Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process.

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

Overlaps in pharmacology for the treatment of chronic pain and mental health disorders.

There is significant overlap in the pharmacological management of pain and psychological disorders. Appropriate treatment of patients' comorbid psychological disorders, including sleep disturbances often leads to an improvement in reported pain intensity. The three first line agents for neuropathic pain include tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors which are medications originally developed as antidepressants. The other first line medication for chronic neuropathic pain are anticonvulsant medications initially brought to the market-place for the treatment of epilepsy and are also now being used for the treatment of anxiety disorders and substance withdrawal symptoms. The efficacy of opioids for chronic pain is contentious, but it is agreed that the patients at highest risk for opioid misuse and addiction are patients with underlying psychological disorders who use opioids for their euphoric effects. Similarly, benzodiazepines may present a problem in patients with chronic pain, as up to one third of patients with pain are concomitantly prescribed benzodiazepines, and when combined with other sedating analgesic medications they put patients at increased risk for adverse events and polysubstance misuse. Finally, there is growing evidence for the efficacy of cannabis for treating neuropathic pain, but the consumption of cannabis has been associated with increased risk of psychosis in adolescents, and may be associated with an increased risk for developing bipolar disorder and anxiety disorders. The use of cannabis is associated with an increased risk of substance misuse in both adolescents and adults. In this narrative review, we examine the evidence for the use of several medications used for the treatment of both pain and psychological disorders, and their proposed mechanisms of action, in addition to special concerns for patients with comorbid pain and psychological disorders.

Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials.

BACKGROUND: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. MATERIALS AND METHODS: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias. RESULTS: Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2-3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding. CONCLUSION: This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.

Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service.

BACKGROUND: The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. AIMS: To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. METHODS: Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. RESULTS: Six months postoperatively, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. CONCLUSIONS: The TPS enabled almost half of opioid-naïve patients and one in four opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.

Contexte: La période périopératoire constitue un créneau déterminant pour s'attaquer à la consommation d'opioïdes, en particulier chez les patients qui ont une histoire de douleur chronique et de consommation préopératoire d'opioïdes. Le Service de la douleur transitionnelle de l'Hôpital général de Toronto a été mis sur pied pour s'attaquer au problème de la douleur et de la consommation d'opioïdes après une chirurgie.But: Présenter les résultats de l'évaluation du programme du Service de la douleur transitionnelle à l'Hôpital général de Toronto en mettant l'accent sur les taux de sevrage des opioïdes ainsi que sur la prise en charge de la douleur chez les patients n'ayant jamais consommé d'opioïdes et ceux qui en avaient déjà consommé.Méthodes: Avant d'être opérés, 251 patients à haut risque du Service de la douleur transitionnelle ont été séparés en deux groupes, l'un réunissant les patients n'ayant jamais consommé d'opioïdes et l'autres réunissant ceux qui en avaient déjà consommé. Les résultats portaient sur la douleur, la consommation d'opiodes, les taux de sevrage, ainsi que les comorbidités psychosociales et médicales.Résultats: Six mois après l'opération, la douleur et le fonctionnement s'étaient améliorés de manière significative. Les patients qui n'avaient jamais consommé d'opioïdes et ceux qui en avaient déjà consommé avaient réduit leur consommation de 69 % et 44 % respectivement, et 46% et 26 % d'entre eux étaient complètement sevrés. La consommation au moment du congé de l'hôpital prédisait le sevrage chez les patients qui n'avaient jamais consommé d'opioïdes auparavant. La catastrophisation de la douleur, la neuropathie et l'usage de drogues récréatives prédisaient le sevrage chez les patients qui avaient déjà consommé des opioïdes.Conclusions: Le Service de la douleur transitionnelle a permis le sevrage de près de la moitié des patients qui n'avaient jamais comsommé d'opioïdes auparavant et à un patient sur quatre parmi ceux qui avaient déjà consommé des opoïdes auparavant. Le Service de la douleur transitionnelle cible avec succès la consommation préopératoire d'opioïdes chez les patients souffrant de douleur complexe.

Guidelines for preoperative investigations for elective surgery at Queen Elizabeth Hospital: effects on practices, outcomes, and costs.

STUDY OBJECTIVE: We endeavor to assess the impact of introduction of guidelines for preoperative investigations (PIs) on anesthetic practices and costs and compare their efficacy to current practices. DESIGN: A prospective study. SETTING: Queen Elizabeth Hospital, Barbados. PATIENTS: Participants comprised all patients undergoing general, epidural, spinal, and regional anesthesia, with the exception of emergency cases or instances where an anesthesiologist was not required. INTERVENTION: Introduction of formal guidelines for preoperative investigations. MEASUREMENTS: The patterns of preoperative testing were assessed by audit, and this assessment was repeated postintervention. PI guidelines developed were presented to all surgical departments. MAIN RESULTS: For younger patients (<60 years), the mean number of tests decreased from 3.42±1.8 in the preguideline group to 2.89±1.98 in the postguideline group (P=.042). The total number of chest x-rays decreased by 14.8% (P=.012) and full blood counts by 7.6% (P=.036). The implementation of PI guidelines led to overall savings of US $7589 per 1000 patients, which is equivalent to (US $40,745.50 per annum). The most notable savings were due to decreased number of chest x-rays. PIs were performed routinely even in the absence of clinical indications. CONCLUSION: Our findings indicate that introduction of guidelines has reduced the level of preanesthetic investigations to some extent; nevertheless, further change is desirable. In addition, costs to the institution were decreased with no compromise to patient safety.