Elsevier

The Lancet

Volume 393, Issue 10180, 13–19 April 2019, Pages 1537-1546
The Lancet

Series
Transition from acute to chronic pain after surgery

https://doi.org/10.1016/S0140-6736(19)30352-6Get rights and content

Summary

Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.

Introduction

Acute pain is almost ubiquitous after surgery. Fortunately, it can be controlled and mostly resolves within 1 week. It should not cause distress or limit postoperative recovery.1 However, for some patients acute postoperative pain persists beyond the usual time of tissue healing and transitions into a chronic pain state.2, 3, 4, 5, 6

The prevalence of chronic postsurgical pain (CPSP), which is bad enough to cause substantial functional impairment, is approximately 10% after all surgeries (table 1).6 Globally, more than 320 million people have surgery each year, which represents a vast potential for CPSP.25 As a result, CPSP is increasingly recognised as a public health problem, not only because of the discomfort, distress, and disability it causes, but also because past approaches to managing it have contributed substantially to the current opioid crisis.26 The use of opioids for atients who have surgery presents a particularly challenging problem requiring clinicians to balance two competing interests: managing acute pain in the immediate postoperative period and minimising the risks of persistent opioid use after surgery. Finding ways to minimise this risk is particularly salient in light of a growing literature suggesting that patients who have had surgery are at increased risk of chronic opioid use.27 As a result, in 2016, the Joint Commission in the USA began a project to revise its pain standards and address the opioid epidemic.26 In January, 2018, the Commission added an emphasis on the need to actively engage medical staff and hospital leaders to include strategies to decrease opioid use. This included the use of at least one of non-pharmacological modality for pain treatment and access to prescription drug monitoring programmes. There was also a stronger focus on pain assessments of how the pain affects patients' physical function.28

Postsurgical pain is a paradigm for understanding and studying other pain that is also iatrogenic.29, 30 Because CPSP occurs from a planned incision at a specified point in time, it has the potential to be prevented and better controlled. However, there are many factors that contribute to the development and persistence of CPSP, and only some of these are related to the surgery. As with non-surgical chronic pain, psychological and social factors have an important influence. All clinicians—not just surgeons and anaesthetists—should have some knowledge on CPSP and how to manage established cases, which can persist for months or years after the procedure. As with many other chronic conditions, early intervention is likely to improve outcomes and so identifying patients at risk is crucial.

Section snippets

Definition

CPSP is pain that occurs at the site of the incision or related areas of the surgery and persists a month longer than it takes for most injured tissues to fully heal. Consequently, the time of onset has mostly been set between 3 and 6 months.22, 31, 32 Definitions of CPSP also vary as to whether or not other causes of pain, such as disease recurrence after surgery or presence of a pre-existing pain syndrome, are included under the CPSP rubric.32 For example, chronic pain after lumbar spine

Clinical features

The nature of CPSP is often poorly characterised in clinical studies,35 but aching is the most commonly chosen sensory descriptor of persistent pain after a range of different surgical procedures.9 Neuropathic descriptors such as hyperalgesia (heightened sensitivity to painful stimuli), dysaesthesia (an unpleasant, abnormal sense of touch), and allodynia (sensitivity to normally non-painful, often repetitive, stimulation) are frequently used. These descriptors suggest that nerve damage during

Epidemiology: incidence and prevalence

The definitional issues related to chronology and whether recurrence of pre-existing pain is included have hampered definitively establishing the true incidence and prevalence of CPSP. Methodological issues related to data collection have also contributed to this situation. Most studies report on data collected in a single institution or at a national level but this can be problematic, for different reasons.42 Single institution studies use patient-based data from the perioperative period, are

Natural history and prognosis of CPSP

Without large, long-term, prospective studies, the natural history and prognosis of CPSP is hard to predict. On the basis of data in table 1 CPSP does appear to often resolve by the end of the first year. In one study,42 the syndrome was reported to be present 12 months after surgery in 315 (14%) of 3120 patients, being moderate in 12% and severe in 2%. In the aforementioned Tromso study,46 40% of patients reported CPSP an average of 18 months after surgery, and 18% rated it as moderate or

Mechanisms of transition from acute to CPSP

Some molecular mechanisms responsible for the transition of acute to chronic pain and their neurobiological correlates have been identified in animal models of chronic pain.60, 61, 62, 63, 64, 65 The sensory aspects of pain are carried by a bidirectional network of neurons that transmits a variety of noxious signals from peripheral nociceptive Aδ-fibres and C-fibres to the dorsal horn of the spinal cord (SCDH). Here, noxious signals are passed to ascending projection neurons that convey them to

Predictors of CPSP

The ability to predict who is at risk of developing CPSP is clearly important, especially if the risk factors are modifiable. Despite the progress in understanding the transition from acute to chronic pain, the research to date mainly identifies clinical risk factors. This literature is summarised in table 2. To facilitate future research in this field, a standardised approach to data collection of patient-reported and clinical outcomes has been proposed by the Initiative on Methods,

Predictive tools

Because there are multiple, interacting risk factors for developing CPSP, attempts have been made to develop predictive tools that quantify the level of composite risk. Most have been operation specific, but one generic tool evaluated the effect of 14 biomedical and psychosocial items that were derived from a systematic review of the CPSP risk factor literature.106 From a training set of 150 patients, of whom almost half developed CPSP, five of the 14 items were independently predictive of

Prevention of transitional postsurgical pain and CPSP

Some CPSP risk factors are modifiable (eg, body-mass index, preoperative pain, and some comorbidities), especially if surgery is elective, whereas others (eg, demographics, genetics, and pain sensitivity) are not. The very name of CPSP implies the pain is caused by surgery and therefore can be controlled if not prevented.109 Intraoperative nerve injury is a probable contributor to the development of at least some CPSP, but few studies have assessed whether intraoperative nerve handling or

Potential role of a transitional pain clinic

A more pragmatic approach to prevention of CPSP has been the development of transitional pain clinics, which aim to overcome the disconnect between ward-based acute postoperative pain management and outpatient chronic pain management (figure 2). Such a comprehensive and integrated pain service can identify patients at risk of chronic pain through inpatient screening on the basis of established prognostic indicators.3, 4, 6, 33, 39, 54, 55, 117, 118, 119, 120 A further clinic visit of at-risk

Treatment of established CPSP

In a review of CPSP in 2006, numerous potential symptomatic targets were proposed.22 The main two targets for which success has been achieved are the α2 and δ-1 subunit of calcium channels by gabapentin and pregabalin, and the monoamine transporters (which augment descending inhibition) by serotonin norepinephrine reuptake inhibitors such as duloxetine and venlafaxine.123, 124 These drugs are widely used for chronic neuropathic pain but their effects are variable, with the number needed to

Conclusions

CPSP is a growing problem as the population ages and more surgeries are done. Poorly controlled acute postoperative pain is a predictor of CPSP development but the drugs currently available to treat acute pain are mostly ineffective at preventing it. Opioids are too often overused, particularly in the post-discharge period. Preclinical research might yield new drug treatments, but ultimately, CPSP is similar to other chronic pain and therefore requires a comprehensive biopsychosocial approach

References (136)

  • IK Crombie et al.

    Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic

    Pain

    (1998)
  • A Johansen et al.

    Persistent postsurgical pain in a general population: prevalence and predictors in the Tromso study

    Pain

    (2012)
  • MT Chan et al.

    Chronic postsurgical pain in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia (ENIGMA)-II trial

    Br J Anaesth

    (2016)
  • LF Azevedo et al.

    Epidemiology of chronic pain: a population-based nationwide study on its prevalence, characteristics and associated disability in Portugal

    J Pain

    (2012)
  • RS Roth et al.

    Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction

    Breast

    (2018)
  • PS Myles et al.

    Clinical update: postoperative analgesia

    Lancet

    (2007)
  • CB Sieberg et al.

    Pain prevalence and trajectories following pediatric spinal fusion surgery

    J Pain

    (2013)
  • AI Basbaum et al.

    Cellular and molecular mechanisms of pain

    Cell

    (2009)
  • RP Bonin et al.

    Restoring ionotropic inhibition as an analgesic strategy

    Neurosci Lett

    (2013)
  • G Descalzi et al.

    Epigenetic mechanisms of chronic pain

    Trends Neurosci

    (2015)
  • CA von Hehn et al.

    Deconstructing the neuropathic pain phenotype to reveal neural mechanisms

    Neuron

    (2012)
  • P Inquimbert et al.

    NMDA receptor activation underlies the loss of spinal dorsal horn neurons and the transition to persistent pain after peripheral nerve injury

    Cell Rep

    (2018)
  • L Luongo et al.

    Allodynia Lowering Induced by Cannabinoids and Endocannabinoids (ALICE)

    Pharmacol Res

    (2017)
  • S Mitrirattanakul et al.

    Site-specific increases in peripheral cannabinoid receptors and their endogenous ligands in a model of neuropathic pain

    Pain

    (2006)
  • BK Lau et al.

    Descending modulation of pain: the GABA disinhibition hypothesis of analgesia

    Curr Opin Neurobiol

    (2014)
  • M De Felice et al.

    Engagement of descending inhibition from the rostral ventromedial medulla protects against chronic neuropathic pain

    Pain

    (2011)
  • I Elman et al.

    Common brain mechanisms of chronic pain and addiction

    Neuron

    (2016)
  • D Fletcher et al.

    Chronic postsurgical pain in Europe: an observational study

    Eur J Anaesthesiol

    (2015)
  • A Huang et al.

    Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service

    Pain Management

    (2016)
  • 2014 National Hospital Discharge Survey: annual summary with detailed diagnosis and procedure data

  • E Hsu et al.

    Postamputation pain: epidemiology, mechanisms, and treatment

    J Pain Res

    (2013)
  • J Jin et al.

    Prevalence and risk factors for chronic pain following cesarean section: a prospective study

    BMC Anesthesiol

    (2016)
  • FM Perkins et al.

    Chronic pain as an outcome of surgery. A review of predictive factors

    Anesthesiology

    (2000)
  • AM Flexman et al.

    Acute and chronic pain following craniotomy

    Curr Opin Anaesthesiol

    (2010)
  • LC de Gray et al.

    Acute and chronic pain following craniotomy: a review

    Anaesthesia

    (2005)
  • M Manangi et al.

    Chronic pain after inguinal hernia repair

    Int Sch Res Notices

    (2014)
  • SJ Atlas et al.

    The Maine Lumbar Spine Study, part II. 1-year outcomes of surgical and nonsurgical management of sciatica

    Spine (Phila Pa 1976)

    (1996)
  • S Weir et al.

    The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES)

    BMJ Open

    (2017)
  • Z Baber et al.

    Failed back surgery syndrome: current perspectives

    J Pain Res

    (2016)
  • L Macdonald et al.

    Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome

    Br J Cancer

    (2005)
  • J Meyerson et al.

    The incidence of chronic post-sternotomy pain after cardiac surgery—a prospective study

    Acta Anaesthesiol Scand

    (2001)
  • ET Higgins

    Beyond pleasure and pain

    Am Psychol

    (1997)
  • F Hetmann et al.

    Post-thoracotomy pain syndrome and sensory disturbances following thoracotomy at 6- and 12-month follow-ups

    J Pain Res

    (2017)
  • SA Schug et al.

    Risk stratification for the development of chronic postsurgical pain

    Pain Reports

    (2017)
  • T Renton

    Persistent pain after dental surgery

    Reviews in pain

    (2011)
  • TG Weiser et al.

    Size and distribution of the global volume of surgery in 2012

    Bull World Health Organ

    (2016)
  • DW Baker

    History of the joint commission's pain standards: lessons for today's prescription opioid epidemic

    JAMA

    (2017)
  • JM Hah et al.

    Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic

    Anesth Analg

    (2017)
  • Pain Management Standards 2018

  • JS Merlin et al.

    The association of chronic pain and long-term opioid therapy with HIV treatment outcomes

    J Acquir Immune Defic Syndr

    (2018)
  • Cited by (468)

    View all citing articles on Scopus
    View full text