Pain Management

Significant acute postoperative pain is common, even among those on an established pain management protocol (1). Pain after surgery is associated with increased risk of postoperative readmission to hospital, emergency department visits, myocardial injury, delirium, and chronic pain (2-7). Postoperative pain control may be improved by addressing modifiable patient risk factors such as sleep, BMI, depression, anxiety, and preoperative pain (8).

Screening Tools

The Perioperative Opioid Quality Improvement (POQI) score is a screening tool being developed at St. Paul's Hospital to identify patients at increased risk of significant postoperative pain and long-term opioid use. While the POQI score is not yet validated, it was selected to support postoperative pain risk stratification based on clinical experience using this tool in British Columbia. 

Preoperatively, it screens patients for common variables associated with an increased risk for developing postoperative pain. Postoperatively, inpatient consumption of > 90 morphine milligram equivalents per day is used as a surrogate marker for assessing performance of the preoperative screening tool (9).  Patients with a POQI score >= 7 (out of a possible total of 35) are considered to be at ‘increased risk’ of significant postoperative pain and long-term opioid use and should receive a personalized care plan to help reduce their initial exposure to opioids. (9)

Perioperative Opioid Quality Improvement (POQI) Assessment

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education
  • Set patient expectations for postoperative pain management
  • "Achieving zero pain is not realistic. The goal is to achieve a level of pain that allows patients to breathe deeply and cough, get up and move, do exercises or physio, and rest or sleep when it is time to do so. There are many ways to achieve this."
Self-Referral Options
  • Refer to online patient resources including access to the following:
    • Managing Pain Before and After Surgery (PainBC): A free self-paced online program for people having surgery and their families to better manage pain after surgery and decrease complications.
    • Coaching for Health (PainBC): A free one-on-one telephone coaching program designed to help people living with chronic pain learn self-management skills, regain function, and improve well-being
    • Empowered Relief (Pain Canada) - a free 2 hour CBT module for managing pain
    • Power Over Pain Portal - a national hub for pain resources
    • Gentle Movement at Home video series
Referral for Anesthesia Consult
  • To develop effective pain management strategies and explore options for anesthesia and postoperative pain control, especially in moderate to severely invasive surgery
Physician-Referral Options
  • Mind-space.ca - MSP-funded virtual group medical visits for mental wellbeing, anxiety, depression. *All patients referred to Mind Space must have a current primary care provider.
  • Referral to Transitional Pain Clinic
    • Transitional pain clinics are short-term outpatient services that manage pain before and after surgery to prevent acute pain from becoming chronic. Currently available at Vancouver Coastal Health and Providence Health sites.
  • Referral to Chronic Pain Clinic - find local clinics on Pathways BC.

References

1. Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G., Peters, M. L., Geurts, J. W., Gramke, H. F., & Marcus, M. A. (2008). The prevalence of postoperative pain in a sample of 1490 surgical inpatients. European journal of anaesthesiology, 25(4), 267–274. https://doi.org/10.1017/S0265021507003031

2. Katz, J., Jackson, M., Kavanagh, B. P., & Sandler, A. N. (1996). Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. The Clinical journal of pain, 12(1), 50–55. https://doi.org/10.1097/00002508-199603000-00009

3. Hernandez-Boussard, T., Graham, L. A., Desai, K., Wahl, T. S., Aucoin, E., Richman, J. S., Morris, M. S., Itani, K. M., Telford, G. L., & Hawn, M. T. (2017). The fifth vital sign: Postoperative pain predicts 30-day readmissions and subsequent emergency department visits. Annals of Surgery, 266(3), 516–524. https://doi.org/10.1097/SLA.0000000000002372

4. Dubljanin Raspopović, E., Meissner, W., Zaslansky, R., Kadija, M., Tomanović Vujadinović, S., & Tulić, G. (2021). Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty. PLOS ONE, 16(7), e0253147. https://doi.org/10.1371/journal.pone.0253147

5. Buvanendran, A., Della Valle, C. J., Kroin, J. S., Shah, M., Moric, M., Tuman, K. J., & McCarthy, R. J. (2019). Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: A prospective cohort study. Regional Anesthesia & Pain Medicine, 44(3), e100036. https://doi.org/10.1136/rapm-2018-100036

6. Turan, A., Leung, S., Bajracharya, G. R., Babazade, R., Barnes, T., Schacham, Y. N., Mao, G., Zimmerman, N., Ruetzler, K., Maheshwari, K., Esa, W. A. S., & Sessler, D. I. (2020). Acute Postoperative Pain Is Associated With Myocardial Injury After Noncardiac Surgery. Anesthesia & Analgesia, 131(3), 822–829. https://doi.org/10.1213/ANE.0000000000005033

7. Khaled, M., Sabac, D., Fuda, M., Koubaesh, C., Gallab, J., Qu, M., Lo Bianco, G., Shanthanna, H., Paul, J., Thabane, L., & Marcucci, M. (2024). Postoperative pain and neurocognitive outcomes after noncardiac surgery: a systematic review and dose-response meta-analysis. British journal of anaesthesia, S0007-0912(24)00550-6. Advance online publication. https://doi.org/10.1016/j.bja.2024.08.032

8. Yang, M. M. H., Hartley, R. L., Leung, A. A., Ronksley, P. E., Jetté, N., Casha, S., & Riva-Cambrin, J. (2019). Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ open,9(4), e025091. https://doi.org/10.1136/bmjopen-2018-025091

9. Görges, M., Sujan, J., West, N. C., Sreepada, R. S., Wood, M. D., Payne, B. A., Shetty, S., Gelinas, J. P., & Sutherland, A. M. (2024). Postsurgical Pain Risk Stratification to Enhance Pain Management Workflow in Adult Patients: Design, Implementation, and Pilot Evaluation. JMIR perioperative medicine, 7, e54926. https://doi.org/10.2196/54926