Background & Aims
Pain which persists longer than 3 months after surgery is common and associated with functional disability. Patients with pre-existing chronic pain, opioid use, and psychosocial factors are at greatest risk. Furthermore, the use of prescribed opioids for persistent pain has increased substantially, causing additional harm to this population.
The Austin Transition Clinic treats patients with complex pain of any cause during the sub-acute period, up to 3 months after hospital discharge. However, most patients are seen and discharged by the clinic within one month. We provide targeted follow-up aiming to reduce the risks of persistent pain, disability, and opioid use. Pain Nurse Consultants assess patients’ pain experiences, functional progress, and analgesia use, provide patient education, physiotherapy referrals, and letters to GPs, with the guidance of a Specialist Anaesthetist.
We sought to evaluate clinic outcomes by examining audit data from patients first seen in 2023.
Methods
The clinic collected audit data on all patients in 2023, including patient characteristics and opioid dose at baseline and clinic discharge.
To estimate the risks of Persistent Post-Surgical Pain and opioid use, we measured outcomes 3-6 months after hospital discharge in a sample of patients. Data was sourced from a quality improvement pilot survey conducted by the clinic from November 2023 to January 2024 (n=29), and the Austin Orthopaedic Clinical Quality Registry (n=18). Both projects assessed function using the EQ-5D-5L.
The clinic survey included 5-point Likert scales for patients to rate the degree to which pain limited the other dimensions of health, and how much these had changed from baseline levels. The orthopaedic registry also measured EQ-5D at baseline.
We compared patients seen from January to July 2023 (n=110), with those followed up at 3-6 months (n=47) using chi-squared and Wilcoxon rank-sum tests; and change in opioid dose using Signed-Rank tests in Stata 15.
Results
Median [IQR] oral morphine equivalent daily doses (oMEDD) were reduced from baseline to clinic discharge (45mg [15-80] to 30mg [0-60], p<0.01), and further reduced at follow up (20mg [4-45], p<0.01). At follow up, most patients had slight or no problems with mobility, self-care, usual activities, and mental state, rating their overall health 60 [50-80] out of 100. Ongoing pain affected 81%, with moderate limitations in mobility, usual activities and sleep reported by >50% of the survey group. However, 70-80% of survey and 100% of orthopaedic patients rated these as equal or improved from baseline. 37% attributed some or all their pain to other causes, and 34% were readmitted within 90 days.
There were no differences between groups in gender (64% female), prevalence of chronic pain (68%), psychosocial risk factors (45%), baseline oMEDD, or time to clinic discharge (29 [20-59] days). Patients followed up had a higher median age by 8 years (60 [53-66] vs. 52 [38-65] years, p=0.04).
Conclusions
An interdisciplinary Transition Clinic can effectively support patients with complex pain during the sub-acute period after a hospital admission, and mitigate risks of post-operative opioid use.
Meaningful reductions in opioid doses from baseline are achievable and likely to continue even after clinic discharge.
Although many patients with complex pain at baseline continue to experience some pain, education and support during this time of change can facilitate the adoption of new management strategies, resulting in improvement in symptoms and function as they recover.
The public health burdens of persistent pain and opioid use warrant development of transitional pain services to improve patient outcomes.
Future work in the clinic aims to integrate functional assessments for all patients at baseline and follow-up, and conduct a prospective controlled study to measure clinic impact.
References
1. Treede, R; Rief, W; Barke, A; Aziz, Q; Bennett, M; Benoliel, R; et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). PAIN 160(1):p 19-27, January 2019.
2. Australian Institute of Health and Welfare (2020) Chronic pain in Australia, AIHW, Australian Government, available at: https://www.aihw.gov.au/reports/chronic-disease/chronic-pain-in-australia/summary
3. Mikhaeil J, Ayoo K, Clarke H, W?sowicz 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):148-153. ?
4. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276-86. doi: 10.7326/M14-2559. PMID: 25581257.
5. Katz J, Weinrib AZ, Clarke H. Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service. Can J Pain. 2019 Jul 30;3(2):49-58.
Presenting Author
Ms Margaret Phillips
Poster Authors
Margaret Phillips
MSc
Austin Health
Lead Author
Charlotte Heldreich
BSc(Hons) MBChB FANZCA
Austin Health
Lead Author
Frances Pontonio
BNurs MScMed (Pain Management)
Austin Health
Lead Author
Jennifer Collins
BNurs
Austin Health
Lead Author
Ali Jarman
BMBS BA(Hons) FANZCA MA (Science Writing)
Austin Health
Lead Author
Chong Tan
MBBS
Austin Health
Lead Author
Topics
- Treatment/Management: Pharmacology: Psychological and Rehabilitative Therapies