HSS Preoperative Pain Screening Service Shows Success in Identifying Opioid-Tolerant Patients, Reducing Their Opioid Use and Improving Their Clinical Outcomes
Preoperative Pain Screening Services, a pain screening and pain management program developed by clinicians at Hospital for Special Surgery (HSS), has demonstrated success in identifying and treating opioid-tolerant patients before elective orthopedic surgery, leading to better clinical outcomes and eventual opioid independence.
There are many reasons why optimizing patients with chronic pain for surgery can be challenging.
“What ‘optimization’ means is different for every individual,” said Faye Rim, MD, FAAPMR, assistant attending physician and Director of Pre-Surgical Chronic Pain Management at HSS. “Part of the optimization process is setting realistic expectations and then working from there. This may take more time than we have with a scheduled surgery.”
Patients with chronic pain often have higher preoperative opioid use. Long-term opioid use can cause physical dependence as well as opioid-induced hyperalgesia, which is an abnormally increased sensitivity to pain. As a result, these patients often request increased amounts of opioids after surgery and have decreased opioid independence.
Patients with chronic pain also often have a higher prevalence of psychiatric disorders such as depression and anxiety that contribute to poor pain management. Alcohol and recreational drug use can also cause perioperative complications.
“While standardization of processes and procedures helps minimize medical errors and improve overall standard of care, it does not account for individual preferences and needs,” said Dr. Rim. “Preoperative pain screening and an integrated perioperative pain service allows a patient-centered model to exist within ‘checklist medicine.’ For those patients who don’t fit a standard mold, we can tailor a pain program to best meet their needs.”
HSS has developed a method of identifying opioid-tolerant patients before surgery, as well as interventions to reduce their risk profile and increase optimal outcomes.
During preoperative evaluation, patients are asked five questions as part of screening questionnaires administered at the surgical office. If patients answer “yes” to any of the questions, they are reviewed for a possible substance use disorder and opioid tolerance and are referred for a pain management consultation before surgery.
In the pain management consultation, there are three main goals: identifying patients who are at risk for opioid misuse or poor pain control; setting expectations regarding the planned procedure and the expected intensity and duration of pain; and developing a plan for postoperative pain management.
During the consultation, a pain history is taken regarding the patient’s past and current treatments for pain and comorbid disorders. A urine toxicology screening is conducted, and prescription monitoring databases are reviewed. Patients with inconsistent finds or evidence of aberrant behavior are referred to a pain management social worker or to addiction medicine services. Patients who are on high opioid doses (defined as greater than 100 mg oral morphine equivalents) are tapered to lower doses before surgery, with coordinated care from their outside pain medicine prescribers.
A series of case studies from HSS published by A&A Practice Journal demonstrates examples of the program’s success. These case studies contain both men and women ranging in age from 38 to 72. All were using high doses of opioids before surgery. Some were using high doses of prescribed medications; some were “doctor shopping” to acquire prescription opioids from multiple sources; and some were using concurrent prescription medications and illicit drugs. In most cases, patients had surgery delayed for approximately three months to taper off high doses of medication and to treat dependence or addiction; all were able to taper off high doses of medication prior to surgery and had positive outcomes. In one case, stopping opioid and benzodiazepine use reduced pain levels and improved mental health so thoroughly that surgery was no longer necessary.
These success stories demonstrate that a structured program to identify and optimize patients before elective orthopedic surgery can lead to better clinical outcomes and eventual opioid independence.
The Preoperative Pain Screening Service at HSS has been in place since 2015 and has formally screened about 800 patients per year.
“It is specifically the cooperation within the hospital that makes this program so successful,” said Dr. Rim. “We have had the support of administration, surgical services, nursing and anesthesia. We coordinate from outpatient and inpatient and cooperate with physicians outside the HSS system as needed.”
Surgeons raised initial concerns that referral to pain management might deter patients from getting surgery that was important to their care. However, this coordinated, patient-centered care model does not appear to affect overall patient satisfaction.
It will be important for future work to identify which preoperative interventions are beneficial; the best methods for opioid tapering and to what levels; and how various interventions for substance use may affect overall morbidity, mortality or length of stay.
HSS is currently in the process of collecting data on adherence to tapering plans, drop-out rates, missed patients and outcome data such as opioid use, patient satisfaction and lengths of stay.
While starting a program similar to this one may require additional resources, it may be cost-efficient over time, and it is likely that larger systems will be able to implement and support similar programs.
1. Justin Donofrio, LCSW, Christine Peterson, MD, Spencer Liu, MD, Faye Rim, MD. “Impact of structured patient centered pre-operative pain consult and interventions from a dedicated Perioperative Pain Service: A case series of four patients [published online July 17, 2020].” A&A Practice. doi: 10.1213/XAA.0000000000001279
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.