Jean-Pierre Estebe MD, PhD, ESA subcommittee 8: acute and chronic pain and palliative medicine pain management
During this year’s ESA meeting held in London, many discussions clarified the strong link between some preoperative factors and the risk of a high level of postoperative pain. It was also confirmed that the presence of postoperative pain is highly correlated with the risk of persistent postoperative pain (also called chronic postoperative pain). Discussions have therefore focused on the best way to manage these factors at these different steps; in particular, the relevance of the APS organization for such challenges.
The APS have clearly demonstrated their effectiveness in the treatment and/or prevention of postoperative pain in patients in a targeted manner (e.g., opioid-tolerant patients or following epidural protocols) or in a more systematic way. Their organization depends largely on socioeconomic influences. Their structure reflects the national choices and the local opportunities. University hospitals have the opportunity to use training staff (nurse and doctor students). Anesthesia residents (and fellows) will be able to enhance their expertise (i.e., management of procedures or protocols, and management of risk factors) during their rounds in the APS. Such experience will educate residents on listening to all the patients’ problems and not just application of magic recipes.
Because the mechanism of pain is complex, it was shown during the ESA meeting that the answer would not be based on or only with opioids. Many discussions have centered not only on the best-known old side effects (nausea and vomiting, pruritus, constipation, or urinary retention), but more on aspects most recently highlighted by experimental data or suggested by clinical data (such as hyperalgesia, increased risk of cancer recurrence or metastasis).
The faster and more suitable the management of the postoperative pain, the more effective it will be. Historically, the first APS organizations were focused on taking charge of patients when they became chronic pain patients. Then, they progressively shifted to improvement of the acute postoperative pain for some specific patients or specific procedure (e.g., regional analgesia). It is probably the right time to move on to the preoperative period.
The research of preoperative factors could be time consuming and probably could not be completely checked during the pre-anaesthesia evaluation. The evaluation of the patient’s fragility for pain is the first key point. A single questionnaire is not enough to screen patients. As an example, research of hyperalgesia requires specific tools, expertise, and organization. Various focused questionnaires are available for the evaluation of stress, anxiety, depression, catastrophizing, or addictive behaviors.
Some of these factors could not be modified such as: age, gender, and genotype. Some others could be treated or ameliorated, such as addictive behaviours (alcohol, tobacco, benzodiazepines or other sleeping medication, opioids tolerance), psychological disturbance, and/or pain (at many different parts of the body). All these factors could be preoperatively improved with a specific organization and expertise as demonstrated by the APS. It is also at this time that the preoperative anaesthesia protocol be determined as a function of all these factors (e.g., regional anaesthesia, anti-epileptic drugs, hypnotic induction). It could be a good moment for patient education.
With such organizations, we could expect to improve all the enhanced rehabilitation programs (ERAS program). At this time, the cost efficacy of the APS could be clearly demonstrated. This is particularly true if specific billing is attributed to such activity. So, there is an urgent need that funding of these APS is recognized. It is important that all the medical insurance companies (private or governmental) recognize the importance of the APS for the further benefit of the patient and thus reimburse the cost of its daily functionality. Eventually, it would save money since the post-surgery patient would need less postoperative management and will go back to work sooner. Without delay, we must show imagination to begin to organize such a care system in our institutions with, from the beginning, a self-assessment process (improvement model: identify goals; identify objectives, specify approaches, specify measures, share results, and make changes).
To summarize all the discussions that took place during the last ESA Congress, we can remember that perioperative pain is complex and multifactorial. Morphine is no longer the right answer. This specific treatment should be started as soon as the preoperative period and continued during the postoperative period. This personalized treatment can be well realized by a specialized organization such as the APS.