A systems approach to perioperative pain management

Introduction

As a result of the ongoing public health crisis of opioid addiction in the United States, increased focus and scrutiny have been placed on physicians' pain management practices. Moreover, postoperative opioid prescribing practices after routine surgical procedures are often not standardized and can vary widely. While the current epidemic of opioid addiction is multifactorial and cannot solely be ascribed to surgeons' prescribing practices, the impact of conscientious and evidence-based perioperative pain management has certainly become clearer and more evident. However, reducing opioid prescribing is only one piece of a larger puzzle. Effective perioperative pain management is multifaceted, and, as with many other aspects of surgical practice, it is most successful when implemented systematically. To that end, this chapter will discuss several key components of a systems-based approach for perioperative pain management in otolaryngology including preoperative pain management assessment and education, current best evidence for perioperative pain management strategies, and incorporating pain management into successful enhanced surgical recovery (ERAS) processes.

Why a systems-based approach to perioperative pain management?

A systematic or systems-based approach to healthcare is an evolving concept that has gained popularity and traction in recent years. However, the idea that solutions to complex problems are multifaceted and interconnected is far from novel. In fact, it can be traced as far back as the philosopher Aristotle who famously remarked that the whole is greater than the sum of its parts . This simple yet insightful observation is especially pertinent to surgical practice where fostering a strong team dynamic is foundational. However, translating this abstract concept into more defined, systems-based approaches is challenging. While a full discussion of the theory and nuances of systems-based healthcare delivery is beyond the scope of this chapter, it is important for clinicians to have a general understanding of how this concept relates to the ongoing conversations on how to improve current perioperative pain management practices.

Proponents of a systematic approach to healthcare delivery cite similarities between medicine and other “high-risk” industries such as commercial aviation and petroleum engineering. While these are admittedly imperfect analogies to surgical practice, there is a common theme—namely mitigating and managing potential risks and continuously pursuing higher-level goals of safety and quality. In response to reports published by the Institute of Medicine detailing disparities in quality and patient safety, the President's Council of Advisors on Science and Technology (PCAST) recommended that a systems [based] approach be promoted at all levels of the American healthcare system. The PCAST report went on to recommend employing key principles of systems engineering—i.e., integrating pertinent disciplines, understanding the operational environment, and utilizing available metrics to evaluate quality and performance—to improve the quality and efficiency of healthcare delivery. Although germaine in theory, applying these principles to actual clinical practice has proven challenging. Critics of systems-based healthcare argue that such approaches lead to overreliance on standardized, formulaic care, reduce clinician autonomy, and shift responsibility and accountability for errors away from individuals and onto a faceless “system.” While these concerns are certainly valid, as Dekker and Levenson observe, such reservations often result from a misunderstanding of what is meant by a systems-based approach. Far from simply creating standardized checklists, the goals of systems-based healthcare are to recognize the inherent linkages within a given healthcare environment and to design evidence-based frameworks that promote synergy, collaboration, and accountability. Successful real-world examples of systems-based approaches to healthcare delivery include the Surviving Sepsis Campaign to promote early identification and directed therapy for sepsis in critical care patients, employing information technology resources to track and support evidence-based care in chronic health conditions, and navigation programs to improve access and coordination of complex, multidisciplinary care for cancer patients.

The consequences of the historically fragmented and disparate approaches to postoperative pain management have been rendered even more salient by the ongoing opioid addiction crisis. As with other surgical specialties, significant variations in pain management and opioid-prescribing practices have been repeatedly demonstrated among otolaryngologists—head and neck surgeons performing common procedures. A retrospective review of five common outpatient surgical procedures demonstrated significant variations in the total amounts of opioids prescribed with the widest variance seen in patients undergoing thyroidectomy. Similarly, a recent survey study demonstrated divergent pain management practices among a cohort of endocrine-focused head and neck surgeons and a heavy reliance on postoperative opioids following outpatient thyroid and parathyroid surgery. These studies are just a few examples among many with similar results that speak to the scope and scale of the problem.

The reasons for such varying perioperative pain management practices are myriad and include a historical lack of evidence-based recommendations, practice variations as a result of training and location, disparate expectations between providers and patients, and shifting societal knowledge and priorities. Moreover, this problem goes beyond simply overprescribing and overreliance on opioids. A complex problem like this requires innovative solutions, and we need a systematic review and revamping of how we approach and manage perioperative pain. Therefore, shifting focus from simply trying to alter individual clinicians' behavior to pursuing systems-based approaches has so much potential benefit. As Dekker and Leveson aptly observe :

It is unrealistic to believe that [physician] behavior is not affected by the context in which it occurs … The goal of a systems approach is … to design a system in which individual responsibility and competence can effectively create desired outcomes.

With this rationale in mind, surgeons are well advised to work within their respective institutions and healthcare systems to construct clinical care pathways that promote and support perioperative pain management. In the following sections, we will discuss the rationale and available evidence for the primary components of a systematic approach to perioperative pain management including preoperative patient-specific pain assessment, surgeon-performed pain management counseling and education, multimodality pain regimens, and enhanced recovery protocols as a comprehensive, systematic approach to perioperative pain management.

Preoperative pain assessment and counseling

A systematic, comprehensive approach to perioperative pain management spans the continuum of the surgical encounter and begins at the initial preoperative consultation. To promote successful postoperative outcomes, surgeons are well accustomed to assessing patients' underlying medical risk factors and providing educative counseling regarding surgical complications and expectations. Similarly, evaluating patient-specific risk factors for perioperative pain and delivering focused counseling on pain management risks and expectations are important elements of the preoperative consultation. Just as failing to recognize an underlying cardiac or hematologic disorder increases the risk of serious surgical complications, failing to appreciate patients' unique pain management requirements and indiscriminate prescribing of opioid medications can have significant, negative consequences. As evidence, it has been reported that up to 20% of people suffering from opioid addiction were initially exposed to opiates via legitimately obtained prescriptions. Even more alarming, a recent large-scale study of opioid-naïve patients found that those prescribed opioids for even short-term management of acute postoperative pain experience a 44% relative risk of long-term opioid use, and as many as 10% of those patients may still be taking an opioid medication at 12 months or beyond after surgery. Thus, the potential positive or detrimental impacts of perioperative pain management practices cannot be overstated.