Perioperative Pain Management for the Chronic Pain Patient With Long-Term Opioid Use

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions.Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

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Perioperative Pain Management and Avoidance of Long-term Opioid Use

Sports Medicine and Arthroscopy Review ◽

10.1097/jsa.0000000000000244 ◽

2019 ◽

Vol 27 (3) ◽

pp. 112-118 ◽

Cited By ~ 2

Author(s):

Michael S. Patzkowski ◽

Jeanne C. Patzkowski

Keyword(s):

Pain Management ◽

Opioid Use ◽

Perioperative Pain ◽

Perioperative Pain Management

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Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery

Otolaryngology ◽

10.1177/01945998211071116 ◽

2022 ◽

pp. 019459982110711

Author(s):

Michael T. Chang ◽

M. Lauren Lalakea ◽

Kimberly Shepard ◽

Micah Saste ◽

Amanda Munoz ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Lower Amount ◽

Opioid Use ◽

Protocol Implementation ◽

Perioperative Pain ◽

Management Protocol ◽

Before And After ◽

Perioperative Pain Management ◽

Low Levels

Objective To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. Study Design Retrospective cohort study. Setting County hospital otolaryngology practice. Methods A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. Results We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 ( P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased ( P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased ( P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. Conclusion Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

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Perioperative Pain Management: Multi-modalities to Prevent Postoperative Chronic Pain

The SAGES Manual of Groin Pain ◽

10.1007/978-3-319-21587-7_14 ◽

2016 ◽

pp. 193-208

Author(s):

Brian J. Dunkin

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Perioperative Pain ◽

Perioperative Pain Management

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Online group pain management for chronic pain: Preliminary results of a novel treatment approach to teletherapy

Journal of Telemedicine and Telecare ◽

10.1177/1357633x19870369 ◽

2019 ◽

pp. 1357633X1987036

Author(s):

Timothy Y Mariano ◽

Limeng Wan ◽

Robert R Edwards ◽

Asimina Lazaridou ◽

Edgar L Ross ◽

...

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Group Discussion ◽

Preliminary Investigation ◽

Skills Training ◽

Chronic Pain Patient ◽

Behavioural Therapy ◽

Pain Patient ◽

Cognitive Behavioural ◽

Online Group

Objective This pilot study was designed to determine the feasibility, tolerability, safety, and efficacy of group teletherapy for persons with chronic pain. The aim was to present preliminary outcomes of an open trial of group cognitive behavioural therapy (CBT) teletherapy compared with an in-person chronic pain patient group. Methods We recruited 47 chronic pain patients to participate in an 8-session, 2-hour-per-week, online, structured, CBT-oriented pain management group using WebEx and compared them with 46 subjects who participated in a parallel, content-matched, in-person, weekly group. Both groups included goal setting, skills training, relaxation exercises, group discussion, and practice assignments. All subjects completed baseline measures, which were repeated post-treatment. Those in the online group participated in weekly telephone interviews and rated the perceived helpfulness of the remote group. Results The average age of the online group participants was 54.5 ( ± 14.3) years and 70.2% were female, compared with 59.7 ( ± 13.0) years of age and 57.8% females among the in-person group members. On follow-up, both CBT groups showed modest improvements on the outcome measures. Results of this preliminary investigation comparing online teletherapy with in-person CBT suggest similar benefit. Many participants in the online group rated their experience as very helpful (62.5%; 7–10/10) and most would recommend this programme to others (93.7%; 7–10/10). Discussion Preliminary findings suggest that online group CBT may be as effective in improving coping among persons with chronic pain as in-person groups. More rigorous controlled trials are needed to adequately assess the outcome benefit of online teletherapy for chronic pain.

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Achieving the Right Balance in Oversight of Physician Opioid Prescribing for Pain: The Role of State Medical Boards

The Journal of Law Medicine & Ethics ◽

10.1111/j.1748-720x.2003.tb00057.x ◽

2003 ◽

Vol 31 (1) ◽

pp. 21-40 ◽

Cited By ~ 42

Author(s):

Diane E. Hoffmann ◽

Anita J. Tarzian

Keyword(s):

Pain Management ◽

Pain Treatment ◽

Chronic Pain Patient ◽

Disciplinary Action ◽

Pain Patient ◽

Disciplinary Actions ◽

Noncancer Pain ◽

The Right ◽

State Medical Boards

Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have investigated and, in some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment.

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