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Postoperative Pain and
Prevention Dr. Hance Clarke
Director of Pain Services, Toronto General Hospital
June 23rd, 2016
Faculty/Presenter Disclosure
Faculty: Hance Clarke MD PhD
Relationships with commercial interests:
Nothing to Declare
Learning Objectives
Chronic Postsurgical Pain & Cost Associated with
the The Development of CPSP
Perioperative Opioid Use
Transitional Pain Service
Experience of Pain
Differentiating CPSP
• Systematic review - 281 studies
assessed investigating PSPS in 11 surgical types
• Prevalence of NeuP determined using NeuP grading
system
• Prevalence of NeuP high after thoracic and breast
surgery (66/68%). 31% after groin hernia repair and
6% after THA and TKA
• Prevalence of PneuP varies by type of surgery and
probability of nerve injury
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Incidence of Chronic Pain Post Surgery
Cost of CPSP
Persistent postoperative pain can incur personal costs of up
to $12,000 per year, and indirect losses (i.e. lost income) of
$30,000 per year (Sadosky, 2013)
In 2012, the top 10 priority surgeries performed on
~445,000 Canadians resulted in an estimated total cost of
$900 million based on a conservative, annual 5%, incidence
of severe postsurgical pain (Katz, 2015)
Acute postoperative pain that progresses to a chronic pain
syndrome in a 30-year old individual is as much as $1
million (US) over the course of their lifetime(Labatt, 2000)
Learning Objectives
Chronic Postsurgical Pain & Cost Associated with
the The Development of CPSP
Perioperative Opioid Use
Transitional Pain Service
Tahir Janmohamed, PEng, MBA Founder & CEO
Joel Katz, PhD Canada Research Chair in Health Psychology
Hance Clarke, MD, PhD Medical Director,
Transitional Pain Service
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$5,000 annual Ontario estimate
$13,000 is U.S. published number in direct costs
new cases of chronic post-surgical pain
(5% of all surgeries)
worsening cases of chronic pain post-surgery
(12.5% of all surgeries)
~4,000 patients receiving major surgery at Toronto
General annually
200 300
$1.0 to $2.6M
$5,000 annual cost
$1.5M
Chronic pain as a consequence of surgery at the Toronto General Hospital costs the Ontario Health Care System $2.5 – 4.1 M annually
Pain Management, Huang et al., In Press, July 2016
Two Distinct Populations
Non-Chronic Pain Patient (80 - 85%)
Chronic Pain Patient / Persistent Opioid Patient (15 -20%)
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Methods
• Population based cohort study
• Major elective surgery 2003-2010 in Ontario
• Prolonged opioid use in opioid naïve patients
• Multivariable logistic regression
Rationale
• Does this apply to major surgery?
▫ Increased patient concern about addiction
▫ Opioid exposure unavoidable
▫ Risks unknown
3.1% Prolonged Opioid Use Rate
Clarke et al., British Medical Journal, 2014
What this study adds
• Approximately 3.1% of patients who had not used opioids previously continued to use them for more than 90 days after major elective surgery
• Although 3.1% risk is low at an individual patient’s level, it represents an important public health concern because millions of patients undergo major surgery every year
Clarke et al., British Medical Journal, 2014
0 2 4 6 8 10
Radical prostatectomy (5193)
CABG via sternotomy (9488)
MI lung resection (720)
Open lung resection (2423)
MI colorectal surgery (3202)
Open colorectal surgery (8642)
MI hysterectomy (5287)
Open hysterectomy (4185)
% With Prolonged Opioid Use
Pro
ced
ure
Typ
e (
# C
ases)
Prolonged Opioid Use By Surgery
OR 2.58
OR 1.95
Clarke et al., British Medical Journal, 2014
Risk Factors for prolonged opioid use after surgery: • Younger age • Lower income • Specific comorbidities (Renal Failure) • Specific preoperative drugs (Benzodiazepines & SSRIs) • Thoracic surgical procedures
Clarke et al., British Medical Journal, 2014
The Transitional Pain Service
1. Modify trajectory of postoperative pain
1. Provide regular monitoring and safe weaning
of opioids
2. Team-based approach to management of
pain and return to baseline level of function
1. Facilitate safe discharge and transition from
hospital to community.
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Referral Criteria to The Transitional
Pain Service
Psychological co-morbidities (Dr. Aliza Weinrib)
Average NRS >5 on POD #4 / POD #5 and still on APS
Repeat consult to APS post discharge from service
Pre-operative Chronic Pain Diagnosis +/- chronic opioids
> 80 mg of PO morphine in initial 24 hours after surgery
Long acting opioid (hydromorphone or oxycodone controlled release)
Previous / Current addiction (case by case)
Delayed D/C due to pain
Up To 6 months postoperatively
Patient Demographics
186 Complex Postsurgical Pain Patients
60% of TPS patients having a pre-operative chronic pain diagnosis
24% had a history of opioid addiction
20% having a documented history of mental health issues
60% taking opioids before surgery.
65% having 3 or more major medical comorbidities
Mean postoperative hospital stay of these individuals was 10.3 days (4-5
days beyond target)
Chronic Neuropathic Pain Guidelines
Moulin, Boulanger, Clark, Clarke, Dao, Finley et al., Pain Res. & Management Dec, 2014
TPS Pain Trajectory Data
Clarke et al. DRUGS, March2015
Acceptance and Commitment
Therapy for Post-Surgical Pain
ACCEPTANCE
-mindfully noticing pain
-watching thoughts
-accepting emotions
-accepting circumstances
COMMITTED ACTION
-taking manageable & consistent steps
toward personal recovery goals
-choosing when to engage in activities based on values (rather than pain)
Better pain coping
Less depression and
anxiety
Less medication usage as appropriate
Better functioning
Less time in hospital
More engaged in
physiotherapy
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Can I show you a point of view?
Towards Away
ACT Matrix (Polk & Schoendorff, 2014) TPS On-Line Mindfulness Program
Page et al., PAIN, 2015
Opioid Misuse Demographics
In the 1990s we believed that the rate of addiction was 0.1% after starting opioid
based medication
Systematic Review in CNCP ≈ 5 – 24% (Kahan, 2015)
In the U.S. 259 million prescriptions were written (2012)
Four in five new heroin users reported misusing prescription painkillers
-as a consequence, the rate of heroin overdose deaths nearly quadrupled from
2000 to 2013
Canada leads the world in opioid analgesic prescriptions 815 mg per Capita
vs. 749 mg in the U.S. vs. 483 mg Denmark (WHO, 2014)
White House Press Release
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Addiction Medicine in The
Perioperative Context
Patient Risk Factors For Problematic Use
Current alcohol above safe drinking guidelines
History of previous addiction
History of Anxiety, Depression, or PTSD
Social Isolation
Referrals From Primary Care
Future Directions For The TPS
E-Health Ontario Technology Company
Primary Care Integration
Palliative Care Link
Addiction Medicine
Pharmacy Integration
Validation Trial / ICES Analysis
Acknowledgements
TPS Physicians: Rita Katznelson, Karen McCrae, Sheldon Lyn,
Diana Tamir & Hance Clarke TWH: Paul Tumber, Philip Peng,
Anuj Bhatia & Neilesh Soneji
Psychologists: Joel Katz, Aliza Weinrib, Sam Fashler, Abid
Azam
Co-ordinator(s): Kayla McMillan & Sarah Russell
Nursing: Salima Ladak, Jaio Jiang, Quing Li
Postdoctoral Fellow: Janice Montbriand
Database Developer: Andrew Cheng