Clinical Indications for a Preoperative Pain Consultation: A Review of Registry Cases at an Orthopedic Specialty Hospital

Authors: Rim F, Chan W, Kim D, Kelly M, Schuessler S, Terry J, Fritz P, Langford D, Wu CL, Waldman S, Memtsoudis S, Liu J, Poeran J, Liu S, Sideris A

Introduction

Patients with a history of opioid tolerance, chronic pain and/or substance use disorder presenting for surgery are at increased risk for severe post-surgical pain and opioid-related adverse events.[1] Significant knowledge gaps exist in the perioperative pain management of these high-risk patients, but multiorganizational consensus emphasizes comprehensive and multidisciplinary care, including preoperative screening.[1] At our institution, patients with complex pain are referred to the Perioperative Pain Service (POPS) for a preoperative pain consultation where additional screening facilitates risk stratification.[2,3] Tailored multimodal pain management plans, incorporating regional anesthesia, are devised to optimize preoperative rehabilitation, postoperative pain control and mitigate adverse outcomes. To gain a richer understanding of the orthopedic surgical population presenting with complex pain, we performed a retrospective study leveraging an institutional registry[4] to characterize the indications for a preoperative pain consultation.

Methods

After IRB approval, surgical cases requiring a preoperative pain consult at Hospital for Special Surgery between January 1^st, 2024, and November 14^th, 2024, were extracted from an institutional, Epic-based POPS registry. Patient demographics, medications, medical and surgical histories, and strings of text/ Epic smartphrases from consultation notes were extracted to identify clinical indications (figure 1). Descriptive statistics were used to characterize this surgical population.

Results

A total of 983 cases performed during the study period required a preoperative pain consultation. Most patients were female, non-Hispanic, and White (table 1). Overall, 40.1% (n=394) had a diagnosis of anxiety and 28.4% (n=279) had a diagnosis of depression; 65.1% (n=640) and 34.9% (n=343) of pain consults were office and telehealth visits, respectively. Consult note extracts revealed that 79% (n=777) of patients had a history of or current chronic opioid use, 24.6% (n=242) reported illicit or unhealthy substance use, and 39.4% (n=387) had a history of uncontrolled pain; approximately 6.5% (n=64) reported all three issues. Overall,  6.0% (n=59) had toxicology findings inconsistent with reported use and 37% (n=364) were referred to a social worker specializing in complex pain for additional support. In patients with chronic opioid use, 78.6% (n=611) had an active opioid at surgical admission, with 80.4% (n=491) taking a combined opioid-NSAID/acetaminophen tablet, oxycodone, or tramadol, and approximately 11.3% (n=69) on buprenorphine, buprenorphine-naloxone or methadone (table 2). Approximately 0.8% (n=8) of patients did not have complex pain and were otherwise not considered high-risk but were candidates for the institution’s take-home catheter program requiring formal preoperative pain management clearance to proceed.

Discussion

POPS partners with the surgical team to screen patients, offering both in-person and telehealth visit options for preoperative pain consults. Most patients requiring preoperative optimization reported chronic opioid use, many experienced uncontrolled pain and 1 in 4 admitted to current or historical illicit substance use. Toxicology findings revealed discordance between self-reported and actual use of controlled or illicit substances in a small subset of patients, suggesting risky and polypharmacy behaviors. Though most patients had an active, short-acting opioid prescription at surgical admission, approximately 11% were on medication assisted treatment. Continued granular data collection through our registry[5] will enable the study of interindividual pain differences in patients with complex pain before and after surgery.     

References

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