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

The correlation coefficient for opioid-experienced patients in Figure 1 (r = 0.46) is lower than that in Figure 2 (r = 0.59), providing evidence for the efficacy of Transitional Pain Service treatment, which likely was responsible for reducing the magnitude of the relationship between hospital discharge and end of Transitional Pain Service treatment opioid use.

“Finally, note that the correlation coefficient for opioid-experienced patients shown in Figure 1 (r = 0.46) is lower than that in Figure 2 (r = 0.59), providing evidence for the efficacy of TPS treatment, which likely was responsible for reducing the magnitude of the relationship (i.e., breaking the link) between hospital discharge and end of TPS treatment opioid use.”

TPS treatment is associated with improvements in pain, pain interference, pain catastrophizing, symptoms of anxiety and depression, and opioid use.

“Preliminary results from two nonrandomized, clinical practice–based trials indicate that TPS treatment is associated with improvements in pain, pain interference, pain catastrophizing, symptoms of anxiety and depression, and opioid use.”

By the 6-month mark, among opioid-experienced patients, 35 (25%) had been completely weaned, 50 (36%) had reduced opioid use by >50% of the hospital discharge dose, 27 (19%) had reduced opioid use by <50%, and 27 (19%) had increased opioid use since hospital discharge.

“In terms of weaning rates, by the 6-month mark, 35 opioid-experienced patients (25%) had been completely weaned, 50 (36%) had reduced their opioid use by >50% of the hospital discharge dose, 27 (19%) had reduced their opioid use by <50%, and 27 (19%) had increased opioid use since hospital discharge.”

Brief Pain Inventory pain intensity and interference scores at the last Transitional Pain Service visit were significantly lower than their respective post-hospital discharge scores in both opioid-naïve and opioid-experienced groups.

“Importantly, Brief Pain Inventory (BPI) pain intensity and interference scores at the last TPS visit were significantly lower than their respective post–hospital discharge scores (pre-TPS treatment) in both opioid-naïve and opioid-experienced groups”

For the entire sample of opioid-experienced patients, the predictors of opioid dose reduction from hospital discharge to the last Transitional Pain Service visit included lower pain catastrophizing scores, lower prevalence of neuropathic pain, and a negative history of recreational drug use.

“For the entire sample of opioid-experienced patients, the predictors of opioid dose reduction from hospital discharge to the last TPS visit included lower pain catastrophizing scores, lower prevalence of neuropathic pain, and a negative history of recreational drug use.”

By 6 months after surgery, among opioid-naïve patients, 51 (46%) had been successfully weaned from opioids, 39 (35%) had reduced opioid use by >50% of their hospital discharge dose, 11 (10%) had reduced opioid use by <50%, and 9 (8%) had increased opioid use from hospital discharge.

“In terms of weaning rates, by 6 months after surgery, 51 (46%) had been successfully weaned from opioids, 39 (35%) had reduced opioid use by >50% of their hospital discharge dose, 11 (10%) had reduced opioid use by <50%, and 9 (8%) had increased their opioid use from hospital discharge.”

Almost half of opioid-naïve patients and one in four opioid-experienced patients were opioid free by the 6-month point.

“Almost half of opioid-naïve patients and one in four opioid-experienced patients were opioid free by the 6-month point.”

The daily opioid dose of opioid-experienced patients almost doubled to 140.5 ± 124.0 MME/day by the time they were discharged from hospital after surgery.

“The daily dose almost doubled to 140.5 ± 124.0 MME/day by the time they were discharged from hospital after surgery.”

At the last Transitional Pain Service visit approximately 6 months after surgery, opioid-experienced patients were taking 78.3 ± 113.9 MME/day, a 44.3% decrease, essentially the same dose they had been taking prior to surgery.

“At the last TPS visit ~6 months after surgery they were taking 78.3 ± 113.9 MME/day (44.3% decrease), which was essentially the same dose they had been taking prior to surgery (Figure 1).”

Opioid-experienced patients (n = 137) were taking a mean of 78.8 ± 100.2 MME/day prior to surgery.

“Opioid-experienced patients (n = 137) were taking a mean of 78.8 ± 100.2 MME/day prior to surgery.”

Opioid-naïve patients' opioid dose was reduced to 37.3 ± 61.1 MME/day at the final Transitional Pain Service visit, a 65% decrease, approximately 6 months after surgery.

“which was reduced to 37.3 ± 61.1 MME/day at the final TPS visit (65% decrease) ~6 months after surgery.”

Among opioid-experienced patients who increased opioid use from hospital discharge to 6 months, the subgroup was more likely to be male, an organ transplant patient, and to have been diagnosed with a mental health disorder.

“When compared with opioid-experienced patients who successfully reduced opioid consumption, this subgroup was more likely to be male, an organ transplant patient, and to have been diagnosed with a mental health disorder.”

The only predictor of dose reduction for opioid-naïve patients was the daily morphine milligram equivalent at hospital discharge.

“In contrast, the only predictor of dose reduction for opioid-naïve patients was the daily morphine milligram equivalent at hospital discharge.65”

The opioid-naïve group reported larger improvements in pain interference than the opioid-experienced group.

“with the former group reporting larger improvements in pain interference than the latter group (Figure 3).”

Opioid-naïve patients (n = 110) were taking a mean of 106.7 ± 80.6 MME/day at the time of hospital discharge after surgery.

“In contrast, opioid-naïve patients, who nonetheless were identified as high risk for postsurgical pain (n = 110), were taking a mean of 106.7 ± 80.6 MME/day at the time of hospital discharge after surgery”