Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service

Abstract

BackgroundChronic postsurgical pain and opioid use is a problem among patients undergoing many types of surgical procedures. A multidisciplinary approach to perioperative pain management known as a transitional pain service (TPS) may lower these risks.MethodsThis retrospective cohort study was conducted at the Salt Lake City VA Medical Center to compare patients undergoing elective primary or revision total knee, hip, or shoulder replacement or rotator cuff repair in the year before (2017) and after (2018) implementation of a TPS. The primary outcome is the proportion of patients taking opioids 90 days after surgery. Secondary outcomes include new chronic opioid use (COU) after surgery as well as the proportion of previous chronic opioid users who stopped or decreased opioid use after surgery.ResultsAt 90 days after surgery, patients enrolled in TPS were significantly less likely to be taking opioids (13.4% TPS vs 27.3% pre-TPS; p=0.002). This relationship remained statistically significant in a multivariable logistic regression analysis, where the TPS group had 69% lower odds of postoperative COU compared with the preintervention group (OR: 0.31; 95% CI: 0.14 to 0.66; p=0.03). Opioid-naive patients enrolled in TPS were less likely to have new COU after surgery (0.7% TPS vs 8.4% pre-TPS; p=0.004). Further, patients enrolled in TPS with existing COU prior to surgery were more likely to reduce or completely stop opioid use after surgery (67.5% TPS vs 45.3% pre-TPS; p=0.037) as compared with pre-TPS.ConclusionsThese data suggest that a TPS is an effective strategy for preventing new COU and reducing overall opioid use following orthopedic joint procedures in a Veterans Affairs hospital.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

“…The key characteristics of the 66 included studies [ 5 , 50 – 114 ] are detailed in Table 1 : Study Characteristics, Description of Strategies and Outcomes. Most studies used a retrospective cohort ( n = 35) [ 5 , 52 , 56 , 60 , 72 – 74 , 78 – 89 , 91 – 94 , 97 – 99 , 101 – 105 , 108 , 109 , 111 , 112 ], a randomized controlled trial (RCT) ( n = 24) [ 50 , 51 , 53 – 55 , 57 , 59 , 61 , 62 , 65 – 71 , 75 , 76 , 95 , 100 , 106 , 107 , 113 , 114 ] or a prospective cohort ( n = 7) [ 58 , 63 , 64 , 77 , 90 , 96 , 110 ] design. Almost all the studies were conducted in the U.S. ( n = 58) [ 5 , 50 – 57 , 59 – 61 , 63 , 67 – 74 , 77 – 99 , 101 – 114 ].…”

“… Multimodal Urban 2021 USA [ 108 ] Retrospective cohort 267 67 63% TKA Preoperative cryoneurolysis (1 min 45 sec cycle in the infrapatellar branches of the saphenous nerve near the knee and branches of the femoral cutaneous nerves in the mid-to-distal anterior thigh + standard multimodal regiment. Standard multimodal regiment (preoperative protocol + postoperative : oral acetaminophen 500 mg every 6 hours, oral meloxicam 7.5mg twice daily, oral tramadol 50 mg every 6 hours as needed for pain, oral oxycodone 5 mg every 3 hours as needed) Cumulative MED 6 weeks: Mean: I: 894; C: 1,406.00 Ratio estimate : 0.64 95% CI 0.57-0.71, p < 0.001 Proportion of patients who received ≥ 1 prescription at 6 weeks I: 12.00%; C: 20.00% Ratio estimate : 0.61 95% CI 0.29-1.28, p < 0.19 Buys 2020 USA [ 109 ] Retrospective cohorte 336 65 10 % RCR, THA, TKA, TSA (veteran population) Implementation of a Transitional Pain Service. Multidisciplinary providers work together to deliver comprehensive pain management for any surgical patient at risk for CPSP and COU in preoperative, surgical hospitalization and postoperative period up to 6 months.…”

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

“…One promising model of care is the transitional pain service which bridges the gap between acute postoperative recovery and the return to routine primary and preventative care. [63][64][65][66][67] This type of service may offer the potential benefit of early detection and intervention related to greater than expected postoperative pain amplitude, duration, and opioid use as well as preoperative consultation. 28 63 It is important to note that principle 7 was identified by participants as one of the most challenging to implement, primarily due to access to specialists.…”

The opioid epidemic from the acute care hospital front line

“…4 , 30 In some centres this has been made easier because of the development of newer, integrated models of care, including transitional pain services, acute pain service outpatient services and the perioperative surgical home, which may first see patients prior to admission, then during admission and also after discharge. 111–114 Review by one of these multidisciplinary teams also provides an opportunity to improve preoperative pain, function and psychological distress, which in turn can reduce postoperative pain, anxiety and depression, optimise pharmacological and non-pharmacological pain therapies and improve physical function, and provide appropriate education. 4 , 76 , 113 Postoperative reviews after discharge by these services may also decrease the risk of PPOU and chronic postsurgical pain.…”

“…4 , 76 , 113 Postoperative reviews after discharge by these services may also decrease the risk of PPOU and chronic postsurgical pain. 113 , 115–117…”