A unique pain program is helping complex surgical patients wean off opioids safely and effectively, while offering alternative ways to cope with their pain and improve how they function.
Prescription opioids play an important role in addressing certain kinds of pain – they are the best pharmacological option available for acute pain and widely used for cancer-related pain.
But the high overall rate of opioid prescribing in Canada has raised concerns, and prescribing in the context of non-cancer pain has been called into question. Health Quality Ontario and the Canadian Pain Society have created guidelines indicating opioids should not be considered the first line of defense in non-cancer pain.
Results are published in the Canadian Journal of Pain in August, under the title, “Opioid Weaning and Pain Management in Post-Surgical patients at the Toronto General Hospital Transitional Pain Service.”
The study followed patients at high-risk for developing chronic pain and problematic opioid use for six months after surgery. In patients who did not take opioids for a year before surgery, the study found that 69 per cent were able to reduce their opioid consumption, with 45 per cent of them being able to stop completely.
Those patients who were taking a prescription opioid before surgery reduced their opioid use by 44 per cent, with 26 per cent of them weaning off completely.
“The assumption is that all patients after surgery are fine with their opioid use, but we have found that in a high-risk segment of patients, that is not the case,” says Dr Hance Clarke, Director of the Transitional Pain Service at TG. “We need better ways of identifying these patients, and then helping those who are having difficulty in reducing or eliminating their opioid use.”
“Otherwise, we run the risk of de-escalating patients too fast and having them look elsewhere for opioids or other drugs if we don’t guide them.”
A 2016 study on the Transitional Pain Program at TG estimated that about 15 per cent of complex postoperative pain patients develop moderate to severe chronic, post-surgical pain, have significant disability and continue to use opioids for pain relief long-term.
Follow-up for the surgical patients referred to the Transitional Pain Program in this study included a phone call within 72 hours after surgery and follow-up meetings twice a month initially, and then monthly from three to six months. The goal is to prevent acute pain from becoming chronic post-surgical pain and taper opioid use or wean to zero if possible.
The Transitional Pain Program at TG uses a variety of methods to help and teach patients to manage their pain. These include prescribing non-opioid medications, use of psychological techniques, such as mindfulness or moment-by-moment awareness of our thoughts and sensations, as well as “exercise prescriptions” and acupuncture by a team of pain specialists, including physicians, nurses, psychologists, and physiotherapists.
The program also provides much-needed support for patients and primary care physicians after hospital discharge.
Sheldon Fine, 67, who is a medical oncologist in Peel Region, had thoracic surgery to remove a huge benign mass on his right lung in 2017. Because of the pain after his hospital discharge, he found himself on a daily dose of 120 milligrams of hydromorphone, a strong opioid that is five times more powerful than morphine.
With the help of the Transitional Pain Program at TG, his family and a strong desire to get off the opioid, he was able to taper down to 5 milligrams a day within five weeks, and eventually was able to get off the opioid completely.
Today, he runs marathons with his daughters and is back at work full-time.
“It was team work,” he says. “The program involves patients every step of the way and sets milestones with them. They use different techniques such as physiotherapy and mindfulness training and the staff are so responsive to a patient’s concerns and questions.”
One of the strongest predictors in the study of remaining on opioids long-term after hospital discharge is the dose upon discharge: the higher the dose, the more likely the patient will remain on opioids long-term.
For patients who were on opioids before surgery, emotional distress factors such as anxiety or depression, and pain catastrophising – excessive pain-related worry, along with an inability to deflect thoughts from pain – were important factors in how well these patients could wean off opioids.
A 2017 study on the Transitional Pain Program of post-surgical patients showed that a combined approach of mindfulness meditation along with specific psychological coping skills helped patients wean off high-doses of opioids and reduce their pain-related distress and disability.