Pre-op CBT to Reduce the Risk for Development of Chronic Post-surgical Pain in Patients undergoing Total Knee Arthroplasty

摘要

ABSTRACT Knee joint replacement is among the most common elective surgeries performed in the United States, and only expected to increase as the population ages. Total knee arthroplasty (TKA) is the definitive treatment for patients suffering degenerative joint disease or arthritis causing limited function and persistent pain, which most often results in improvements in function and quality of life. However, a not inconsequential proportion of patients (up to 53%) undergoing TKA develop chronic post-surgical pain (CPSP) following the procedure. CPSP brings with it significant consequences not only to functionality and quality of life, but often leading to long-term opioid therapy and economic burden. Risk factors for the development of CPSP have been identified, the most predictive of which are pre-existing chronic pain; pre-operative chronic opioid use; depression; anxiety; and pain catastrophizing. In addition, more severe post-operative pain has been linked to the increased likelihood for developing CPSP, due to postulated central pain sensitization processes which set the stage for ongoing and in some cases magnified chronic pain. Despite increased understanding of the role of these predictors in the development of CPSP, little is provided to at-risk patients prior to surgery to mitigate the occurrence of these life-changing outcomes. Proposed is the development and preliminary efficacy testing of a targeted cognitive-behavioral therapy (CBT) opioid taper intervention delivered in the 4 weeks immediately prior to planned TKA to mitigate pre-operative risk factors for CPSP, reduce the severity of acute post-operative pain, and thereby the risk for development of CPSP following surgery. Specifically, in a sample of adult men and women with chronic pain, on opioid therapy and undergoing a planned TKA, a randomized clinical trial will be implemented to evaluate the ability of this novel intervention to decrease pre-operative chronic pain intensity, opioid use, anxiety, depression and pain catastrophizing from baseline will be evaluated immediately prior to the surgical procedure, and group differences in post-operative 72hr pain intensity and incidence of CPSP at 3 and 6 months will be compared subjects randomized to treatment-as-usual. The novel intervention will be based upon modification of an existing, validated computer- assisted CBT intervention for chronic pain (PAINTrainer) to include a motivational interviewing opioid taper component. The proposed work is developmental research reflecting the early, conceptual stage of a project designed to prevent the transition of acute post-surgical pain into CPSP. It is anticipated the findings will result in a novel, cost-effective, and evidence-based intervention that will meaningfully impact pain outcomes following joint replacement surgery, and ready for testing in a subsequent randomized clinical trial. In that CPSP brings with it significant health consequences, including diminished functionality and quality of life, ongoing opioid use, and direct patient costs, it is critical that interventions aimed at mitigating its development are implemented and evaluated in the clinical setting.