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Revista de la Sociedad Española del Dolor

versão impressa ISSN 1134-8046

Rev. Soc. Esp. Dolor vol.27 no.6 Madrid Nov./Dez. 2020  Epub 08-Fev-2021

https://dx.doi.org/10.20986/resed.2020.3840/2020 

REVIEWS

Transitional pain clinic

M Bolívar1  4  , M Toro2  3  4  , ME Seijas2  , A Bolívar1  , M Bolívar-Jr1 

1Hospital de Clínicas Caracas. Caracas, Venezuela

2Instituto Médico La Floresta. Caracas, Venezuela

3Grupo Médico Santa Paula. Caracas, Venezuela

4Curso de Perfeccionamiento Profesional en Medicina del Dolor. Universidad Central de Venezuela. Caracas, Venezuela

INTRODUCTION

In the last 20 years, important advances have been made in the management of acute postoperative pain (APOP). However, the incidence of persistent postoperative pain (PPP), also called chronic postoperative pain, has not significantly decreased 1,2. Surgery produces postoperative pain that must be relieved as soon as possible and as effectively as possible to reduce suffering, promote the healing and rehabilitation process, and prevent complications. APOP, as a manifestation of acute pain, is a more complex phenomenon than was thought years ago, and its potential for chronification is high. For this reason, its therapeutic approach cannot be simplistic, it must be approached at different levels of the nociception process. Additionally, we know that the pain caused by surgery occurs at a known time, it is anticipated. For these reasons, we should identify risk factors and decrease peripheral and central sensitization of the nervous system responsible for primary and secondary hyperalgesia, reducing the possibility of chronic pain. Despite all this, the clinical management of postoperative pain is far from being successful, resulting in a high incidence of severe postoperative pain, many of these patients will develope chronic pain.

Although neural tissue damage and inflammation occur, the pathophysiology of postoperative pain is unique and the consequences are specific. However, the treatment strategies commonly used are not yet based on these findings, in addition to the lack of analgesics and techniques with limited adverse effects and/or with benefits directed at specific aspects of postoperative pain 3,4,5).

From a pathophysiological point of view, APOP has two components: inflammatory and neuropathic.

Inflammatory pain occurs in response to the release of local inflammatory mediators after a painful stimulus. These substances, called by some inflammatory soup, will lower the excitation threshold of peripheral nociceptors, which is called peripheral sensitization, which is responsible for primary hyperalgesia (pain in the surgical scar). A neuronal depolarization is generated that will be transmitted through the peripheral pathways to the dorsal horn of the spinal cord, magnifying the pain signal and calling it central sensitization, which is responsible for secondary hyperalgesia (pain around the surgical scar). These changes are usually reversible, of known onset and end generally related to tissue repair, in addition to responding to non-steroidal anti-inflammatory drugs, acetaminophen (paracetamol) and opioids.

The neuropathic component develops after an injury in the nerves or sensory transmitting systems of the spinal cord and brain. There is a loss of sensitivity with paradoxical hypersensitivity that results in the appearance of sensory phenomena such as: loss of sensations of touch, temperature, pressure, spontaneous pain, dysesthesias, allodynia, hyperalgesia and hyperpathia. This pain, once established, will not respond to the aforementioned analgesics for inflammatory pain and it is present in postoperative pain syndromes 5.

The eleventh revision of the International Classification of Diseases defines PPP as pain that develops or increases in intensity after a surgical procedure, in the area of surgery, that persists beyond the healing process (that is, at least three months) and that is not explained by another cause, such as infection, malignancy or a pre-existing pain condition 6). The prevalence of this chronic pain remains high, being reported between 10% and 50% of adults undergoing major surgery 7,8. It can appear with any surgery, however it has a high prevalence in thoracic and breast surgery, inguinal hernia, low back spine, hip, knee and trauma surgeries and burns 9. The PPP is an important public health problem, not only because of the distress and disability it produces, but it could have contributed to the opioid epidemic in the 1980s, because part of the tools used for its treatment may have contributed to that crisis in the United States 10. The long-term use of opioids in patients with non-cancer pain was promoted at that time 11.

To reduce the transition from APOP to PPP, multidisciplinary approaches are required to prevent and treat the different risk factors that anticipate this disease 3,4,5,12. This is how transitional pain services (TPS) appeared in 2014 (13,14), and later the transitional pain clinics (TPC) 15.

In countries such as Finland, an outpatient clinic of the acute pain service has been used to follow up patients at risk of PPP, suggesting the results of patients evaluated an average of five risk factors for the development of the disease. This conception implies the early, preoperative identification of patients at risk of severe APOP and PPP for their effective and safe management, both in the hospital and at home 16.

All cases with unsuccessful treatment of APOP in the hospital ward (numerical scale larger than 6), patients with chronic pain requiring high doses of opioids or patients with substance abuse should have multidisciplinary care through a pain doctor. This care should begin preoperatively, continue after the surgery, and finally after discharge from hospital 13. The early identification of these complex patients and their timely and appropriate management would make it possible to reduce the chronic use of opioids and the incidence of PPP 13,15,17.

For this purpose, the TPC or TPS were created. An TPS or TPC is a novel program that aims to effectively manage APOP, facilitate opioid weaning, reduce the development of chronic pain disability, and help decrease deaths related to opioid overprescription 18. These units were created to effectively manage patients' perioperative pain, maintain function, reduce opioid use, and monitor the efficacy of these interventions. In 2014, the first program of this type was organized, which focuses on the PPP in three stages: 1) pre-operative, 2) postoperative in the hospital setting, 3) postoperative in the outpatient setting up to 6 months after surgery 13,19.

The services offered by the TPC are divided into three categories 13 (Table 1):

Table I.  Individualized treatments provided by transitional pain services (TPS) 

  1. Implementation and optimization of multimodal analgesia to improve pain management and facilitate weaning from opioids.

  2. Non-pharmacological interventions, including physical therapy and acupuncture.

  3. Psychological interventions by a pain psychology team trained on an acceptance and commitment therapy (ACT) model. The ACT approach consist of the education on pain and on symptom coping by encouraging engagement in worthwhile life activities, while promoting acceptance and mindfulness of the pain experience 20,21).

Two types of patients are treated in TPS 22:

  1. Opioid naïve patients, without a pre-existing pain condition, who have 5% to 10% risk of developing moderate to severe PPP.

  2. Patients who have a pre-existing pain condition or are taking preoperative opioid drugs.

This is managed through an interdisciplinary team consisting of anesthesiologists, acute pain nurse practitioners, clinical psychologists, palliative care specialists, an exercise physiologist, and a patient care coordinator 19. These units allow the early detection of patients with risk factors for PPP and timely therapeutic and psychological medical interventions to reduce the transition to chronic pain and reduce dependence on opioids 17. Shorter hospital stays, early weaning from opioids, less emotional distress, better quality of life, lower incidence and severity of PPP and disability, and substantial savings are achieved in this way 17.

These units serve as intermediaries between the treatment of APOP in the inpatient ward and the management of chronic outpatient pain. There, patients that could present with chronic pain will be identified among hospitalized patients, based on prognostic indicators 15. The patient should visit the TPC after the discharge. At the TPC, the formulated treatments are reviewed, the patient's treating physician is contacted for the corresponding surgical review, and the patient is referred to other services, such as physical medicine and rehabilitation, mental health, addiction medicine and multidisciplinary services of chronic pain if necessary. This behavior should identify, treat and modify the pain course of patients with a higher risk of PPP and of excessive opioid use 13,17,23. The operation of a TPC is shown in Figure 1.

Fig. 1.  Operation of a transitional pain clinic (TPC). 

A TPC conceived in this way will allow (15):

  1. Early and timely interventions to prevent PPP.

  2. Lower cost effectiveness.

  3. Decrease in unplanned readmissions.

  4. Decrease in long-term disability.

  5. Accelerate job reinstatement (return to work).

  6. Better support for the patient, family and healthcare providers.

  7. A source for research, auditing, training, and education on PPP management.

The criteria for referral to the TPS are varied 13,16,22) (Table 2).

Risk factors for PPP to be considered in the TPC, TPS or acute pain services (APS).

Table II.  Criteria for referral to the transitional pain clinic (TPC) 

Five categories of risk factors for PPP have been identified: demographic, genetic, clinical, related to surgery and psychological, only four of them can be measured with validated tools (pain, physical functioning, psychological functioning and global score of the result 15,16,24,25,26 (Table 3).

Table III.  Persistent postoperative pain (PPP) risk factors 

The TPS is the first service that comprehensively addresses the problem of PPP after major surgery through multidisciplinary care that begins preoperatively, extends post-operatively, and continues until the period of discharge from hospital once patients have returned home. The main objectives of the TPS are: 1) To provide a novel and uninterrupted approach to pre- and postoperative pain management for patients at higher risk of developing PPP and pain disability, 2) To manage opioid medications for medically complex patients after discharge, and 3) improve management and functioning of the patient to guarantee the best possible quality of life after surgery 13.

As an example of this modality of pain services we will mention the TPS of the Toronto General Hospital. Structurally, it consists of five anesthesiologists with advanced training in acute and chronic interventional pain, two clinical psychologists, two physiotherapists with experience in acupuncture, a palliativist family doctor, a patient care coordinator, and an administrative assistant 13.

When patients are discharged, they are evaluated at 2-3 weeks or sooner in the TPS if needed. The patient's progress regarding pain and opioid weaning plans are evaluated. This evaluation is performed every 2-3 weeks, and among other aspects, analgesics are adjusted until the patient is at a safe level, patient's pain is under control and patient's activities of daily living are close to their preoperative level.

The TPS is designed to address the historic gap in pain management of the surgical patient by providing continuous care preoperatively, during hospital stay, and on discharge home after hospital discharge. These stages are relevant in the prevention of PPP, reducing hospital stay, readmissions, opioid consumption and general costs for medical care. However, we must not overlook that we are in the COVID-19 pandemic. This new situation demands innovations in medical care and it is time to look for alternatives to the conventional choices for the follow-up of patients, it is time forTelehealth. Telehealth encompasses the use of telecommunications to provide health care, patient education, and public health 18. With the pandemic situation, restrictions on non-urgent medical care are imposed, TPS consultations are limited, being the use of existing technologies, such as telephone, FaceTime, Skype, Zoom or other platforms for video conferences, an option to reduce this barrier. The COVID-19 pandemic forces social distancing, but we must leverage video telehealth and TPS to continue monitoring our patients 18. Patients, through mobile applications, can collaborate in their self-assessment of pain scores, which facilitates their follow-up and their active participation in pain management 27.

BIBLIOGRAFÍA

1. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis. Anesth Analg. 2012;115(2):428-42. DOI: 10.1213/ANE.0b013e318249d36e. [ Links ]

2. Katz J, Clarke H, Seltzer Z. Review article: preventive analgesia: quo vadimus? Anesth Analg. 2011;113(5):1242-53. DOI: 10.1213/ANE.0b013e31822c9a59. [ Links ]

3. Pogatzki-Zahn EM, Segelcke D, Schug SA. Postoperative pain-from mechanisms to treatment. Pain Rep. 2017;2(2):e588. DOI: 10.1097/PR9.0000000000000588. [ Links ]

4. Borsook D, Youssef AM, Simons L, Elman I, Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain. 2018;159(12):2421-36. DOI: 10.1097/j.pain.0000000000001401. [ Links ]

5. Ribera H, Esteve N, Garrido JP. La transición de dolor agudo postoperatorio a crónico: ¿qué sabemos? Rev Soc Esp Dolor. 2012;19(4):197-208. 80462012000400006&lng=es. [ Links ]

6. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD 11. Pain. 2015;156(6):1003-7. DOI: 10.1097/j.pain.0000000000000160. [ Links ]

7. Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: Risk factors and protective factors. Expert Rev Neurother. 2009;9(5):723-44. DOI: 10.1586/ern.09.20. [ Links ]

8. Kehlet H, Edwards RR, Brennan T. Persistent postsurgical pain: Pathogenic mechanisms and preventive strategies. In: Srinivasa RN, Sommer CL (eds): Pain 2014: Refresher Courses, 15th World Congress of Pain. Washington, DC, IASP Press; 2014. p. 111-24. [ Links ]

9. Mauck MC, Smith J, Liu AY, Jones SW, Shupp JW, Villard MA, et al. Chronic pain and itch are common, morbid sequelae among individuals who receive tissue autograft after major thermal burn injury. Clin J Pain 2017;33(7):627-34. DOI: 10.1097/AJP.0000000000000446. [ Links ]

10. Baker DW. History of the joint commission's pain standards: lessons for today's prescription opioid epidemic. JAMA. 2017;317(11):1117-8. DOI: 10.1001/jama.2017.0935 [ Links ]

11. Collier R. A short history of pain management. CMAJ. 2018;190(1):E26-E7. DOI: 10.1503/cmaj.109-5523. [ Links ]

12. Clarke H, Poon M, Weinrib A, Katznelson R, Wentlandt K, Katz J. Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain. Drugs. 2015;75(4):339-51. DOI: 10.1007/s40265-015-0365-2. [ Links ]

13. Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, 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. DOI: 10.2147/JPR.S91924. [ Links ]

14. Huang A, Katz J, Clarke H. Ensuring safe prescribing of controlled substances for pain following surgery by developing a transitional pain service. Pain Manag. 2015;5(2):97-105. DOI: 10.2217/pmt.15.7. [ Links ]

15. Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet. 2019;393(10180):1537-46. DOI: 10.1016/S0140-6736(19)30352-6. [ Links ]

16. Tiippana E, Hamunen K, Heiskanen T, Nieminen T, Kalso E, Kontinen VK. New approach for treatment of prolonged postoperative pain: APS OutPatient Clinic. Scand J Pain. 2016;12:19-24. DOI: 10.1016/j.sjpain.2016.02.008. [ Links ]

17. Miclescu A. Chronic pain patient and anaesthesia. Romanian Journal of Anaesthesia and Intensive Care 2019;26(1):59-66. DOI: 10.2478/rjaic-2019-0009. [ Links ]

18. Hunter OO, Mariano ER, Harrison TK. Leveraging Video Telehealth for Transitional Pain Service in Response to COVID-19. Regional Anesthesia and Pain Medicine First posted online: Jun 09, 2020. DOI: 10.1136/rapm-2020-101742. [ Links ]

19. Clarke H, Azargive S, Montbriand J, Nicholls J, Sutherland A, Valleva L, et al. Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service. Can J Pain. 2018;2:236-47. DOI: 10.1080/24740527.2018.1501669. DOI: 10.1080/24740527.2018.1501669. [ Links ]

20. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain. 2011;152(3):533-42. DOI: 10.1016/j. pain.2010.11.002. [ Links ]

21. Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and Commitment Therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain. 2017;33(6):552-68. DOI: 10.1097/AJP.0000000000000425 [ Links ]

22. Clarke H. Transitional Pain Medicine: novel pharmacological treatments for the management of moderate to severe postsurgical pain. Exp Rev Clin Pharmacol. 2016;9:3, 345-349. DOI: 10.1586/17512433.2016.1129896. [ Links ]

23. Vetter TR, Kain ZN. Role of the perioperative surgical home in optimizing the perioperative use of opioids. Anesth Analg. 2017;125(5):1653-7. DOI: 10.1213/ANE.0000000000002280. [ Links ]

24. Fregoso G, Wang A, Tseng K, Wang J. Transition from Acute to Chronic Pain: Evaluating Risk for Chronic Postsurgical Pain. Pain Physician 2019;22(5):479-88. [ Links ]

25. Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013;(7):CD008307. DOI: 10.1002/14651858.CD008307.pub2. [ Links ]

26. Koneti KK, Perfitt JS. Chronic pain management after surgery. Surgery (Oxford). 3 2019;7(8):467-71. DOI: 10.1016/j.mpsur.2019.05.008. [ Links ]

27. Mikhaeil J, Ayoo K, Clarke H, Wasowicz M, Huang A. Review of the Transitional Pain Service as a method of postoperative opioid weaning and a service aimed at minimizing the risk of chronic post-surgical pain. Anaesthesiology Intensive Therapy. 2020;52(2):148-53. DOI: 10.5114/ait.2020.96018. [ Links ]

Received: August 14, 2020; Accepted: November 24, 2020

Correspondence: Marcos Bolívar Bolívar mjbolivar2005@gmail.com

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