Screening Tools for Chronic Post-Surgical Pain [Internet]

Chronic post-operative pain (or chronic post-surgical pain [CPSP]) is a potential long-term complication of surgical interventions. CPSP is generally defined as pain that develops after a surgical intervention, lasts greater than 2 months, interferes with quality of life, is a continuation of pain developed in the acute phase post-surgery, or develops after a period with no pain, localized to the surgical area, and is not caused by other factors. Prolonged post-operative pain can lead to high health care utilization and costs, poorer clinical outcomes for patients, and lower quality of life. Depending on which surgery is performed, the incidence of lasting chronic pain can be from 5% to 85%. In Ontario, chronic pain (in general) costs CA$1,742 per person in 2014 (approximately CA$10 billion per year). As CPSP is a common driver of the rates of chronic pain, CPSP contributes to a large portion of health care spending in Ontario, not including a patient’s direct or indirect out-of-pocket costs. Additionally, the development of CPSP is linked to higher rates of opioid consumption. Persistent opioid use is associated with higher mortality and morbidity, and patients taking opioids to help with CPSP still report moderate to severe pain, higher disability, and lower overall global health. As opioid use and misuse is a global epidemic, strategies to reduce the development of CPSP may lower the use of opioids for pain relief.Risk factors for the development of CPSP can include pain before and after the operation (and severity of that pain), the type of surgery being performed, posttraumatic negative affect, and pain catastrophizing (i.e., exaggeration of a negative mental health state). In 1 systematic review examining factors related to the development of CPSP, preoperative factors that showed significant correlation with pain development were younger age (excluding pediatric patients), female sex, smoking, history of depressive or anxiety symptoms, sleep difficulties, higher body mass index, preoperative pain, and use of preoperative analgesia. Other suggested factors included genetics, length of surgery, and surgical techniques (e.g., type of surgical method, amount of trauma to area, and amount of tissue handling).,It has been proposed that tools that are used to measure these factors may be applicable in both predicting patients who may develop chronic pain and in the prevention of chronic pain. Tools that can classify patients as a higher risk may help physicians tailor both treatment and preventive measures for these patients or may prompt them to provide more intensive care.Validated tools to assess risk factors associated with CPSP include psychological assessments (e.g., Hospital Anxiety and Depression Scale, Pain Anxiety Symptoms Scale, Beck Depression Inventory, Amsterdam Preoperative Anxiety and Information Scale), pain catastrophizing (e.g., pain catastrophizing scale12), pain assessments (e.g., 6-factor risk model for CPSP13), and quality of life assessments (e.g., EuroQuol 5-Dimensions Questionnaire14). However, some models used to predict chronic pain can be narrow in that they do not include multiple surgical factors (e.g., laparoscopy versus open surgery) that can contribute to CPSP; specifically, they may not provide consistent definitions of psychosocial factors leading to CPSP and may not be fully validated in certain populations. Additionally, these models may be underpowered (lacking large datasets required for accuracy) and do not identify all the factors relevant to CPSP. With the goal of using validated tools for predicting the development of CPSP, it has been suggested that, if a patient is identified to be at high risk of developing CPSP, preventive measures could be taken. Some potential measures include providing preoperative analgesia, providing selective norepinephrine and serotonin reuptake inhibitors, using laparoscopic or less invasive surgery when possible, using regional anesthesia, and providing other pain-minimizing pharmaceuticals such as IV lidocaine, ketamine, or glucocorticoids.The objective of this report is to summarize evidence regarding the clinical utility of perioperative screening or prediction tools for preventing CPSP.

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