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Abstract
Chronic postsurgical pain (CPSP) is a prevalent yet unintended consequence of surgery with substantial burdens to the individual and their family, the healthcare system, and society at large. The present article briefly reviews the evidence for transitional pain services (TPSs) that have arisen in an effort to prevent and mange CPSP and persistent opioid use, and provides an update on recent novel risk factors for CPSP. Available evidence from one randomized controlled trial (RCT) and three non-randomized cohort studies suggests that TPS treatment is associated with better opioid use outcomes, including fewer opioid tablets prescribed at discharge, better opioid weaning results, a lower incidence of new-onset chronic opioid use, and lower consumption of opioids even at later time points up to 1 year after surgery. Another RCT indicates TPS treatment can be enhanced by provision of perioperative clinical hypnosis. While these preliminary studies are generally positive, large-scale, RCTs are needed to provide a more definitive picture of whether TPSs are effective in reducing opioid consumption and improving pain and mental health outcomes in the short and long term. With the expansion of TPSs across North America and globally, perioperative care focused on reducing the transition to pain chronicity has the potential to help millions of patients. With additional evidence from well-controlled RCTs, TPSs are well poised to continue to evolve and strengthen the role of multidisciplinary care teams in the immediate postdischarge period and beyond.
- Acute Pain
- Pain, Postoperative
- CHRONIC PAIN
- Pain Management
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Background
The Toronto General Hospital Transitional Pain Service (TGH-TPS) was designed to proactively identify patients at high risk of developing chronic postsurgical pain (CPSP) and persistent opioid use through assessment and multidisciplinary intervention across the perioperative period. The TGH-TPS aims to deliver multiprofessional pain care to patients with complex health issues for up to 6 months following surgery. Patients undergo risk factor screening for both physical and mental health issues and are recommended for further assessment if they have a background of anxiety, depression, significant levels of catastrophic thinking about pain, preoperative opioid use, and/or pre-existing chronic pain. Patients at the greatest risk of developing CPSP and engaging in persistent, high-dose opioid use are offered increased clinical resources to manage postsurgical pain.
In the first part of this paper, we will briefly review the evidence for the efficacy of TPSs in reducing opioid use in the short and long term after a variety of surgical procedures. In doing so, we refer to TPSs, in general, using the abbreviation TPS to denote research not specifically tied to one institution; otherwise, we will use the name of the specific program to make it clear when we are referring to a specific TPS (eg, TGH-TPS). This is not an exhaustive review of all programs designed to proactively address the problems of CPSP and persistent opioid use; rather the review focuses specifically on research addressing these problems by TPSs. In the second section, we describe recent evidence from the TGH-TPS for novel risk factors for CPSP and how these may impact TPS effectiveness. We also describe the integration of the mobile app, Manage My Pain into the TGH-TPS as well as its usefulness in ongoing research activities. We conclude with recommendations for future research and clinical activities related to the prevention and management of CPSP, in particular, two ongoing projects, one involving a digital health solution focusing on the provision of psychological interventions for pain clinics that do not have a dedicated psychologist and the other, a psychological intervention aimed at modifying a specific type of memory for pain that has been shown to be a risk factor for CPSP up to 1 year after surgery.
Toronto General Hospital Transitional Pain Service
The TGH-TPS1 2 was established in 2014 to address the problem of CPSP with a seamless approach to perioperative pain care and opioid use by a multidisciplinary team. Patients are assessed and managed across the perioperative care pathway, in some cases, as early as the preoperative visit. Treatment is provided in hospital after surgery and continued for ideally up to 6 months in an outpatient setting after patients have been discharged home. The TGH-TPS offers treatment to high-risk patients scheduled for major surgical procedures for cancer (eg, thoracic, breast, gastrointestinal, head and neck), cardiac disease (eg, coronary artery bypass graft, heart valve repair), and organ transplantation (eg, kidney, lung, liver, heart, pancreas). Recently, these indications have been extended given requests from neighboring hospitals within the University Health Network system. The Toronto Western Hospital has also launched a TPS in the past year with a focus on orthopedic and spine surgery. The TGH-TPS has three main goals: (1) to provide comprehensive pre and postoperative pain care for patients who are at high risk of developing CPSP and pain disability, (2) to manage in-hospital opioid use and help patients to wean off opioids after hospital discharge, and (3) to help patients cope and improve functional activities across the perioperative trajectory. The multidisciplinary team at the TGH-TPS provides multimodal medication optimization by anesthesiologists trained in pain medicine, postsurgical acute pain care by nurse practitioners and advanced practice nurses, physical therapy and acupuncture by physical therapists, mind-body/psychological interventions by pain psychologists trained in pain education, mindfulness-based approaches, clinical hypnosis, acceptance and commitment therapy (ACT) and more traditional cognitive–behavioral therapy, and more recently a psychiatrist with expertise in chronic pain, substance use disorders, and other concurrent psychiatric illnesses. The TGH-TPS also has an administrative assistant and a patient care coordinator. A common thread that runs through TGH-TPS research and clinical activities has been a partnership with ManagingLife, a technology startup company whose digital solution, Manage My Pain, allows patients to efficiently track their pain and functional activity on a daily basis using an Android or Apple smartphone or a mobile or desktop browser.3 Manage My Pain also serves as the hub through which questionnaires are administered to users for both clinical and research purposes.4 5
TPS: literature search
The first publication1 describing the development and implementation of the TGH-TPS provided a blueprint for other institutions that were interested in advancing a TPS for children6 and adults.7–10 Other similar clinics and services have since emerged, including the enhanced recovery after surgery approach,11 Acute Pain Service Out-Patient Clinic,12 Johns Hopkins Personalized Pain Program,13 Vanderbilt TPS,14 Duke Transitional Pain Services,15 Perioperative Pain Management, Education, and De-escalation service,16 and the POET-Pain TPS.17
To evaluate the extent to which TPSs, in general, have penetrated the scientific and clinical academic literature, we searched the PubMed National Library of Science for journal articles published in peer-reviewed journals between 2015 and March 2024 containing “transitional pain service” OR “transitional pain clinic” in the title or abstract (March 8, 2024). This search yielded 71 published articles which we retrieved and downloaded. Next, we searched the Clarivate Web of Science for published articles that cited the foundational articles by Katz et al1 (March 14, 2024) and Huang et al2 (March 16, 2024), the former yielding 156 articles after removing duplicates and the latter yielding an additional 43 articles after removing duplicates. This resulted in a total of 270 published articles. Figure 1 shows an increasing yearly and cumulative yearly number of published articles that mention TPS and provides an indication of the international interest and research addressing the twin problems of chronic pain and persistent opioid use after surgery.
Yearly number and cumulative yearly number of published articles since 2015 retrieved from a March 8, 2024 title and abstract search of PubMed Central for “transitional pain service” or “transitional pain clinic”, and a March 14, 2024 and March 16, 2024 search of Clarivate Web of Science for published articles citing the article by Katz et al1 and Huang et al,2 respectively. Each green bar represents the number of citations in that year (left y-axis). The filled black circles and the numbers above them are the cumulative yearly number of citations (right y-axis).
TPS: assessing the evidence for efficacy
Of the 270 articles identified through the literature search, 16 articles with a total of 4173 patients evaluated some aspect of TPS management. Table 1 shows a summary of the 16 studies listing the study design, population recruited, sample size, when participants were admitted to the TPS relative to surgery, a description of the nature of TPS treatments received, length of time under TPS care, pain, opioid, and/or mental health outcomes measured, and highlights of the main results. The 16 articles comprised 3 randomized controlled trials (RCTs),7 18 19 3 non-randomized, 2-group cohort studies that compared a TPS group with a non-TPS matched control group20 or a historical control group,21 22 5 single group, retrospective, longitudinal cohort studies,13 23–26 4 single group prospective, longitudinal cohort studies,5 27–29 and 1 cross-sectional survey assessing treating physicians’ satisfaction working within a TPS.7
Summary of the 16 articles identified through the literature search, showing the author and year of publication, study design, population recruited, sample size, when participants were admitted to the TPS relative to surgery, a description of the nature of TPS treatments received, length of time under TPS care, primary outcome measures, and highlights of the main results
Given the space limitations, we will describe the four studies that compared patients seen by a TPS with control patients not seen by a TPS. We will also present the primary and secondary outcomes of an RCT that evaluated the added benefit of an intervention over-and-above TPS treatment (eg, TPS+ hypnosis vs TPS+ treatment-as-usual (TAU)).18 19 The remaining studies in table 1 will not be reviewed in this section since they do not evaluate the comparative efficacy of a TPS, being either single group cohort studies describing patients or subsets of patients seen by a TPS over time,5 13 23–29 or a satisfaction survey.7
RCT comparing TPS-treated and non-TPS-treated patients
A single RCT evaluated the efficacy of a TPS in improving quality of life (QoL) on the third day after surgery as the primary outcome, as well as on secondary outcomes, including opioid consumption, pain severity, and subjective satisfaction 3 and 6 months after surgery.7 176 patients scheduled for a variety of elective surgeries were randomly assigned to a multidisciplinary TPS group or a standard of care (SOC) group and followed up at 3 and 6 months after surgery. The results did not show a significant difference between the groups in the primary outcome measure, QoL on the third postoperative day. Data for the secondary outcomes are provided in tabular form and appear to favor the TPS group over the SOC group in terms of 6-month opioid consumption, new-onset disability, and incidence of chronic pain at 6 months, but the authors did not conduct statistical analyses comparing the groups.
Non-randomized, cohort studies comparing TPS-treated and non-TPS-treated patients
Three non-randomized studies compared TPS patients with non-TPS controls. Buys et al22 compared 164 TPS patients with 176 historical controls who underwent orthopedic surgery at the same institution but 1 year before the TPS had been established. The two groups were similar in baseline characteristics including demographic variables and surgical procedures. Analysis of the primary outcome showed that 90 days after surgery, TPS patients (13.4%) were significantly less likely to be taking opioids than the non-TPS historical control group (27.3%). Analysis of secondary outcomes indicated that the number of opioid tablets prescribed at hospital discharge was significantly lower for the TPS group than the control group. The percentage of patients who were opioid-naïve prior to surgery and developed new onset of chronic opioid use (defined as still using after 90 days) was significantly lower in the TPS group (0.7%) than the controls (8.4%). Similarly, among patients who were using opioids before surgery, a significantly greater percentage of TPS (67.5%) patients than controls (45.3%) were off opioids or had reduced opioid use at the 90-day time point. Pain and mental health outcomes were measured for patients in the TPS group, but these results were not available for the historical controls.
Featherall et al21 compared 137 opioid-naïve patients undergoing primary total joint arthroplasty at a Veterans Affairs Medical Center who received TPS treatment with 71 historical controls who underwent similar surgery at the same institution prior to the establishment of the TPS. The two groups were similar in baseline characteristics including demographic variables and surgical procedures with the exception that a greater proportion of patients in the TPS group versus the control group had been diagnosed with an anxiety disorder. Analysis of the primary outcome showed that the percentage of patients with persistent opioid use at 90 days postdischarge was significantly greater in the historical control group (9.9%) than in TPS group (0.07%). In univariable and multivariable analyses, the mean number of tablets prescribed in the 90-day postdischarge period for the TPS group (n=49) was significantly lower than in the historical control group (n=119). Pain and mental health outcomes were measured for patients in the TPS group, but these results were not available for the historical controls.
Ladha et al20 compared a sample of 209 TPS patients with a matched cohort of 209 non-TPS treated patients from other hospitals using administrative data. The two cohorts were matched 1:1 without replacement on mean past 90-day opioid daily dose in MME (0, 1–59, >60), sex, age group in years (18–34, 35–49, 50–64, and ≥65), income quintile, discharge date ±5 years, and surgery type. The primary outcome was postoperative, pharmacy-dispensed opioid use (MME) in the 12 months after hospital discharge. Over the 12-month period after surgery, both groups showed a significant decrease in MME with the TPS group decreasing by 3.53 MME per month compared with a decline of 1.05 MME for the control group. The mean difference (2.48 MME) in the reduction of monthly opioid use between the TPS group and the control group was significant indicating a greater decrease in opioid use in the former than the latter group. A second matched cohort that underwent surgery at the same institution but did not receive TPS treatment was compared with a new TPS group with the pattern of results being the same as the main analysis. The mean daily MME per month decreased by 3.32 MME for the TPS group vs 0.51 MME for the matched controls.
RCTs to enhance TPS treatment
Two articles presented data from a single RCT using the same cohort of patients.18 19 One evaluated the effects of clinical hypnosis versus treatment as usual (TAU) on (1) in-hospital opioid consumption in the first week after surgery (primary outcome) and the second, on (2) high-frequency heart rate variability (HF-HRV) and pain 1 month after surgery (secondary outcomes). Since all participants were treated by a TPS the study essentially evaluates the effects of TPS care plus clinical hypnosis versus TPS care alone. 92 participants awaiting oncological surgery were randomized to receive TAU or clinical hypnosis after completion of questionnaires and ECG and respiration recording for HF-HRV analysis. HF-HRV is clinical biomarker of vagal heart rate modulation that is inversely associated with acute pain. Higher levels of HF-HRV are viewed as advantageous and correlate with greater adaptability, lower stress, and greater vagal tone. Participants assigned to the clinical hypnosis group received one in-person session of clinical hypnosis 1–2 weeks prior to surgery and a second session in-hospital 1–3 days after surgery. Intention-to-treat analyses showed an opioid-sparing effect of clinical hypnosis during the acute postoperative period showing significantly less opioid (MME) consumed by clinical hypnosis participants than TAU participants on the first and fourth days after surgery. Hypnosis also protected participants against the negative effects of increases in catastrophic thinking about pain that the TAU participants exhibited 1 week after surgery.19 One month after surgery, HF-HRV was significantly higher in the clinical hypnosis group than the TAU group and in the latter, but not the former, group HF-HRV decreased significantly from before surgery to 1 month after surgery.18 Taken together, these findings indicate that among patients undergoing oncological surgery, provision of perioperative clinical hypnosis over-and-above TPS treatment reduces in-hospital opioid consumption and suggests that hypnosis may mitigate the adverse effects surgery has on autonomic function, thereby contributing to improving postsurgical recovery.
Summary of TPS efficacy studies
The four outcome studies that compared TPS patients to a non-TPS control group were conducted by two research groups from institutions that have similar TPSs though they are in different countries. Both admit patients into the TPS based on preoperative CPSP risk factor assessment, provide preoperative education, and offer similar medical and psychological treatment, including ACT. Taken together, the results of these four studies suggest that TPS treatment is associated with better opioid use outcomes, including fewer opioid tablets prescribed at discharge, better opioid weaning results, a lower incidence of new-onset chronic opioid use, and lower consumption of opioids even at later time points up to 1 year after surgery but the magnitude of some of these differences20 raises the question of clinical significance. All four studies have methodological problems; some have been acknowledged by the authors but others have not. Apart from the potential for selection bias and confounding associated with non-randomized studies, use of historical controls raises a host of other possible biases that may influence the results. The decision to use a measure of QoL on day 3 after surgery as the primary outcome is questionable as is the choice not to perform statistical analysis on secondary outcomes.30 Although Patient Reported Outcome Measurement Information System pain measures and mental health outcomes were assessed in TPS patients in two of the studies, these data were not available in the historical control groups.21 22 The absence of these results raises the question of whether or not the significant differences in opioid use were achieved at the expense of higher levels of pain severity, pain interference, and poorer mental health outcomes (see Katz et al).31 While these preliminary studies are generally positive, large-scale, RCTs are needed to provide a more definitive picture of whether TPSs are effective in reducing opioid consumption and improving pain and mental health outcomes in the short and long term.
Novel risk factors for CPSP
Over the years, we and others have identified many risk and protective factors for CPSP,32–42 although the strength with which they predict CPSP varies considerably, and few have been shown to be causal34 43 44 It is likely that some risk factors are universal to all surgeries and others are surgery specific. Type of surgery is one of the most consistent risk factors identified with surgeries that involve unavoidable or inadvertent nerve damage producing the highest rates of CPSP,32 34 although not all CPSP is neuropathic in nature.45 A recent comprehensive umbrella review identified 39 presurgical risk factors classified into six categories, comprising (1) psychological, (2) pain-related, (3) health-related, (4) social/lifestyle-related, (5) demographic, and (6) genetic factors.46 A consistently high level of evidence was found for preoperative pain (eg, presence, intensity), depressive symptoms, anxiety symptoms, and catastrophic thinking about pain. To this, we would add age (younger or older depending on the surgery),46 female sex,46 and preoperative opioid use.25 31 47 Risk factors for higher opioid consumption up to 1 year after surgery include male sex, preoperative substance use disorder, and higher levels of pain-related interference.48
Two recent prospective, longitudinal studies conducted by the TGH-TPS have identified novel or rarely studied psychological risk factors for CPSP; namely, preoperative distress over bodily sensations (formerly known as somatization)49 and an overgeneral autobiographical memory retrieval style.50
Distress over bodily sensations
In the first study, 543 adults undergoing cardiac or thoracic surgery were assessed at baseline before surgery and followed up to 6 months after surgery.49 Before surgery, participants completed questionnaires measuring demographic, clinical, and psychological factors (distress about bodily sensations, catastrophic thinking about pain, anxiety sensitivity, symptoms of anxiety and depression) and were followed up 6 months later when they recorded current pain intensity (0–10 NRS) and completed a measure of pain disability using the Pain Disability Index. Multinomial logistic regression was used to determine the extent to which presurgical measures of distress over bodily sensation, and catastrophic thinking about pain separately predicted pain intensity and pain disability 6 months after surgery after controlling for important confounders. Age and presurgical scores on the Symptom Checklist-90 (SCL-90) Revised Somatization subscale significantly predicted CPSP intensity whereas presurgical SCL-90- Revised Somatization scores were the sole predictor of CPSP pain disability. Taken together, these results show that greater presurgical distress over bodily sensations predicts greater chronic pain intensity and disability 6 months after cardiothoracic surgery and raise the possibility that intervening preoperatively to reduce presurgical distress about bodily sensations may prevent or obtund the development of CPSP intensity and disability.
Autobiographical memory and CPSP
Interest in the role of memory processes in general, and autobiographical memory, in particular, in initiating and maintaining chronic pain has gained traction in recent years.50–52 Autobiographical memory describes a memory system involving personal episodic and semantic details of a person’s past. Autobiographical episodic memories can vary in degree of specificity. Specific episodic memories include personal information tied to time and place (eg, “Last Thursday morning just before breakfast, I slipped on the kitchen floor and twisted my left ankle.”) whereas overgeneral memories lack such specificity (eg, “I’m always twisting my ankle.”). Previous research has shown that people with chronic pain tend to recall memories with reduced specificity to time and place51 leading us to predict that an overgeneral memory style might be a risk factor for CPSP and conversely, that autobiographical memory specificity might be a protective factor.50
To test this hypothesis, we conducted a prospective, longitudinal observational study of 97 adult participants scheduled for major surgery.50 Before and 1 month after surgery, participants’ memories were assessed with the Autobiographical Memory Test in which they were asked to recall personal events in response to five positive and five pain-related word cues. The presence or absence of pain and measures of psychological functioning were assessed before and 1, 3, 6, and 12 months after surgery. Generalized estimating equations were used to model pain at each time point after surgery using memory variables as predictors. The results showed that, as hypothesized, the greater the number of preoperative-specific pain memories recalled, the lower the odds of pain across all time points. As well, the longer the time taken to recall the memories and the more surgery-related content in the memories at the 1 month assessment were associated with greater odds of reporting postsurgical pain up to 12 months after surgery. These results show that an overgeneral presurgical autobiographical memory retrieval style is a risk factor for postsurgical pain up to 1 year after surgery. At the present time, it is unclear whether this memory bias is a causal risk factor for CPSP, but to the extent that it is, perioperative interventions aimed at improving the specificity and modifying the content participants’ memories may be effective in preventing or reducing the incidence of CPSP.
Future directions in TGH-TPS interventions
Psychology is a critical pillar of the multidisciplinary care offered at most TPS’s. But access to TPS care is, at present, limited to in-person, specialized hospital-based clinics. Such clinics, by necessity, prioritize patients at highest risk for CPSP to the exclusion of others equally in need of care. They often require physician referrals for access and have unacceptably long wait times. Moreover, one of the major challenges in providing quality care after surgery is the shortage of specialized pain psychologists, which further limits access to the relatively few pain treatment facilities that employ psychologists. To address this gap in service provision, the TGH-TPS is evaluating the feasibility of a self-guided, online ACT intervention, specifically for postsurgical patients titled Advancing Online Psychology Tools for the TPS (ADOPT-TPS) developed for use on the Manage My Pain mobile app. A two-arm, randomized, controlled pilot feasibility trial will compare the efficacy of ADOPT-TPS with a pre-existing psychologist-guided workshop.53 Accessible online pain interventions of this sort will allow for the dissemination of pain psychology tools directly to the people who are in need as well as to services and clinics that currently do not have a psychologist on staff.
Another area of future research at the TGH-TPS involves evidence of associations among chronic pain, alterations in autobiographical memory, and structural and functional changes in the hippocampus.51 52 Our data, briefly reviewed above, showed that the number of time-and-place-specific (vs overgeneral) pain memories generated in response to pain-related cues prior to surgery was associated with significantly lower odds of CPSP suggesting that the ability to retrieve specific memories of pain events protects against CPSP.50 Autobiographical memory specificity can be enhanced using Memory Specificity Training (MeST)—a brief, targeted cognitive intervention that teaches patients strategies to enhance specificity of retrieved autobiographical memories. MeST is effective in enhancing specificity of retrieved memories in other clinical populations with an overgeneral memory bias54 but it has yet to be evaluated in patients undergoing surgery who are at high risk of developing CPSP. The TGH-TPS is currently conducting a blinded, randomized, two-arm, controlled internal pilot trial of 44 adults undergoing thoracic surgery comparing MeST to an attention control condition. Structural and functional neuroimaging, memory specificity assessment, and self-report measures are completed before surgery and 3 months later. Results will determine whether we proceed with a full-scale RCT.
From a clinical care standpoint, the TGH TPS has recently recruited a psychiatrist specialized in managing pain and substance abuse. It has become clear that chronic pain and substance use are both highly prevalent, frequently comorbid, and of considerable public health concern.55 56 Pain-substance use models indicate that these two conditions operate in a positive feedback loop.57–60 Harm reduction in the field of pain has become a highly relevant topic given the increase in intravenous drug use in North America and for patients struggling with other active substance use disorders (ie, alcohol, cannabis, methamphetamine) who present for surgery.61 Improving care for patients with substance use disorders as well as for other marginalized populations will be an area of TGH TPS program expansion in the coming years.
Common barriers to implementation of a TPS
While there has been implementation and growth of TPSs internationally, the adoption and expansion of these services has not been without challenges. Almost every institution that performs major surgery should have a service that helps those struggling with postoperative pain disability and increased opioid consumption out of keeping with a normal trajectory. The economic impact of TPS is a hot topic of discussion in the USA.15 Some argue that if a TPS reduces emergency room visits, the cost to society is reduced but the cost to a hospital system may actually be increased (as a hospital would otherwise be able to bill for these visits).9 What is likely true, regardless of the healthcare system or geographical location in which a TPS is built, is that increased funding for administrative assistants, and non-fee for service providers (ie, psychologists, physiotherapists, acupuncturists) likely requires new and ongoing base funding. The ability to advocate successfully for additional financial resources continues to be the major barrier to entry for many Departments of Anesthesiology and Pain Medicine interested in pursuing these endeavors.
Conclusions
Over the past 10 years, TPSs have developed to assess and manage patients at high risk of CPSP. Patients are identified as early as possible and are provided comprehensive care by a multidisciplinary team. Preliminary results suggest that TPS treatment is associated with better opioid use outcomes, including fewer opioid tablets prescribed at discharge, better opioid weaning results, a lower incidence of new-onset chronic opioid use, and lower consumption of opioids even at later time points up to 1 year after surgery. The TGH-TPS is conducting a multisite RCT titled Reducing Opioid Use for Chronic Pain Patients Following Surgery (RECOUP). The RECOUP trial’s inclusion criteria consist of adults aged 18 years and older who are undergoing any type of surgical procedure and taking 10–400 mg of preoperative oral MMEs preoperatively for at least 1 month prior to surgery. In addition to the primary outcomes of pain disability and opioid weaning, the four core chronic pain outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials62—pain intensity, physical functioning, emotional functioning and participant rating of overall improvement are key secondary outcomes as well. The above trial and others (eg, a German multisite trial) are ongoing, and the expansion of TPSs across the US and abroad continues. The building of future TPSs will continue to close a critical gap in perioperative care at many institutions worldwide. TPSs are likely to continue to evolve and strengthen the role of multidisciplinary care teams in the immediate postdischarge period, a critical time when patients can benefit from education and care regarding pain and postoperative opioid consumption.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Acknowledgments
HC is supported by a Merit Award from the Department of Anesthesiology and Pain Medicine at the University of Toronto. AAternali and KA are supported by a Canadian Institutes of Health Research (CIHR) Canada Graduate Scholarship (CGS) Doctoral Award. AW is supported by a CIHR CGS Vanier Doctoral Award. KSL is supported by a Merit Award from the Department of Anesthesiology and Pain Medicine at the University of Toronto, a Career Scientist Award from the Canadian Anesthesiologists’ Society and the Evelyn Bateman Recipe Chair in Ambulatory Anesthesia and Women’s Health at Women’s College Hospital. JK was supported by a CIHR Canada Research Chair in Health Psychology at York University.
References
Footnotes
X @drhaclarke, @DrAlaMahamid, @Joel Katz
Contributors HC, AW, AAternali, KA, MS and JK were involved in the research, creation, writing and revising of the manuscript. All other coauthors (ie, AAlmohawis, KC, JF, MF, PG, AH, RK, SL, KSL, AL, AM, MM, MGP, HL-R, BNR, DT, LT, PT, CW, JW and EW), were involved in editing and revising several versions of the manuscript. HC is the guarantor of this submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.