JPM | Free Full-Text | Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service

Ensuring successful recovery after surgery is critical. Over 100 million surgical procedures are performed annually in the US [1], and approximately 25% of patients undergoing surgery are on preoperative opioids [2,3,4,5,6]. Chronic postoperative pain and long-term opioid use are significant and challenging complications that hinder recovery [7,8]. Preexisting pain [9,10] and use of preoperative opioids [11,12,13] are robust predictors of chronic pain, escalation of opioid use, and impaired recovery after surgery [9,11,12,13,14,15]. Additionally, age, sex, substance abuse, anxiety, and depression increase the risk of poorly managed pain and long-term opioid use following surgery [15,16,17,18]. Furthermore, wide variability in opioid prescribing and care coordination across transitions of the perioperative period increases the risk of opioid chronicity and dose escalation [19,20,21,22,23]. While patients express interest in tapering or discontinuing opioids after surgery, their efforts can be hindered by severe acute postoperative pain, fears of managing chronic pain without opioids, unclear opioid taper plans, and lack of effective communication with their providers [19]. One strategy to improve the delivery of pain care and reduce the risk of high-dose, long-term opioid use for surgical patients includes increased access to a multidisciplinary team of pain and opioid experts who provide personalized multimodal pain management and individualized opioid taper plans that align with patients’ treatment goals and address the underlying conditions that impact chronic pain [8].

Toronto General Hospital pioneered the Transitional Pain Service (TPS) to address gaps in pain management and opioid stewardship across the continuum of perioperative care [24]. Internationally, subsequent programs exist within academic medical centers [24,25,26,27,28] and the United States Veterans Affairs [29] to shepherd high-risk complex surgical patients (e.g., individuals with chronic pain, preoperative opioid use, opioid use disorder (OUD), psychological distress) through three stages of surgical care: preoperative preparation, acute postoperative care, and long-term postoperative recovery. Patients may receive pain psychoeducation, multimodal pain analgesia, opioid tapering plans, and access to non-pharmacological and psychological therapies tailored to their medical conditions at each stage of the surgical period.

The Johns Hopkins Personalized Pain Program (PPP) is a transitional perioperative pain service offering specialized pain management and concurrent psychiatric treatment for patients with preoperative pain and opioid use or those at risk of long-term opioid therapy [26]. Consistent with findings from other institutions [30,31,32,33], the PPP has shown success in facilitating reductions of postoperative opioid consumption with concurrent improvements in clinical outcomes [34,35,36]. Collectively, these data evidence that long-term, multidisciplinary, coordinated pain management adds healthcare value for surgical patients at greatest risk of chronic pain and high-dose long-term opioid use. These outcomes are important; equally important is the pain management experience and quality of recovery from the patient’s perspective. While previous literature has demonstrated buy-in from clinicians for increased access and expansion of transitional perioperative pain services [23,25,28], no study has examined patient experiences with TPSs and patient perceptions of pain and functioning after discharge from transitional perioperative pain services. To address this gap and identify strategies to optimize patient-centered care, this study aimed to examine patient experiences of care delivery in the PPP and perceptions of their pain and quality of life after discharge from the PPP and quantify opioid use from initial PPP treatment to time of interview.

The establishment of an effective patient–physician relationship, which includes both emotional (e.g., trust, empathy, respect, acceptance) and cognitive (e.g., expectation management, patient education, communication) care components, is essential in pain management [45]. The shifting responsibility of opioid prescribing across the transitions of perioperative care between surgeons and primary care providers [19,46,47,48] exacerbates the difficulties of effective relationship building in pain management [49]. The process of tapering patients’ long-term opioids can also fracture the patient–provider relationship [50,51]. Our qualitative analysis evidenced that pain specialists established effective patient–physician relationships while facilitating opioid tapering. These findings complement evidence that individualized care, validation of pain experiences, and shared decision-making during the opioid tapering process promote success [52,53,54] and suggest that access to the transitional perioperative pain care model may address gaps in routine care that hinder opioid tapering. Participants also described how engaging families in PPP treatment provided an opportunity to educate caregivers about multimodal analgesia and address their concerns; however, family members also dissuaded participants from continuing treatment, specifically tapering opioids. This highlights the complexity of family dynamics on the pain experience [55,56] and may partly explain our previous findings that family engagement was not significantly associated with opioid tapering after surgery [35].

We have previously demonstrated that transitional perioperative pain services have the potential to facilitate opioid reductions during treatment [34,35,36,57]. To our knowledge, this is the first study to report sustained reductions in opioid use, in terms of the number of participants who discontinued opioids and mean opioid doses, nearly three years after initiating treatment in a transitional perioperative pain service. Although this is a small qualitative study, this finding is still important; it demonstrates a new clinical care pathway that has the potential to address the opioid crisis more broadly by facilitating sustainable opioid reductions after surgery. While the limited effectiveness of chronic opioid therapy and the benefits of tapering opioids are well-established, patient fears about and negative experiences with opioid tapering persist [58,59,60,61]. This study contributes to the growing literature on the long-standing benefits of opioid tapering, such as improved pain, physical and mental health, capacity to work, and interpersonal relationships [62,63,64,65], and demonstrates that patients have experienced potentially enduring benefits of initiating opioid tapering in the perioperative period.

A finding unique to this study is the perceived value of concurrent psychiatric treatment, with participants repeatedly highlighting this medical specialty as critical to their long-term recovery after surgery. The PPP is the first transitional perioperative pain service to include psychiatrists rather than psychologists [24,25]. While it is well known that psychiatric disorders (e.g., depression, anxiety, substance use disorders, posttraumatic stress disorder) are common in chronic pain, often they are not recognized or, when recognized, undertreated [66]. Psychiatric comorbidities are associated with increased opioid use, surgical complications, and decreased likelihood of post-surgical opioid cessation [67,68,69]. Tapering opioids has also been associated with the onset or exacerbation of anxiety, depression, and aberrant drug use [50,70,71,72]. We found that participants comprehended the bi-directionality of their pain and mental health and attributed the initiation or modification of psychotropics and access to psychotherapy as crucial contributions to improved pain, physical function, mood, sleep, and cognition. Moreover, participants welcomed individualized therapeutic approaches that facilitated self-efficacy, re-established relationships with family, and helped modify maladaptive pain behaviors. Notably, participants did not spontaneously identify the stigmatization of psychiatric care, a well-known challenge in accessing psychiatric treatment, as a barrier to care. Taken together, patients accepted and benefited from the integration of psychiatry into perioperative pain care.

While most participants perceived PPP as a positive and helpful treatment, several key growth areas emerged from this study’s findings. Since most patients commence PPP treatment postoperatively, participants requested to meet the PPP treatment team and learn more about the program’s patient population and treatment goals before surgery. Although the evidence of educational interventions on pain- and opioid-related outcomes are mixed [73,74], these materials are important to patients and should be part of patient-centered perioperative care. An ongoing research study (clinicaltrials.gov, NCT05252767) will shed light on whether educational materials can improve knowledge and understanding about the PPP and subsequently facilitate improvements in patient engagement during the opioid tapering process.

Participants also recommended that physicians clarify the opioid taper plan as early as possible and introduce more non-pharmacologic approaches to pain care. Readiness to taper opioids is associated with a more positive opioid tapering experience [75,76]. Consistent with previous findings, we found that participants who expected multimodal analgesia and postoperative opioid tapering, or those who welcomed those expectations early in treatment, had better treatment experiences. Experiences with opioid tapering are highly variable. Further quality improvement approaches are warranted to optimize patient-centered individualized approaches to perioperative pain management, including dedicating more time and resources to pain expectation setting, optimizing pharmacological and non-pharmacological multimodal analgesia, facilitating a slower opioid taper, providing early access to mental health care, or expanding access to other behavioral interventions.

Tapering opioids is a vulnerable experience in part due to stigmatization associated with chronic opioid use, discomfort from opioid withdrawal, mood and pain fluctuations, and uncertainty of the quality of life without opioids [58,59,60,61]. Importantly, we found that participants preferred to undergo the process of opioid tapering with the same physician. Participants described how difficulty adjusting to a new physician’s management plan and opioid tapering expectations negatively impacted their treatment experience. This is a consequential finding because it sheds light on the discrepancies between patient and physician priorities: patients prioritized the continuity of a well-established trusted patient–physician relationship, while PPP physicians prioritized facilitating opioid tapering regardless of provider. This finding also supports the need for the widespread adoption of specialty perioperative pain services, which, as mentioned previously, can lessen the variation and uncertainty of opioid prescribing responsibility between surgeons and other providers [77], thus aligning with patients’ preferences and increasing the likelihood of successful opioid tapering. Taken together, efforts to improve patient-centered care should include strategies to maintain stable patient–physician relationships and improve physician-to-physician communication if provider continuity is not feasible.

Fourth, participants reported how determinants of health, such as cost of parking, availability of transportation, and commute time, negatively affected their experience. Participants recommended telemedicine to increase PPP accessibility, especially for patients who had difficulty ambulating after surgery or lived farther away. These interviews were conducted with participants who were initially seen prior to the COVID-19 pandemic. The PPP transitioned to telemedicine services in March 2020 [78]; ongoing studies are evaluating how this transition has impacted clinical outcomes [57] and patients’ experiences in the PPP.

Our findings must be considered in the context of study limitations. Since interviews were conducted between 6 months and 3 years after treatment, participants may have experienced recall bias. We had a low response rate, which left our data vulnerable to only capturing a subset of patient experiences within the clinic. Our sample overrepresents patients who received psychiatric co-treatment, and although some participants had OUD, they were underrepresented in this study. We completed study enrollment once qualitative analyses reached saturation. Thus, the sample size was too small to conduct Bonferroni analyses to determine baseline or clinic differences between participants with positive and negative treatment experiences (not an a priori study aim). Larger studies are needed to determine if baseline measures such as pain catastrophizing (a robust predictor of pain outcomes), treatment duration, or psychiatric co-treatment, which were not significantly different in this small cohort, are associated with positive versus negative treatment experiences. The small sample size and missing data also precluded analysis of patient engagement and satisfaction outcomes during PPP treatment. Finally, it is well-known that lower participation rates among minority populations is an ongoing problem. While one-fifth of study participants were African American, our findings likely inadequately represent the experience of minority participants undergoing opioid tapers, especially given well-established health inequities in pain management [79,80]. Balancing these limitations, these qualitative data still provide clear directions for quality improvement efforts specific to postoperative pain and opioid management.