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New Preoperative Pain Program Benefits Patients

By Karl Wittnebel, MD, MPH

In October 2014 we began to identify Cedars-Sinai Spine Center patients on high doses of opiates and treat them before surgery to reduce their opiate intake. This Preoperative Pain Program uses interdisciplinary methodology, involving medical management, psychiatric care, pain psychology, physical and occupational therapy and pharmacy services.

These services are all co-located within the Spine Center to provide both patient convenience and opportunities for ad lib team collaboration among providers. We see the patients twice per week, ideally for six to eight weeks, depending upon their initial intake of medication. Our targets are individualized to some degree, but overall, we hope to reduce daily opiate intake to below the equivalent of 80mg of morphine per day.

Among patients who enroll in the program and participate, we have had success reducing opiate doses without undue suffering. We track patient-reported outcomes with the PROMIS-29 tool using an iPad interface developed by Spine Center staff, and the data for each patient is then uploaded to a Research Electronic Data Capture (REDCap) database.

Though not yet available in CS-Link™, this data provides excellent longitudinal tracking of pain levels, how much pain interferes with daily activities, and co-variates such as depression and anxiety, in a response format that is generally easily managed by each patient during a clinic visit. This tool also is used at follow-up visits after surgery to track post-surgical functional status.

The effort has not been without its challenges. Our main issues have included changing the workflow of surgery scheduling to permit time for this program to work, the sensitive and complex nature of opiate medication use, and the geographic referral pattern of the Spine Center itself.

For instance, it may not be feasible for a scoliosis patient requiring a T10-pelvis fusion to travel from Bakersfield twice per week to participate in our program. Similarly, some patients are hesitant to enroll due to anxiety about changing long-established methods of coping with pain, and this is counterbalanced against the need for safe intraoperative and postoperative care.

We have, however, been pleasantly surprised by the number of patients who look forward to the opportunity to reduce their medication intake and relish the chance to participate in the program. Many have been taking high doses of medication for years, and have simply not been encouraged or able to find any provider with a plan to help them achieve this goal.

The main reasons for creating the Preoperative Pain Program were to avoid cancellations at the time of surgery, to improve postoperative pain control and to avoid undue complications such as extended intubation or care in an intensive care unit, extended length of stay or respiratory failure requiring reintubation. During the course of the program, participants have largely been able to avoid these adverse outcomes, while patients not participating have continued to experience them. Our total numbers remain modest, however, and data collection continues for what remains a pilot effort.

Though the Preoperative Pain Program has not formally been expanded to include nonspine patients, we routinely field consults from anesthesiologists and surgeons on a variety of preoperative patients and are always willing to assist in whatever way we can to provide perspective on pain medication use and other comorbidities such as depression and anxiety that can complicate care at the time of surgery. Please feel free to contact us with questions at 310-423-8886.