Prevention Of Chronic Postsurgical Pain Research Articles

Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in “at-risk” veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. PerspectiveThis pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.

Perioperative lidocaine infusions for the prevention of chronic postsurgical pain: a systematic review and meta-analysis of efficacy and safety.

Chronic postsurgical pain (CPSP) occurs in 12% of surgical populations and is a high priority for perioperative research. Systemic lidocaine may modulate several of the pathophysiological processes linked to CPSP. This systematic review aims to identify and synthesize the evidence linking lidocaine infusions and CPSP. The authors conducted a systematic literature search of the major medical databases from inception until October 2017. Trials that randomized adults without baseline pain to perioperative lidocaine infusion or placebo were included if they reported on CPSP. The primary outcome was the presence of procedure-related pain at 3 months or longer after surgery. The secondary outcomes of pain intensity, adverse safety events, and local anesthetic toxicity were also assessed. Six trials from 4 countries (n = 420) were identified. Chronic postsurgical pain incidence was consistent with existing epidemiological data. Perioperative lidocaine infusions significantly reduced the primary outcome (odds ratio, 0.29; 95% confidence interval, 0.18-0.48), although the difference in intensity of CPSP assessed by the short-form McGill Pain Questionnaire (4 trials) was not statistically significant (weighted mean difference, -1.55; 95% confidence interval, -3.16 to 0.06). Publication and other bias were highly apparent, as were limitations in trial design. Each study included a statement reporting no adverse events attributable to lidocaine, but systematic safety surveillance strategies were absent. Current limited clinical trial data and biological plausibility support lidocaine infusions use to reduce the development of CPSP without full assurances as to its safety. This hypothesis should be addressed in future definitive clinical trials with comprehensive safety assessment and reporting.

The efficacy and safety of first-line therapies for preventing chronic post-surgical pain: a network meta-analysis.

BackgroundDue to conflicting evidence regarding first-line therapies for chronic post-surgical pain (CPSP), here we comparatively evaluated the efficacy and safety of first-line therapies for the prevention of CPSP.Materials and MethodsMEDLINE, EMBASE, and Cochrane CENTRAL databases were searched for randomized, controlled trials (RCTs) of systemic drugs measuring pain three months or more post-surgery. Pairwise meta-analyses (a frequentist technique directly comparing each intervention against placebo) and network meta-analyses (a Bayesian technique simultaneously comparing several interventions via an evidence network) compared the mean differences for primary efficacy (reduction in all pain), secondary efficacy (reduction in moderate or severe pain), and primary safety (drop-out rate from treatment-related adverse effects). Ranking probabilities from the network meta-analysis were transformed using surface under the cumulative ranking analysis (SUCRA). Sensitivity analyses evaluated the impact of age, gender, surgery type, and outlier studies.ResultsTwenty-four RCTs were included. Mexiletine and ketamine ranked highest in primary efficacy, while ketamine and nefopam ranked highest in secondary efficacy. Simultaneous SUCRA-based rankings of the interventions according to both efficacy and safety revealed that nefopam and mexiletine ranked highest in preventing CPSP. Through the sensitivity analyses, gabapentin and ketamine remained the most-highly-ranked in terms of efficacy, while nefopam and ketamine remained the most-highly-ranked in terms of safety.ConclusionsNefopam and mexiletine may be considered as first-line therapies for the prevention of CPSP. On account of the paucity of evidence available on nefopam and mexiletine, gabapentin and ketamine may also be considered. Venlafaxine is not recommended for the prevention of CPSP.

Does perioperative ketamine have a role in the prevention of chronic postsurgical pain: the ROCKet trial.

Identifying operations and individuals with an increased risk of chronic postsurgical pain (CPSP) has led to significant interest in interventions with the potential to achieve primary prevention of this condition. Pharmacological prevention remains controversial with a Cochrane review identifying perioperative ketamine administration as the only intervention with possible benefit although, with only small, heterogeneous studies, the authors called for a large randomised controlled trial (RCT) to confirm the validity of this result. In response to these data, a group of researchers from Australia and Hong Kong designed the ROCKet trial - Reduction Of Chronic Post-surgical Pain with Ketamine, endorsed by the Australian and New Zealand College of Anaesthetists (ANZCA) Clinical Trials Network (CTN).

The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management.

In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major surgery continues to be problematic. This article briefly reviews the known psychological risk and protective factors associated with the development of chronic postsurgical pain (CPSP). We begin with a definition of CPSP and then explain what we mean by a risk/protective factor. Next, we summarize known psychological risk and protective factors for CPSP. Psychological interventions that target risk factors and may impact postsurgical pain are reviewed, including the acceptance and commitment therapy (ACT)-based approach to CPSP prevention and management we use in the Transitional Pain Service (TPS) at the Toronto General Hospital. Finally, we conclude with recommendations for research in risk factor identification and psychological interventions to prevent CPSP. Several pre-surgical psychological risk factors for CPSP have been consistently identified in recent years. These include negative affective constructs, such as anxiety symptoms, depressive symptoms, pain catastrophizing and general psychological distress. In contrast, relatively few studies have examined psychological protective factors for CPSP. Psychological interventions that target known psychological risk factors while enhancing protective psychological factors may reduce new incidence of CPSP. The primary goal of our ACT intervention is to teach patients a mindful way of responding to their postsurgical pain that empowers them to interrupt the negative cycle of pain, distress, behavioural avoidance and escalating opioid use that can limit functioning and quality of life while paradoxically amplifying pain over time. Early clinical outcome data suggest that patients who receive care from TPS physicians reduce their pain and opioid use, yet patients who also receive our ACT intervention have a larger decrease in daily opioid dose while reporting less pain interference and lower depression scores.

Prevention of chronic post-surgical pain: the importance of early identification of risk factors.

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.

Perioperative interventions for the reduction of chronic postsurgical pain

In this issue of PAIN, Martinez and co-workers publish a systemic review with a meta-analysis of randomized trials on the effect of perioperative pregabalin for the prevention of chronic postsurgical pain (CPSP).12 The primary outcome was CPSP after 3 months. Secondary outcomes included CPSP after 6

Postoperative Pain Management: Clinical Practice Guidelines

OVER THE PAST 2 decades, there has been an increased emphasis on the need for effective management of acute pain. The focus on pain management was sharpened when the Joint Commission on Accreditation of Healthcare Organizations integrated the requirement for pain assessment and management into their standards in 2000. 1 Berry P.H. Dahl J.L. The new JCAHO pain standards: Implications for pain management nurses. Pain Manag Nurs. 2000; 1: 3-12 Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar Acute postoperative pain, however, continues to be inadequately controlled. Among patients who have had surgical procedures, 80% experience postoperative pain and 75% or more of them report pain that is at a moderate, severe, or extreme level. 2 Gan T.J. Habib A.S. Miller T.E. White W. Apfelbaum J.L. Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin. 2014; 30: 149-160 Crossref PubMed Scopus (454) Google Scholar Inadequately treated acute pain is associated with the risk for the development of persistent postsurgical pain. 3 Clarke H. Bonin R.P. Orser B.A. Englesakis M. Wijeysundera D.N. Katz J. The prevention of chronic postsurgical pain using gabapentin and pregabalin: A combined systematic review and meta-analysis. Anesth Analg. 2012; 115: 428-442 Crossref PubMed Scopus (298) Google Scholar , 4 Page M.G. Katz J. Romero Escobar E.M. et al. Distinguishing problematic from nonproblematic postsurgical pain: A pain trajectory analysis after total knee arthroplasty. Pain. 2015; 156: 460-468 Crossref PubMed Scopus (68) Google Scholar Poor pain control has significant physiological consequences that can ultimately result in impaired recovery, decreased function, and reduced quality of life. 2 Gan T.J. Habib A.S. Miller T.E. White W. Apfelbaum J.L. Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin. 2014; 30: 149-160 Crossref PubMed Scopus (454) Google Scholar , 5 Argoff C.E. Recent management advances in acute postoperative pain. Pain Pract. 2014; 14: 477-487 PubMed Google Scholar Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner, Pain Management, Westchester Medical Center, Valhalla, NY

Antidepressant Drugs for Postsurgical Pain: Current Status and Future Directions.

Current treatments for postsurgical pain are often inadequate and adverse effects are substantial such that residual pain and/or side effects impair recovery. The recognition of analgesic efficacy with antidepressant drugs for chronic pain suggests the potential for efficacy in acute postsurgical pain. As reviewed here, current evidence suggests that approximately half of previous trials suggest efficacy of various antidepressants for acute postoperative pain. However, most trials are older with deficiencies including: lack of designation of a primary outcome, no assessment of movement-evoked pain, small size and limited safety assessment. Only one of three trials addressing prevention of chronic postsurgical pain suggested any efficacy; however, the evidence base for this indication is limited. Thus, current evidence does not yet support routine use of any one specific antidepressant for treatment of acute, or prevention of chronic, postsurgical pain. However, limitations in available trials are such that one cannot yet rule out the possibility that one or more antidepressant drugs may provide benefit in specific populations. Therefore, future larger trials should explore optimal dosing and duration of antidepressant treatment, procedure specificity, safety evaluation, and assessment of movement-evoked pain.

Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain.

Chronic post-surgical pain (CPSP) is a serious complication of major surgery that can impair a patient's quality of life. The development of CPSP is a complex process which involves biologic, psychosocial, and environmental mechanisms that have yet to be fully understood. Currently perioperative pharmacologic interventions aim to suppress and prevent sensitization with the aim of reducing pain and analgesic requirement in acute as well as long-term pain . Despite the detrimental effects of CPSP on patients, the body of literature focused on treatment strategies to reduce CPSP remains limited and continues to be understudied. This article reviews the main pharmacologic candidates for the treatment of CPSP, discusses the future of preventive analgesia, and considers novel strategies to help treat acute post-operative pain and lessen the risk that it becomes chronic. In addition, this article highlights important areas of focus for clinical practice including: multimodal management of CPSP patients, psychological modifiers of the pain experience, and the development of a Transitional Pain Service specifically designed to manage patients at high risk of developing chronic post-surgical pain.

Risk factors and early pharmacological interventions to prevent chronic postsurgical pain following cardiac surgery.

Chronic postsurgical pain (CPSP) after cardiac surgery represents a significant clinical problem. The prevalence of CPSP varies widely between studies, but severe CPSP is present in less than 10% of the patients. Important differential diagnoses for CPSP after cardiac surgery are myocardial ischemia, sternal instability and mediastinitis. CPSP after cardiac surgery may be thoracic pain present at the site of the sternotomy or leg pain due to vein-graft harvesting. The CPSP can be neuropathic pain, visceral pain, somatic pain or mixed pain. Potential risk factors for CPSP are young age, female gender, overweight, psychological factors, preoperative pain, surgery-related factors and severe postoperative pain. In addition to standard postoperative analgesics, the use of N-methyl-D-aspartate (NMDA) antagonists, alpha-2 agonists, local anesthetics, gabapentinoids, and corticosteroids are all proposed to reduce the risk for CPSP after cardiac surgery. Still, no specific pharmacological therapy, cognitive therapy or physical therapy is established to protect against CPSP. The only convincing prevention of CSPS is adequate treatment of acute postoperative pain irrespective of method. Hence, interventions against acute pain, preferably in a step-wise approach titrating the interventions for each patient's individual needs, are essential concerning prevention of CPSP after cardiac surgery. It is also important that surgeons consider the risk for CPSP as a part of the basis for decision-making around performing a surgical procedure and that patients are informed of this risk.

Post-surgical pain syndromes: a review for the non-pain specialist

This is a selective narrative review of the latest information about the epidemiology, impact, and prevention of chronic post-surgical pain (CPSP), intended primarily for those without a special interest in pain medicine. Chronic post-surgical pain is an important problem in terms of personal impact. It has staggering economic implications, exerts powerful negative effects on the quality of life of many of those it afflicts, and places a significant burden on chronic pain treatment services in general. It is well known that surgery at certain body sites is apt to cause CPSP, but emerging evidence shows a strong correlation between CPSP and demographic (young age, obesity, and female sex) and psychological characteristics (anxiety, depression, stress, and catastrophizing). Severe acute pain is a strong risk factor for CPSP, and this adds yet more weight to the argument that acute pain should be controlled effectively. In specific circumstances, CPSP can be reduced by regional anesthetic techniques, infiltration of local anesthetic, or preoperative use of gabapentin. The ability of other known interrupters of afferent nociceptive transmission-commonly used to reduce CPSP when administered at the time of surgery-is currently unproven, as is the hypothesis that the use of remifentanil during surgery worsens CPSP. Reduction of CPSP is a worthy long-term outcome for anesthesia providers to consider as they plan the perioperative care of their patients. More evidence is needed about the effect of currently used analgesics and other perioperative techniques on CPSP.

In Response

Our systematic review1 was created as outlined in our search strategy by an experienced information specialist. The PRISMA guidelines published in 2009 do not endorse searching clinical trial registries.2,3 Recently, the Methodological Expectations of Cochrane Intervention Reviews4 has been updated with the following statement: Searches for studies should be as extensive as possible in order to reduce the risk of publication bias and to identify as much relevant evidence as possible. Although ClinicalTrials.gov is included as one of the registers within the WHO ICTRP portal, it is recommended that both ClinicalTrials.gov and the ICTRP portal are searched separately due to additional features in ClinicalTrials.gov. However, prompted by Dr. Chelly’s comments5 we have conducted an updated analysis using the ClinicalTrials.gov data to determine whether: (1) there is evidence of a publication bias and (2) the positive effects of pregabalin we reported are maintained. With the new data sets included from the 3 unpublished Pfizer pregabalin studies using participants that received 300 mg of pregabalin 3 months after surgery on the incidence of chronic postsurgical pain after total knee arthroplasty (22/59 pregabalin vs 27/61 placebo),6 total abdominal hysterectomy (22/127 pregabalin vs 14/141 placebo),7 and inguinal hernia repair (5/101 pregabalin vs 3/101 placebo),8 the pooled odds ratio for the incidence of chronic postsurgical pain with the 5 pregabalin studies becomes an odds ratio 0.73 (0.28–1.89, P = 0.51). These new data question the positive pregabalin findings published to date with respect to the prevention of chronic postsurgical pain. We are supportive of the position that IRB-approved clinical trials should be registered and reported to ensure that publication bias is minimized when assessing clinical trials and meta-analyses. However, and in view of the fact that it is unlikely that the unpublished Pfizer data will ever become part of the peer-reviewed literature, it remains to be determined how data not undergoing the scrutiny of rigorous peer review should be weighed against published studies. Our review article was written to examine the use of this class of medication in the perioperative setting for the prevention of chronic postsurgical pain based on the published literature available at that time. Studies evaluating the effectiveness of these agents in the acute and chronic postoperative pain settings continue to be published with mixed results.9,10 It remains to be seen what the final verdict will be with respect to the benefits versus risks of these medications in the perioperative setting. Some institutions have adopted them routinely in a multimodal perioperative care pathway, whereas others have stepped away given the side-effect profiles of these medications. To that end, Dr. Chelly reiterates our cautionary note regarding the use of larger doses of the α-2-Δ ligands given the increase in sedation and somnolence in the acute postoperative period seen most often in the elderly population and patients with compromised renal function. Once again, given the limited number of studies identified in our review, the clinical heterogeneity of the trials identified, and the now documented evidence of a pregabalin publication bias,2 future well-designed, appropriately powered studies are needed to clarify whether the α-2-δ calcium channel blockers have a role in the prevention of chronic postsurgical pain. Hance Clarke, MD, MSc, FRCPC Duminda N. Wijeysundera, MD, PhD, FRCPC Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network, Merit Award Recipients Department of Anesthesia University of Toronto Toronto, Ontario [email protected] Robert P. Bonin, PhD Centre de Recherche Université Laval Robert-Giffard Université Laval, Québec Beverley Orser, MD, PhD, FRCPC Department of Anesthesia Sunnybrook Health Sciences Centre, Toronto Marina Englesakis, BA, MLIS Information Specialist for Surgical Division, Neurosciene, and Medical Education University Health Network, Toronto Joel Katz, PhD Department of Psychology York University, Toronto, Ontario, Canada

Pregabalin Effective for the Prevention of Chronic Postsurgical Pain

Pregabalin Effective for the Prevention of Chronic Postsurgical Pain

Prevention of Chronic Postsurgical Pain

Prevention of Chronic Postsurgical Pain

Prevention of Chronic Postsurgical Pain Using Gabapentin and Pregabalin

Prevention of Chronic Postsurgical Pain Using Gabapentin and Pregabalin

Causes and prevention of chronic postsurgical pain

Surgical incision invariably causes some measure of nerve damage and inflammatory response that, in most cases, heals quickly without long-term negative consequence. However, a subset of these patients go on to develop lasting neuropathic pain that is difficult to treat and, in many cases, prevents the return to normal activities of life. It remains unknown why two patients with identical surgical interventions may go on to develop completely divergent pain phenotypes or no pain at all. Aggressive, early analgesic therapy has been shown to reduce the incidence of chronic postsurgical pain (CPSP), but no specific regional anesthetic technique or systemic pharmacologic therapy has been shown to prevent CPSP. Inflammation and glial cell activation have recently been shown to be just as important in the transition from normal acute pain to pathologic chronic pain as nerve injury itself and that central sensitization may not be solely due to repetitive nociceptive firing at the time of nerve injury. This has opened a number of new therapeutic possibilities for prevention of CPSP. Here, we discuss the causes of CPSP and current useful preventive strategies in the perioperative period. We also discuss future potential disease-modifying treatments of CPSP.

The Prevention of Chronic Postsurgical Pain Using Gabapentin and Pregabalin

Many clinical trials have demonstrated the effectiveness of gabapentin and pregabalin administration in the perioperative period as an adjunct to reduce acute postoperative pain. However, very few clinical trials have examined the use of gabapentin and pregabalin for the prevention of chronic postsurgical pain (CPSP). We (1) systematically reviewed the published literature pertaining to the prevention of CPSP (≥ 2 months after surgery) after perioperative administration of gabapentin and pregabalin and (2) performed a meta-analysis using studies that report sufficient data. A search of electronic databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, IPA, and CINAHL) for relevant English-language trials to June 2011 was conducted. The following inclusion criteria for identified clinical trials were used for entry into the present systematic review: randomization; double-blind assessments of pain and analgesic use; report of pain using a reliable and valid measure; report of analgesic consumption; and an absence of design flaws, methodological problems or confounders that render interpretation of the results ambiguous. Trials that did not fit the definition of preventive analgesia and did not assess chronic pain at 2 or more months after surgery were excluded. The database search yielded 474 citations. Eleven studies met the inclusion criteria. Of the 11 trials, 8 studied gabapentin, 4 of which (i.e., 50%) found that perioperative administration of gabapentin decreased the incidence of chronic pain more than 2 months after surgery. The 3 trials that used pregabalin demonstrated a significant reduction in the incidence of CPSP, and 2 of the 3 trials also found an improvement in postsurgical patient function. Eight studies were included in a meta-analysis, 6 of the gabapentin trials demonstrated a moderate-to-large reduction in the development of CPSP (pooled odds ratio [OR] 0.52; 95% confidence interval [CI], 0.27 to 0.98; P = 0.04), and the 2 pregabalin trials found a very large reduction in the development of CPSP (pooled OR 0.09; 95% CI, 0.02 to 0.79; P = 0.007). The present review supports the view that perioperative administration of gabapentin and pregabalin are effective in reducing the incidence of CPSP. Better-designed and appropriately powered clinical trials are needed to confirm these early findings.

Development of a risk index for the prediction of chronic post‐surgical pain

The incidence of chronic post-surgical pain (CPSP) after various common operations is 10% to 50%. Identification of patients at risk of developing chronic pain, and the management and prevention of CPSP remains inadequate. The aim of this study was to develop an easily applicable risk index for the detection of high-risk patients that takes into account the multifactorial aetiology of CPSP. A comprehensive item pool was derived from a systematic literature search. Items that turned out significant in bivariate analyses were then analysed multivariately, using logistic regression analyses. The items that yielded significant predictors in the multivariate analyses were compiled into an index. The cut-off score for a high risk of developing CPSP with an optimal trade-off between sensitivity and specificity was identified. The data of 150 patients who underwent different types of surgery were included in the analyses. Six months after surgery, 43.3% of the patients reported CPSP. Five predictors multivariately contributed to the prediction of CPSP: capacity overload, preoperative pain in the operating field, other chronic preoperative pain, post-surgical acute pain and co-morbid stress symptoms. These results suggest that several easily assessable preoperative and perioperative patient characteristics can predict a patient's risk of developing CPSP. The risk index may help caregivers to tailor individual pain management and to assist high-risk patients with pain coping.

Chronic post-surgical pain: Epidemiology and clinical implications for acute pain management

Summary Chronic post-surgical pain (CPSP) is an under-recognised and prevalent healthcare problem associated with significant morbidity and potential economic costs. Risk factors include the type of surgery, pre-existing pain, re-operation, nerve damage, moderate-to-severe acute post-operative pain, neurotoxic radio or chemotherapy and psycho-social factors. CPSP has a multifactorial aetiology, principally nerve injury and wound inflammatory response, leading to peripheral and central sensitisation. The extent of wound hyperalgesia following abdominal surgery correlates with the incidence of CPSP but not with acute pain outcomes, reflecting the relative importance of central sensitisation in the development of CPSP. The contributions of genetics, gender, age, opioid-induced hyperalgesia, pre-existing pain disorders and psycho-social factors to the pathogenesis of CPSP have yet to be clarified. The prevention of CPSP includes limiting nerve and tissue injury at the time of surgery and in some cases using preventive analgesia techniques such as regional neural blockade or low-dose ketamine infusion. Other strategies such as education, patient surveillance, management of psycho-social factors and functional rehabilitation may also be beneficial, although there are no data to support this. Further research is required to develop ‘predictive tools’ and to examine the effects of multimodal “protective” analgesia and multidisciplinary approaches in the prevention and treatment of CPSP.