The Perioperative Pain Self-Management (PePS) randomized controlled trial protocol: Preventing chronic post-surgical pain and prolonged opioid use.

BACKGROUND: Total joint arthroplasties are common orthopedic surgeries that carry risk for developing chronic post-surgical pain. In addition to pre- and post-operative pain severity, psychological distress (e.g., anxiety, pain catastrophizing) is a risk factor for chronic postsurgical pain. Cognitive behavioral therapy (CBT) for chronic pain is an empirically supported approach to managing chronic pain, functional impairment, and related distress. While CBT has been used extensively in patients with established chronic pain, using it as a preventive intervention targeting the transition from acute to chronic postsurgical pain is a novel application. OBJECTIVES: The Perioperative Pain Self-Management (PePS) program is a pain self-management intervention based on the principles of CBT. This innovative intervention is brief, flexible, and is delivered remotely. The current study aims to determine the efficacy of PePS compared to standard care on reducing the incidence of significant surgical site pain at 6-months post-surgery. The current study also aims to evaluate the context for subsequent implementation. METHODS: This study is a hybrid type I efficacy-preparing for implementation trial. It is a two-site, single-blind, two-arm, parallel, randomized control trial. Surgical patients will be randomized to either receive: 1) PePS plus standard care, or 2) Standard care. The primary end point will be surgical site pain severity at 6-months post-surgery. CONCLUSION: Results from this study are expected to result in support for a brief scalable intervention (PePS) that can prevent the development of chronic pain and prolonged post-surgical opioid use, as well as key details to inform subsequent implementation. CLINICALTRIALS: govIdentifier:NCT04979429.

Opioid prescribing patterns for acute pain.

PURPOSE: The current study aimed to identify patients presenting with acute pain who may be at risk for a complicated trajectory, via identifying clusters of early opioid prescribing patterns. METHODS: National Veterans Affairs administrative data were utilized to build a cohort of outpatients with acute pain presentations and no more than minimal opioid use in the prior year. Latent Class Analyses (LCAs) identified clusters of early opioid prescribing patterns. The risk of progression to long-term opioid use was contrasted between LCA clusters using log-binomial regression, adjusting for confounding variables. RESULTS: The 2018 cohort included N = 191,283. Among the 27,890 who received an initial opioid prescription, LCA classes were identified using: first supply day, total days dispensed across 30 days, opioid type, dose and number of prescriptions across the first 30 days. In the three-class model: class 1 indicated an immediate, low-dose and brief supply; class 2 included delayed, low-dose and longer duration prescriptions and class 3 included delayed, high-dose and moderate duration prescriptions. Adjusted relative risk ratios for progression to long-term opioid use in the following year were 3.33 (95% CI: 2.71-4.10) for class 1 (absolute risk 1.1%); 7.76 (95% CI: 6.69-8.99) for class 2 (3.1%) and 6.81 (95% CI: 5.72-8.12) for class 3 (2.4%) compared to patients who did not receive an acute opioid prescription (0.3%). CONCLUSIONS: These clusters of acute opioid prescribing could facilitate the identification of patients who may benefit from enhanced pain care earlier in the pain trajectory and decrease future reliance on long-term opioid therapy.