Chapter 10: Pain Medicine 2026

Dr Emma Baird, Dr  Jane Quinlan, Ms Felicia Cox, Dr Nicholas Levy, Dr Emma Davies, Dr Zoey Malpus, Dr Sonia Lockwood

Why do this Quality Improvement Project

Patients undergoing surgery are at risk of pain-related complications.  These complications can occur in the immediate postoperative period, but some may persist beyond the period of normal tissue healing. There are interventions that, if put in place throughout the perioperative period, can reduce these risks, implementation of which is the focus of the project.  

Background

The main pain-related complications we are interested in for this QI project are:

1. Severe uncontrolled pain in the first 24 hours postoperatively. 
Around 11% of patients experience severe pain, and 37% experience moderate pain, in the first 24 hours after surgery¹

2. Postoperative pain trajectory not decreasing as expected 
Some pain lasting longer than 24 hours is normal and to be expected as part of the usual healing process. However, this transitional pain may have an impact on a person’s daily function and quality of life, causing a limitation in activities, contributing to psychological distress and limiting the achievement of rehabilitation goals.²  

3. Chronic postsurgical pain (CPSP).  
CPSP is defined in the ICD-11 classification of diseases as pain developing or increasing in intensity after a surgical procedure or a tissue injury and persisting beyond the healing process, i.e. at least 3 months after surgery or tissue trauma. The pain cannot be attributed to another cause, e.g. infection, malignancy and is localised to the surgical/injury area or related to this area.³ The mean incidence of pain 6-12 months after surgery is 20-30%, but varies hugely based on the surgical procedure, with some operations associated with CPSP rates of 50%, and the severity and impact on quality of life of the chronic pain.⁴  This incidence decreases over time. It is the most frequent postoperative complication associated with pain

4. Persistent postoperative opioid use (PPOU).  
The definition of PPOU for the purposes of this project is the use of opioid medication for more than three months after surgery or injury.⁵ The incidence of PPOU in studies is variable due to a range of data collection methods and the differences in definition.  Broadly speaking, the incidence of PPOU is 0.1-26% of opioid naïve patients and 35-77% of patients on pre-existing opioids.⁶ It is, however recognised that persistent opioid use is a major cause of harm.

Patients at risk of pain complications can be identified during the preoperative period. Risk factors may include:
1.  Patient factors

• Psychological factors
  a. Catastrophic thinking - assess using the PCS questionnaire, with a score over 30 considered concerning
  b. Depression/anxiety- assess using PHQ9 and GAD7 , with a moderate or higher scores indicating increased risk
• Pain-related factors 
  a. History of chronic pain
  b. Preoperative opioid use (Oral morphine equivalent of > 60 mg)
  c. Gabapentinoids

• Co- morbidities

             a. Addiction
             b.  High BMI increases the risk of obstructive sleep apnoea
             c. Low BMI increases the risk of relative opioid overdose
             d. Impaired renal and/or liver function 
             e.   Frailty 

2.    Social factors
       a.   Lack of social network / social support
       b. Unemployment

3.   Surgical factors 
      a. Complex or prolonged surgery
      b. Open surgery
      c. Surgical complications, e.g., wound infection
      d. Requirement for adjuvant chemotherapy or radiotherapy
      e. Recurrent or revisional surgeries.

Strategies to support high-risk patients should start preoperatively. Dose reduction of long-term opioids or psychological interventions takes time to address, so ideally, these patients should be identified by the surgical team at the time of listing for surgery.  Patients may also be flagged up at the pre-operative assessment clinic, although this often occurs a short time before the procedure limits, but doesn’t negate options for optimisation.  
Ideally, these patients should be triaged so that those at high risk can be identified early for more intensive interventions. ⁷
The main aim of this QI project is to assess if high risk patients are being identified throughout the perioperative period, and to ensure the interventions they require are in place.  

Best Practice

Best practice is derived from  the Royal College of Anaesthetists’ Guidelines for the Provision of Anaesthetic Services for inpatient pain, and the associated ACSA accreditation standards; and Faculty of Pain Medicine (FPM) opioid guidelines. ^8,9,10

• While awaiting surgery:   
   Information should be available to support all patients awaiting surgery to address modifiable risk factors including preoperative opioid use, anxiety and depression, pain catastrophising, smoking, and substance misuse ¹¹
• Prehabilitation or surgery school should be available and should set expectations of pain after surgery
• Agree on a pain management plan to address the fear of surgery to encourage movement and optimise function. The plan should include activities of daily living and broader physical activity, information on chronic post-surgical pain and persistent postoperative opioid use.

Provide advice about reducing analgesic medicines once discharged from the hospital. Information should be provided about surgery, preparation and post-op recovery. This should be delivered verbally by staff in clinic and backed up with leaflets BPS & signposting to online videos.  Translations should be available. 

People at increased risk of post-surgical pain complications should in addition:

• Be identified as early as possible in the surgical pathway and informed of potential delays to procedures if additional support is required
• Have an agreed perioperative plan between the inpatient pain, anaesthetic and surgical teams and the patient
• The plan should be shared with primary care providers, especially where medicine changes are proposed
• Patients using high-dose opioids should be referred for preadmission optimisation where services are available, or a plan provided to the patient and their primary care prescriber.^12,13,14 This should include details of support available e.g. patient support groups, and online resources. ¹⁵

Suggested Data to Collect

Define the subset of patients at high risk of pain complications to be reviewed; this could be a particular surgical subtype or patients with a particular risk factor such as pre-existing opioid usage.

Outcome Measures:
•    Length of stay for patients identified at high risk of pain complications compared to average for type of surgery
•    Prevalence of severe pain in the first 24 hours post-operatively for patients identified at high risk of pain complications, compared to average for type of surgery
•    Incidence of patients not experiencing pain trajectory expected
•    Incidence of diagnosis of CPSP in this cohort
•    Incident of PPOU in this cohort
Process Measures:
●    Percentage of patients identified preoperatively as high risk, compared to incidence of patients in cohort who were at high risk
●    Percentage of patients given preoperative education and information such as BPS leaflet “managing pain after your surgery”
●    Usage of multimodal analgesic strategy for patients identified as at high risk of postoperative pain complications
●    Incidence and evaluation of proactive referrals to the inpatient pain team, for instance preoperatively or postoperatively before a complication arose
●    Reactive referrals to inpatient pain team following a complication
●    Percentage of patients on preoperative high dose opioids referred for optimisation eg. to specialist outpatient pain services 
●    The percentage of patients identified as high risk perioperatively with a pain management plan made at discharge that is shared with the patient's general practitioner
●    Balancing measures should be considered to identify if there are any unintended consequences (good or bad) of changes on other parts of a system e.g. preoperative staff burden, inpatient pain team workload

Quality Improvement Methodology and worked example

•    If a baseline evaluation, for instance, found that preoperative patient information was a problem following the IHIs Model for Improvement, the team could look to accomplish improving preoperative patient information about perioperative pain. 
•    The team could establish any changes as an improvement by undertaking a sampling of patients with a preoperative survey about their awareness of perioperative pain following their preoperative assessment. A driver diagram could be formed to consider all the changes that could be made. Co-designing the study with patients is a useful concept here, for example, asking for their opinion about different modalities of information and what works best for them. If providing patient information leaflets at preoperative assessment, an example of a Plan/Do/Study Act cycle for this intervention could be:

• Plan: Our baseline evaluation found very few patients on preoperative opioids get education on pain and opioid stewardship  
• Do: Provide leaflets and education to the preoperative assessment nurses and aim that all patients at preoperative assessment are given the BPS” Managing pain after surgery” leaflet.
• Study: Review a small sample of patients every week who were on opioids preoperatively, and what percentage were given in the leaflet. Talk to the preoperative nurses, get qualitative feedback about the changes made, and have they found any problems that need addressing. It would be recommended to get patient feedback and involvement to assess opinions and plan further changes.
• Act: Review your data, did change happen how you expected, did it reach the level you wanted? Was it sustained? If there is a variability, why is this? Decide how you could improve things further, sustain improvement, or reduce any variability seen. If things have gone well, what can you move onto now – for instance what did the patients who got the leaflet think might help them further, for instance producing a video.

References

1. E M K Walker, M Bell, T M Cook, M P W Grocott, S R Moonesinghe, Central SNAP-1 Organisation, National Study Groups, Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study, BJA: British Journal of Anaesthesia, Volume 117, Issue 6, December 2016, Pages 758–766

2.Richebé P, Capdevila X, Rivat C. Persistent Postsurgical Pain: Pathophysiology and Preventative Pharmacologic Considerations. Anesthesiology. 2018 Sep;129(3):590-607

3.Schug SA, Lavand'homme P, Barke A, Korwisi B, Rief W, Treede RD; IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain. Pain. 2019 Jan;160(1):45-52.

4.Fletcher D, Stamer UM, Pogatzki-Zahn E, Zaslansky R, Tanase NV, Perruchoud C, Kranke P, Komann M, Lehman T, Meissner W; euCPSP group for the Clinical Trial Network group of the European Society of Anaesthesiology. Chronic postsurgical pain in Europe: An observational study. Eur J Anaesthesiol. 2015 Oct;32(10):725-34

5.Levy, N., Quinlan, J., El-Boghdadly, K., Fawcett, W.J., Agarwal, V., Bastable, R.B., Cox, F.J., de Boer, H.D., Dowdy, S.C., Hattingh, K., Knaggs, R.D., Mariano, E.R., Pelosi, P., Scott, M.J., Lobo, D.N. and Macintyre, P.E. (2021), An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia, 76: 520-536

6.Kent, Michael L. MD; Hurley, Robert W. MD, PhD, FASA; Oderda, Gary M. PharmD, MPH; Gordon, Debra B. RN-BC, DNP, FAAN; Sun, Eric MD, PhD; Mythen, Monty MBBS, MD, FRCA, FFICM, FCAI (Hon); Miller, Timothy E. MB, ChB; Shaw, Andrew D. MB, FRCA, FFICM, FCCM; Gan, Tong J. MD, MBA, MHS, FRCA; Thacker, Julie K. M. MD; McEvoy, Matthew D. MD. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesthesia & Analgesia 129(2):p 543-552, August 2019

7.Rosenberger DC, Pogatzki-Zahn EM. Chronic post-surgical pain - update on incidence, risk factors and preventive treatment options. BJA Educ. 2022 May;22(5):190-196

8.https://www.rcoa.ac.uk/safety-standards-quality/anaesthesia-clinical-se…
Surgery and Opioids: Best Practice Guidelines 2021. https://fpm.ac.uk/sites/fpm/files/documents/2021-03/surgery-and-opioids…
9.The Guidelines for the Provision of Anaesthetic Services (GPAS)  Inpatient pain. https://rcoa.ac.uk/sites/default/files/documents/2024-01/Chapter%2011%2…
10.El-Boghdadly, K., Levy, N.A., Fawcett, W.J., Knaggs, R.D., Laycock, H., Baird, E., Cox, F.J., Eardley, W., Kemp, H., Malpus, Z., Partridge, A., Partridge, J., Patel, A., Price, C., Robinson, J., Russon, K., Walumbe, J. and Lobo, D.N. (2024), Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society. Anaesthesia, 79: 1220-1236

11.Opioid Optimisation Guidance for Pain Medicine Specialists. https://fpm.ac.uk/sites/fpm/files/documents/2024-11/Opioid%20Optimisati…

12.Oxford University Hospitals resources for primary care regarding opioids and chronic pain. https://www.ouh.nhs.uk/services/referrals/pain/opioids-chronic-pain/

13.Faculty of Pain Medicine Opioids Aware. https://fpm.ac.uk/opioids-aware

14.Sandhu HK, Booth K, Furlan AD, et al. Reducing Opioid Use for Chronic Pain With a Group-Based Intervention: A Randomized Clinical Trial. JAMA. 2023;329(20):1745–175 https://www.britishpainsociety.org/whocares/patient-publications/#manag…