Transitional Pain Service: How is Smoking Related to Post-Surgical Outcomes? Transitional Pain Service Chronic post-surgical pain is a public health concern with one in five patients in chronic pain clinics identifying their pain as post-surgical 1. Estimates of development of chronic pain post- surgically vary from 5-50% depending on the surgery type 2 The Transitional Pain Service at the Toronto General Hospital is an innovative, world-first post-surgical pain management program based on early intervention in those at risk for long- term post-surgical pain. The service provides inter-disciplinary treatment including pharmacological management, psychology, physiotherapy and acupuncture, with expert pain management for the first three months after surgery. The service aims to identify patient needs and impact their pain trajectory in terms of pain and functioning. As such, modifiable risk factors that impact these outcomes are of special interest. Discussion and Future Directions Smokers had poorer outcomes in terms of pain, functioning, and mood after surgery. Anecdotal evidence suggests that quitting smoking may increase positive outcomes in chronic pain; however, we are unaware of published research in this area, particularly with surgical patients. It is not clear as yet how long after smoking cessation improvements in pain-related outcomes may be seen; however, Shi et al. 6 suggested that changes in pain processing associated with smoking may persevere within the central nervous system for some time. While quitting smoking may help with chronic pain in the in the long run, it may increase pain in the short term 7. This may be why programs to help individuals with chronic pain to quit smoking have been less than successful 7. It is also important to take into consideration that smoking may be a coping mechanism for pain, anxiety, and low mood for many patients. Therefore it will be important to include alternate ways of handling both pain and anxiety in any smoking-reduction program, such as relaxation and mindfulness. Early Results Of the 113 participants, 23% were smokers. A univariate comparison showed that smokers reported higher average pain intensity than non-smokers at their first outpatient visit to TPS after surgery, an average of 4.5 weeks post-surgically (p=.024; See Figure 1). In addition, smoking status was found to predict pain rating (1-10 NRS) at last clinic visit (approximately 3 months after surgery) after controlling for pre-surgical chronic pain (p=.027, B=1.59). Using a Fisher’s exact test, a trend was found with smokers in the top third percentile of reported neuropathic pain quality (McGill Pain Questionnaire, p=.056; See Figure 2). This means that smokers were more highly represented in the top third of neuropathic pain scores than would have been expected. Regression analysis showed smokers were likely to have lower 3- month BPI pain functioning scores than non-smokers after controlling for previous chronic pain (p=.023, B= -1.75; See Figure 3). Higher HADS depression scores were evident in smokers vs non- smokers at three months after surgery (p=.05, T=-2; 10.4 vs 7.6 (sd=4.8); See Figure 4), and multivariate regression found this remained true after controlling for chronic pain (p=. 04). Unlike other studies, smoking status did not predict morphine use at three months, nor did we find a greater number of reported drug abuse in the hospital charts of smokers than non-smokers in our sample (p>.05).. Janice Montbriand, PhD. 1,2.; Aliza, Weinrib, PhD 2, Salima Ladak NP 2, Bansi Shah PT 2, Jiao Jiang NP 2, Karen McRae MD 2, Diana Tamir MD 2, Sheldon Lyn MD 2, Rita Katznelson MD 2, Hance Clarke MD PhD 2 ; Joel Katz, PhD 1,2 1 Department of Psychology, York University, Toronto, Ontario 2 Department of Anesthesia and Pain Management, Pain Research Unit, University Health Network, Toronto General Hospital, University of Toronto, Ontario Smoking and Chronic Pain Patients with chronic pain report more severe pain, increased disability, and greater morphine use if they are smokers. Moreover, smoking may be a causal risk factor for these outcomes. For example, in patients with current back pain, smoking confers greater risk of developing chronic back pain and associated disability 3. To the best of our knowledge, smoking has not previously been investigated as a predictive factor in the development of chronic post-surgical pain. Smoking may lead to greater pain by altering pain processing due to prolonged desensitization of the nicotine analgesic receptors 3. In addition, for surgical patients, smoking impairs the supply of oxygen to tissues, slowing wound healing 4,5. The current investigation examines the effect of smoking status on outcomes after a three month multidisciplinary post-surgical pain treatment service. We hypothesized that patients who are smokers prior to surgery would have higher pain intensity after surgery (including more neuropathic pain), higher levels of opioid medication use, poorer functioning, and poorer mood than non-smokers after controlling for pre-operative chronic pain. 1 Macrae, W.A. (2008). Chronic post-surgical pain: 10 years on. British Journal of Anesthesia, 101, Katz J & Seltzer Z. Transition from acute to chronic postsurgical pain. Expert Rev Neurother 2009;9: Hooten, WM, Townsend, CO, Bruce, BK, Schmidt, JE, Kerkvlet, Jl, Patten, CA, Warner DO. (2009). Effects of smoking status on immediate treatment outcomes of a multidisciplinary treatment center. Pain Med, 10, Shi, Y, Weingarten, TN, Mantilla CB, Hooten, M, Warner DO. (2011). Smoking and Pain: Pathophysiology and clinical implications. Anesthesiology,113, Warner DO. (2006). Perioperative abstinence from cigarettes: Physiologic and clinical consequences. Anesthesiology, 104, Shi, Y, Warner, DO. (2010). Surgery as a teachable moment for smoking cessation. Anesthesiology. 112, Weigarten, TN, Shi, Y. Mantilla CB, Hooten, M, Warner DO. (2011). Smoking and Chronic Pain: A real but puzzling relationship. Minnesota Medicine, March Accessed from: First TPS visit is the first visit to the post-surgical pain clinic Figure 1: Average pain by smoking status Figure 2: Neuropathic pain by smoking status Figure 3: Functioning by smoking status Figure 4: Depression levels by smoking status