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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