About SPC

Surgical Pain Consortium Mission & Vision

SPC Mission improving surgical pain management

 

Vision Statement

Alleviate Surgical Pain Worldwide.

Mission Statement

Raise awareness and develop and disseminate best practices for improving surgical pain management, enhance postsurgical recovery, patient safety, patient satisfaction, and health economic outcomes.

 

Strategic Advisory Group

The Advisory Group members of the Surgical Pain Consortium are key thought leaders that represent the specialties of anesthesiology, surgery, pharmacy, nurses, and management. Members are added as the scope of The Surgical Pain Consortium's efforts grow.

Chair Girish Joshi, MBBS, MD, FFARCSI

Girish Joshi, MBBS, MD, FFARCSI
Chair

Brian Dunkin, MD

Brian Dunkin, MD

Roger Emerson Jr, MD

Roger Emerson Jr, MD


Jeffrey Janis, MD, FACS

Jeffrey Janis, MD, FACS

Deborah Keller, MS, MD

Deborah Keller, MS, MD

Mikio A. Nihira, MD, MPH

Mikio A. Nihira, MD, MPH


Bruce Ramshaw, MD, FACS

Bruce Ramshaw, MD, FACS

Melanie H. Simpson, PhD, RN-BC, OCN, CHPN

Melanie H. Simpson, PhD, RN-BC, OCN, CHPN, CPE


The Surgical Pain Consortium

 

Email:

 

The Surgical Pain Consortium seeks the clinical contributions and ideas of the broader surgical pain community, while synthesizing and amalgamating top level evidence-based procedure-specific pain management protocols proven to improve perioperative outcomes. The Surgical Pain Consortium values the input of all those who manage surgically related pain, as well as the patients who experience it.

In the coming years, the Surgical Pain Consortium hopes to construct forums for both healthcare professionals who manage surgical pain, and for patent feedback. The Surgical Pain Consortium will work to gain feedback on the procedure specific multimodal pain management recommendations it advances.

Industry Sponsors

The Surgical Pain Consortium is made possible through grant support from industry sponsors allied in our efforts to advance optimal procedure-specific surgical pain management.


Pacira Pharmaceuticals, Inc.

Pacira Pharmaceuticals, Inc. is a specialty pharmaceutical company focused on the clinical and commercial development of new products that meet the needs of acute care practitioners and their patients. Pacira Pharmaceuticals primary focus lies in the development of non-opioid products for postsurgical pain control. Learn more about Pacira Pharmaceuticals

Mallinckrodt Pharmaceuticals

Mallinckrodt Pharmaceuticals develops, manufactures, markets and distributes specialty pharmaceutical products and diagnostic imaging agents. The company uses their own active pharmaceutical product ingredients in generic pharmaceuticals sold to other pharmaceutical companies. The company markets global medical imaging products to physicians, technologists and purchasing administrators at hospitals, imaging centers, cardiology clinics and radiopharmacies. Learn more about Mallinckrodt Pharmaceuticals


Cumberland Pharmaceuticals

Cumberland Pharmaceuticals is a specialty pharmaceutical company that acquires, develops and commercializes branded prescription products designed to improve quality of care and address unmet medical needs. Learn more about Cumberland Pharmaceuticals

Related Links

 

Plan Against Pain: Choices matter in pain management

 

PROSPECT- Procedure specific postoperative pain management

 



  Surgical Procedures

Surgical Pain Consortium promotes best practice recommendations for optimal management of pain related to surgical trauma

The Surgical Pain Consortium (SPC) promotes best practice recommendations for optimal management of pain related to surgical trauma.

Examination of current postsurgical pain management standards of care reveals that there are alarming gaps in knowledge and practice in how postsurgical pain is managed across the United States healthcare continuum. This presents an opportunity to make an exceptional contribution to this area of practice, an endeavor that can only be accomplished with direct involvement of and guidance from key multidisciplinary leaders in perioperative pain management.

The current state of postsurgical pain management is associated with an enormous cost and patient safety burden for surgery centers and hospitals.

Managing surgical pain remains a complex and non-uniform process, traversing different geographical and practice strata, often resulting in unnecessary financial and safety burdens for both patients and the healthcare system. The Surgical Pain Consortium endeavors to close existing gaps in management of surgical pain through knowledge, evidence, and recommendations.

The Surgical Pain Consortium provides procedure-specific multimodal pain management recommendations that are built on a foundation of clinical evidence, while considering recently optimized multimodal pain management approaches.

Breast Surgery Recommendations


 

Hernia Surgery Recommendations


SPC Protocols


Multimodal Pain Management Recommendation
The 2015 SPC Hernia Working Group

Surgical Videos

Illustrations


Abdominal Infiltration
Shoulder Surgery Illustration

Shoulder Surgery Recommendations


SPC Protocols


Management of Pain After Shoulder Surgery
SPC Strategic Advisory Group

Surgical Videos

Illustrations


Shoulder Infiltration

    Education

Surgical Pain Management: Current Concepts and Controversies

Girish P. Joshi, MBBS, MD, FFARCSI
Professor of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center
Dallas, Texas

The International Association For the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”  Pain is a complex perceptive phenomenon and is always subjective.  Therefore, clinicians must accept patients’ report of pain.  Pain perception is based on the patients’ biological, psychological, and social factors

Adequately treated pain allows for earlier ambulation and rehabilitation and reduce the possibility of chronic pain syndromes, as well as early return to activities of daily return after an surgical intervention.  In recent years, there is an increased emphasis on implementation of accelerated recovery or enhanced recovery after surgery (ERAS) programs, which are multimodal, multidisciplinary perioperative care pathways that are designed to reduce hospital length of stay.  It is well recognized that provision dynamic pain relief is one of the critical component of ERAS programs, as it is necessary to facilitate rehabilitation and ambulation.

Consequences Of Inadequate Pain Management

There is mounting evidence that inadequately treated surgical pain has profound pathophysiological and psychological effects that can have several short-term and long-term consequences that result in significant costs to patients, families, the healthcare system, and the society as a whole. 

Pain is a potent trigger for the stress response, which activates the autonomic system and is thought to cause adverse effects on various organ systems.  The sympathetic hyperactivity resulting from severe pain can result in myocardial ischemia, which could be particularly detrimental in patients with cardiovascular disease.  Pain can cause diaphragm dysfunction, decrease functional residual capacity, and increase shunting.  In addition, it can cause splinting and increase the incidence of postoperative pulmonary complications.  The autonomic over-activity from unrelieved pain and administration of opioids decrease gastrointestinal motility and lead to paralytic ileus, which can delay return of bowel function.

Surgical stress response increases insulin resistance and causes hyperglycemia.  Also, acute pain leads to hypercoagulability and cause deep vein thrombosis and thromboembolism.  Furthermore, it may reduce immune function, which may increase the incidence of infection, promote tumor spread or recurrence.  In addition, pain can also increase urinary sphincter tone and cause urinary retention.  Surgical trauma and inadequately managed pain changes the nervous system such that acute pain can become maladaptive resulting in chronic pain, commonly termed as persistent postoperative pain.  Unrelieved pain results in patient discomfort and anxiety, which can further increase the perception of pain. Many patients with persistent pain experience depression as well as changes in personalities and social interactions.

Barriers To Pain Management

Despite of the significant evidence that inadequately managed surgical pain can increase morbidity, prolong hospitalization, delay return to daily activities, and increase healthcare costs, it continues to be inadequately managed.  Several studies have reported that patients complaining of moderate-to-severe postoperative pain have remained at the same level over several decades.  Under treatment of surgical pain might be due to lack of knowledge of the principles of pain therapy, misconceptions regarding the pharmacology of analgesics, and inadequate skills to manage pain appropriately. There appears to be a significant misunderstanding of the concept of multimodal analgesia, which is considered an optimal approach to pain management, leading to inadequate or improper application of available therapies.  In addition, inadequate assessment of pain and pain relief are important reasons for unrelieved pain.  

Other reasons include unwarranted concerns for side effects of analgesics, particularly opioids and attitudes of healthcare personnel.  It reported that patients undergoing relatively “minor” invasive surgical procedures have similar pain intensity as those with greater intensity.  The most likely cause of this observation may that healthcare providers prescribe inadequate analgesic for patients undergoing procedures that have a reputation of being less painful.  Although physician education should improve pain management, education alone rarely changes practice.  Also, pain management has largely been relegated to an afterthought in surgical care. Furthermore, factors that impede effective pain management include low institutional priority for pain management, lack of access to analgesics due costs, lack of accountability for poor pain treatment, lack of continuity of care and fragmentation of care. Patient-related factors include reluctance to report pain and reluctance to take pain medications as well as inadequate patient education with regards to available therapies.

Approach to Optimal Pain Management

There are several guidelines that provide excellent evidence-based information such as concepts of optimal pain management, and benefits and limitations of analgesics and analgesic techniques; however, the advice they offer is general and not always applicable to specific surgical procedures.  Furthermore, these guidelines provide conflicting information.  Therefore, it is not surprising that these guidelines have failed to promote improved pain management, and the prevalence of inadequate pain continues to be high.

It is now well-recognized procedure-specific pain management guidelines should allow a practitioner to include them in the ERAS protocols resulting in proper implementation and improved outcome.  The reasons for developing procedure-specific pain management guidelines have been described previously.  Briefly, various surgical procedures have varying pain characteristics including type (e.g., somatic pain and visceral pain), location, intensity, and duration.  Also, different surgical procedures have different consequences if not treated appropriately.  Furthermore, efficacy of analgesic may also be procedure-specific.  Optimal evidence-based procedure-specific pain management guidelines would take into consideration the invasiveness of the surgical procedure and the consequences of inadequately treated pain as well as the balance between the efficacy and adverse effects of analgesics and analgesic techniques.  

Preoperative Considerations

Preoperative pain intensity is a risk factor for development of severe acute postoperative pain and long-term postsurgical pain.  Therefore, preoperative analgesic should not be discontinued.  If it is necessary to discontinue an analgesic (e.g., an NSAID), it should be replaced with another equivalent analgesic.  Preoperative identification of patients at risk for poor pain control should allow modify pain therapy and improve pain control. Evidence suggests that emotional and psychosocial factors play a critical role in the experience of pain.  Patients with preoperative anxiety and catastrophizing tendency as well as those with chronic pain conditions such as fibromyalgia have greater postoperative pain intensity.  Therefore, this patient population needs a special attention with regards to pain management. Preoperative patient education and counseling with regards to appropriate expectations as well as about opioid sparing strategies is an important component of optimal pain management.

Multimodal Procedure-Specific Pain Management Guidelines

Because pain perception is a complex multifactorial phenomenon, it requires a multimodal approach to achieve adequate pain control.  Multimodal analgesia includes combination of analgesics of different mechanism of action, rather than using a single analgesic (e.g., opioids) or a single analgesic technique.  The overall aim of an optimal multimodal analgesic technique is to improve pain relief, while limiting the opioid dose, and thus opioid-relate adverse events (ORAE). Commonly used analgesic modalities in current practice include local anesthetic techniques (surgical site infiltration, intraarticular injection, peripheral nerve blocks, and neuraxial blocks [epidural and paravertebral block]), acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase (COX)-2 specific inhibitors as well as analgesic adjuncts such as steroids (e.g., dexamethasone), N-methyl-D-aspartate antagonists (NMDA) antagonists (e.g., ketamine), alpha-2 agonists (e.g., clonidine and dexmedetomidine), and anticonvulsants (e.g., gabapentin and pregabalin).

It is assumed that combining multiple analgesics may provide superior pain relief with lower incidence of adverse effects.  However, it is commonly misunderstood, as it is not uncommon for practitioners to use inappropriate analgesic combinations with no regard to the type of surgical procedure (e.g., using same analgesic combinations for laparoscopic and open abdominal surgical procedures). Furthermore, administration of several analgesics, although it is not necessary, general termed as “shot gun” approach.  Thus, there is emphasis on developing procedure-specific multimodal analgesic approach.  An ideal multimodal analgesic approach would primarily include local/regional analgesic technique combined with other non-opioids such as acetaminophen and NSAID or COX-2 specific inhibitor with opioids reserved for rescue. In addition, administration of a single intraoperative dose of dexamethasone contributes to analgesic benefit.  Other analgesic adjuncts such as ketamine and gabapentinoids should be procedure- and patient-specific.

Opioid-related Adverse Events

One of the principle aims of a optimal multimodal analgesia technique is to avoid opioid-related adverse events.  Common opioid-related adverse drug events include gastrointestinal (e.g., nausea, vomiting, constipation), central nervous system (e.g., drowsiness, sedation, respiratory depression), and genitourinary (e.g., urinary retention) effects.  These adverse events delay recovery and increase hospital length of stay. In a hospital setting, opioid-related adverse events have been identified as one of the major cause of serious adverse drug events including opioid-induced respiratory depression and death.  Joint Commission recently published a sentinel event alert to emphasize that not all pain can be eliminated and a goal-related approach should be utilized. Thus, a patient may define pain level as tolerable and acceptable on a pain scale. It is recommended to avoid using opioids to achieve an arbitrary pain rating.  It is now well known that we have an opioid abuse epidemic in the US caused by prescription opioids. Unfortunately, so far, only simplistic solutions are being promoted (e.g., prescription regulations).  However, this is a much more complex problem and simple attempts at solutions will have predictable unintended consequences and will not have as much positive impact as needed.  One of the approaches is to identify complex patterns and optimal variety of solutions that could be generated from a more complex systems view of the opioid and pain problems.

Summary

Effective pain control is critical in achieving enhanced recovery after surgery. Patients with favorable experience of their surgical experience have improved satisfaction.  Optimal pain management technique would be procedure-specific non-opioid multimodal techniques that allow reduction in opioid dose and avoid opioid-related adverse events.  It is necessary to use continuous improvement tools to measure and improve outcomes as well as value of care when implementing multimodal pain management approach. Collection of outcomes data (with Continuous Quality Improvement) should allow physicians learn how to optimize postoperative outcomes in their local environment.

References

  • Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016; 17: 131-57

  • Schug SA, Palmer GM, Sco DA, Halliwell R, Trinca J; APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2015), Acute Pain Management: Science Evidence (4th edition), ANZCA & FPM, Melbourne.

  • Joshi GP, Schug S, Kehlet H: Procedure specific pain management and outcomes strategies. Best Prac Res Clin Anesthesiol 2014; 28: 191-201.

  • Joshi GP. Putting it all together: recommendations for improving pain management in plastic surgical procedures. Plast Reconstr Surg 2014; 134 (4 Suppl 2): 94S-100S.

  • Rosero EB, Joshi GP. Preemptive, preventive, multimodal analgesia: what do they really mean? Plast Reconstr Surg. 2014; 134 (4 Suppl 2): 85S-93S.

  • Collins SA, Joshi G, Quiroz LH, Steinberg AC, Nihira MA. Pain management strategies for urogynecologic surgery: a review. Female Pelvic Med Reconstr Surg 2014; 20: 310-5.

  • Joshi GP, Beck D, Emerson RH, et al: Defining new directions for more effective management of surgical pain in the United States: highlights of the inaugural surgical pain congress American Surgeon 2014; 80: 219-28.

  • Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005;23:21-36.

  • Hayhurst CJ, Durieux ME. Differential opioid tolerance and opioid-induced hyperalgesia: a clinical reality. Anesthesiology 2016; 124: 453-63

  • Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep 2016; 65: 1-49.

Journal Publications

Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach

Authors: Joshi GP, Janis J, Haas E, Ramshaw B, Nihira M, Dunkin B
Published: Plast Reconstr Surg Glob Open 2016;4:e1181; doi: 10.1097/GOX.0000000000001181; Published online 23 December 2016.

Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities

Authors: Joshi GP, Gandhi K, Shah N, Gadsden J, Corman S
Published: Journal of Clinical Anesthesia (2016) 35, 524–529.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

Authors: Chou R, Gordon DB, de Leon-Casasola OA, et al.
Published: J Pain 2016; 17: 131-57

Differential opioid tolerance and opioid-induced hyperalgesia: a clinical reality

Authors: Hayhurst CJ, Durieux ME
Published: Anesthesiology 2016; 124: 453-63

CDC guideline for prescribing opioids for chronic pain — United States, 2016

Authors: Dowell D, Haegerich TM, Chou R
Published: MMWR Recomm Rep 2016; 65: 1-49

APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2015), Acute Pain Management: Science Evidence (4th edition), ANZCA & FPM, Melbourne.

Authors: Schug SA, Palmer GM, Sco DA, Halliwell R, Trinca J

 

Procedure specific pain management and outcomes strategies

Authors: Joshi GP, Schug S, Kehlet H
Published: Best Prac Res Clin Anesthesiol 2014; 28: 191-201

Putting it all together: recommendations for improving pain management in plastic surgical procedures

Authors: Joshi GP
Published: Plast Reconstr Surg 2014; 134 (4 Suppl 2): 94S-100S

Preemptive, preventive, multimodal analgesia: what do they really mean?

Authors: Rosero EB, Joshi GP
Published: Plast Reconstr Surg. 2014; 134 (4 Suppl 2): 85S-93S

Pain management strategies for urogynecologic surgery: a review

Authors: Collins SA, Joshi G, Quiroz LH, Steinberg AC, Nihira MA
Published: Female Pelvic Med Reconstr Surg 2014; 20: 310-5

Defining New Directions for More Effective Management of Surgical Pain in the United States: Highlights of the Inaugural Surgical Pain Congress

Authors: Joshi GP, Beck D, Emerson RH, et al
Published: American Surgeon 2014; 80: 219-228

Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain

Authors: Joshi GP, Ogunnaike BO
Published: Anesthesiol Clin North America 2005;23:21-36

   

Slide Presentations

Second Annual Surgical Pain Congress - Saturday Session
Comoderators: Girish P. Joshi, MBBS, MD, FFARCI and David E. Beck, MD, FACS.
Celebration, Florida March 7-9, 2014.

Goals- One: The Congress objectives include developing evidence-based best practices for improving surgical pain management and working with stakeholders in surgery, anesthesiology, and pain specialty organizations to disseminate and implement these best practices in the perioperative setting. Two: To stimulate research in the area of best practices for surgical pain.
Second Annual Surgical Pain Congress - Sunday Session
Comoderators: Girish P. Joshi, MBBS, MD, FFARCI and David E. Beck, MD, FACS
Celebration, Florida March 7-9, 2014.

Goals- One: The Congress objectives include developing evidence-based best practices for improving surgical pain management and working with stakeholders in surgery, anesthesiology, and pain specialty organizations to disseminate and implement these best practices in the perioperative setting. Two: To stimulate research in the area of best practices for surgical pain.
Second Annual Executive Steering Committee (ESC) Meeting
Comoderators: Girish P. Joshi, MBBS, MD, FFARCI and David E. Beck, MD, FACS
Dallas, Texas November 15-16, 2013.

Goals- Review Congress Mission and Goals, healthcare reform (GPO role), review both the PROSPECT and Congress processes, and indentify the most challenging procedures in relation to multimodal pain management for inclusion in the next Surgical Pain Congess meeting to be held in Florida, 2014.

    Opioid Crisis

Perioperative Opioids — A Gathering Storm?

Although recent CDC guidelines have focused on opioids for chronic pain management, little attention has gone to the perioperative setting as a potential contributor to the prescription drug crisis. Dr. Bottros gives his perspective on opioids and other alternatives for postoperative pain.

Opioid Crisis Resources

Eliminating the Need for Opioids in Cesarean Section Deliveries

Authors: Richard Chudacoff, MD, FACOG
Published: U.S. News & World Report, Nov. 16, 2017

The far-reaching effects of the US opioid crisis

Authors: Brennan Hoban, USC-Brookings Schaeffer Initiative for Health Policy
Published: USC-Brookings Schaeffer Initiative for Health Policy, Oct. 25, 2017

Study Finds Hip and Knee Replacement Patients Are Using Fewer Opioids after Surgery

Authors: Gerner P, Poeran J, Cozowicz C, et al. 
Published: International Congress for Joint Reconstruction. Source: Multimodal Pain Management in Total Hip and Knee Arthroplasty: Trends Over the Last 10 Years (abstract A1069). Presented at ANESTHESIOLOGY 2017, Oct. 21-25, 2017, Boston, MA.

   

 

 

 

 


Surgical Pain Consortium

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