trained in TPS. Each clinic APRN rotates in the inpatient setting to carry out TPS plans.

Consultation Criteria and Systems Support

Several guidelines informed the development of consultation criteria (Figure 1). The O-NET+ criteria (Opioid Naïve, Exposed, and Tolerant Plus Risk Modifiers) is our template for stratification and documentation and is used to guide care for multimodal treatment and functional recovery, with appropriate opioid tapering.⁵

Electronic reports exist to identify high-risk patients (eg, those taking buprenorphine), and orders were created for surgical and pre-anesthesia services to consult the TPS for “Pre-/Post-Surgical Optimization and Pain Management.” 

Preoperative Consult Criteria

• Patients on higher-dose opioids (>60 MEDD)
• Patients receiving treatment for OUD
  

Inpatient Consult Criteria

• High-risk by O-NET+ criteria
  • Patient taking high-dose opioids before admission (>60 MEDD) and with rapid-dose escalation
  • Patients newly on opioids with uncontrolled comorbid psychiatric conditions/concerns
  • Patients receiving buprenorphine, etc. for OUD with complex care management considerations
• Select patients that primary service requests to be seen after discharge
  

Postoperative Consult Criteria

• > 30 days after surgery
• Requiring prolonged pain management, functional improvement, opioid taper
  

Figure 1: Initial Criteria for Transitional Pain Consultation

OUD, opioid use disorder; O-NET+, opioid-naïve, exposed, tolerant criteria; MME, morphine equivalent daily dose

Documentation

A shared electronic medical record (EMR) template for documentation has been an important tool for standardization, coordination of care, and data collection. Elements include surgery type and date; contact information for surgeon, pain physician, psychiatrist, and primary care provider; pain history including tolerance of nonopioid analgesics, prior and current opioid use, social history and support system.

The initial O-NET+ risk category (high-risk, moderate-risk, low-risk) is documented, and one goal of the TPS is to document a plan that places the patient in a lower risk class. For example, a patient at high risk might have a slight taper of opioids with the inclusion of nonopioid and non-medication treatments that then results in the patient being classified as moderate risk.

Interventional treatments in the clinic and regional anesthesia on the day of surgery are considered good options for patients with chronic pain, opioid tolerance, and substance use disorders in order to better manage pain and spare the need for large opioid escalation.

Reimbursement

Preoperative TPS consultation by providers registered in the state as anesthesiologists might cause confusion among payers who typically bundle pre-anesthesia visits with the cost of doing anesthesia; therefore, in-clinic TPS visits are differentiated as specialist consultations for high-risk patients, sometimes requiring pre-authorization. Additionally, inpatient specialist consultation requests from surgical services are still a requirement. Postoperative TPS consultation delineates the need for postoperative treatment to taper opioids, manage substance use disorders, and control pain; documentation supports complex medical decision making as part of specialty care. 

The keys for reimbursement have been a clear record of the preoperative request coming from the surgical team for specialist care, documentation well ahead of the surgical date (2-4 weeks) with high medical decision-making (comorbid pain, depression, anxiety, opioid use), provision of care (management of opioids, multimodal analgesia, coordination of care), and postoperative care outside the global period.

Reporting and Sustainability

We track several metrics to ensure the TPS is providing value to patients and the hospital and to guide service improvement (eg, pain and function, analgesia use, consultation volume, referral patterns, length of stay, readmission, reimbursement). To be sustainable, in-clinic APRNs see both standard outpatient and TPS visits. Inpatient, APRNs see TPS patients and help staff chronic pain consults when needed. This allows the physicians to hold a half day of clinic or schedule an operation on the same day while staffing the chronic pain service. This way, the TPS has grown incrementally while being cost-neutral.   

Summary

The Vanderbilt TPS is 1.5 years in and steadily growing in patient volume and hospital support (Figure 2). We look forward to reporting our outcomes and obtaining feedback from our peers at future meetings and in our specialty journals.

Step 1: Determine the goals

• Patient care (quality)
  • Pain control
  • Functional recovery
  • Adverse events
  • Opioid use
  • Acute to chronic pain
  • Satisfaction
• Systems
  • Surgical delay or cancellation
  • Length of stay
  • Readmissions
  • Clinic volumes

Step 2: Use guidelines, scales, and scores developed by experts

• O-NET+, Qor-15,(6) Patient-reported outcome measures

Step 3: Start in the clinic

• APRNs trained in TPS consultation
• Template TPS consult notes to document consistently the information needed both for patient care, quality, communication, and cost
• Coordinate with Preoperative Anesthesia Clinic
  

Step 4: Slow rollout

• Surgery grand rounds, service introduction directly to colleagues offering to manage most complex patients, off-load surgery clinic
• Surgery clinic and inpatient PAs, APRNs were educated on the TPS and how to consult
• EMR order for TPS

Step 5: Expansion of TPS to inpatient

• Clinic APRNs trained on TPS rotated to inpatient and now responsible for consulting and carrying out the plans they created in clinic
  

Step 6: Reporting to leadership

• Growth, service to the hospital, patient outcomes justify further expansion
  

Figure 2: Vanderbilt Transitional Pain Service Rollout

David A Edwards, MD, PhD, is an associate professor of Anesthesiology and Neurological Surgery and chief of the Division of Pain Medicine in the department of Anesthesiology at Vanderbilt University Medical Center in Nashville, TN.

---

References

1. Clarke H. Transitional pain medicine: novel pharmacological treatments for the management of moderate to severe postsurgical pain. Expert Rev Clin Pharmacol. 2016;9:345-9. https://doi.org/10.1586/17512433.2016.1129896
2. 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. https://doi.org/10.2217/pmt-2016-0004
3. Katz J, Weinrib A, Fashler S, et al. 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
4. Hanna MN, Speed TJ, Shechter R, et al. An innovative perioperative pain program for chronic opioid users: an academic medical center's response to the opioid crisis. Am J Med Qual. 2019;34(5-13). https://doi.org/10.1177/1062860618777298.
5. Edwards DA, Hedrick TL, Jayaram J, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on perioperative management of patients on preoperative opioid therapy. Anesth Analg. 2019;129:553-66. https://doi.org/10.1213/ANE.0000000000004018
6. Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology. 2013;118:1332-40. https://doi.org/10.1097/ALN.0b013e318289b84b