ICU Management & Practice, Volume 19 - Issue 1, 2019

Acute pain estimation, postoperative pain resolution, opioid cessation, and recovery

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Acute postoperative pain is associated with persistent postsurgical pain (PPSP). The incidence of PPSP ranges from 10 to 50% while severe, chronic pain after surgery is reported by 2 to 10% of patients. Both the severity and duration of postoperative pain are influenced by other factors including pre-existing pain.

 
A secondary analysis of the Stanford Accelerated Recovery Trial (START), a randomised, double-blind clinical trial, was conducted to assess the effect of perioperative use of gabapentin on postoperative pain resolution and opioid cessation. The researchers used data-mining algorithms to identify patient clusters based on the first 10 daily pain scores (reported as average, current and worst pain) after surgery. They also explored psychosocial characteristics that were associated with each cluster and determined which description best estimated the probability of 3 outcomes which included remote pain cessation, opioid cessation, and surgical recovery. The analysis was based on two hypotheses: that patient clusters predictive of poorer remote outcomes were associated with preoperative psychosocial characteristics, and that high-risk patient clusters were a superior predictor of outcomes over acute pain descriptors.

 
Results
 

A total of 371 participants (225 women and 146 men) scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were included in the analysis. Of these 371 patients, 52% were partitioned into the low pain cluster, and 48% were partitioned into the high pain cluster.

 

Median pain duration in the high vs. low pain cluster was 92.0 vs. 40.0 days; opioid use was 39.0 vs. 12.0 days and time to patient-reported recovery was 89.0 vs. 49.0 days. Median time to pain cessation in the high vs. low-risk group was 92 days vs. 40 days. Median time to opioid cessation in the high vs. low-risk group was 39 days vs. 12 days. Median time to full recovery in the high vs. low-risk group was 89 days vs. 49 days.

 

Overall, the findings of this analysis show that patients categorised to each of the 3 high pain clusters had longer duration of pain and opioid use regardless of the procedure. Some preoperative characteristics that correlated with the assignment of these patients to the high-risk cluster included worse baseline pain at the future surgical site, a history of alcohol or drug abuse treatment, and randomisation to the placebo group. The analysis also showed a sex difference where women were found to be at an increased risk of categorisation to the high pain cluster.

 

Worst pain over the past 24 hours reported on postoperative day 10 (POD 10) was identified as a significant immediate postoperative predictor of remote pain resolution, opioid cessation, and complete surgical recovery. This measure was found to be a better predictor of all three outcomes. Its application to current clinical practice could facilitate early identification of patients requiring more-intensive, interdisciplinary, postoperative pain management as well as help decisions regarding the continuation or discontinuation of multimodal analgesia. The postoperative predictor can facilitate the identification and referral of high-risk patients through transitional pain services.

 

References:

Hah, JM, Cramer E, Hilmoe H et al. (2019) Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery Secondary Analysis of a Randomized Clinical Trial. JAMA Network Open, 2(3):e190168. doi:10.1001/jamanetworkopen.2019.0168




post-operative, opioid cessation, Post-op Acute postoperative pain is associated with persistent postsurgical pain (PPSP). The incidence of PPSP ranges from 10 to 50% while severe, chronic pain af

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