A novel approach for postoperative pain management after discharge.

I welcomed the article by Dr. Duncan Rozario, who described the necessary preoperative patient pain education and need for multimodal analgesia in the intra- and postoperative phase.1 The incorporation of intraoperative regional anesthesia is also highlighted and welcomed from a postoperative opioid-sparing profile. In my experience, surgeons do not always have the experience in managing complex pain patients who then undergo surgery for postoperative pain management. Such patients in my experience have difficulty managing their postoperative pain and frequently visit the emergency department for further pain management or poorly managed pain with escalating opioids. There is also an opportunity, especially with orthopedic trauma, amputation, thoracic and other high-risk surgeries, for patients who have pre-existing factors that increase the risk of developing postoperative surgical pain syndrome.2 Such patients can be referred preemptively to the acute pain service and for follow-up at a reputable community-based pain clinic or a transitional pain service if available.

My recommendation for improving service provision to help bridge the gap for patients with complex postsurgical pain leaving the hospital back into the community is a transitional pain service such as the one at Toronto General Hospital.

This is a novel clinical model that provides specialized pain management strategies for patients who require care plans and strategies to help facilitate discharge. Patients are then seen in the outpatient setting to help increase functioning, optimize pain control, and receive support.

A transitional pain service team also has the ability to follow patients from the point of preadmitting, before a surgery takes place, to review pain management techniques and to prepare for what can be expected during their hospital stay, education and community support. Community support can be in the form of outpatient clinics, or with follow-up at a local community pain clinic.

Other facets of a transitional pain service are to identify patients with opioid dependency, to minimize adverse effects of pain management and to incorporate a multimodal multidisciplinary care when appropriate. Adverse effects related to opioids include nausea, constipation, sedation, and cognitive issues and may lead to further morbidity and hindrance of recovery.

If there is no transitional pain service available, then attempt to liaise with a community pain clinic for patients to be followed up urgently for complex pain management to facilitate opioid management, rehabilitation services and psychosocial support. This is only possible by developing strong relationships with reputable community pain physicians and clinics.