research and devices to emerge around the concept.
• Cryoablation. "This has been used for a long time in chronic
pain management and sometimes for acute pain management,"
says Dr. Dizdarevic. It involves applying low temperature thera-
py and changing nerve structure to blunt response. "We're talk-
ing about situations where you don't plan to destroy the nerves,
but change the architecture of that nerve," he says. "There's
some promising data there. We just have to figure out the safety
of it. Unpredictability is a factor with some of these technolo-
gies, because you can't really predict how long you'll have the
effect of decreased pain sensation."
Beyond the OR
Pain is not adequately controlled if it's addressed only at the time
of surgery, says Dr. Shechter. "It's a broader view, starting way
before surgery. It's before, during and after. Having a good plan
leads to better outcomes. If we don't treat pain well at the time of
surgery, patients may develop more postsurgical pain and chronic
postsurgical pain."
At Hopkins' PPP clinic, the focus is on patients who are expect-
ed to be more challenging, specifically chronic opioid users.
Clinicians there engage high-risk patients a month or so before
surgery to educate and prepare them for the procedure, wean
their opioid use, and optimize their care using multimodal tech-
niques. "Hopefully by the time they come for surgery, they are
less opioid-tolerant and it's easier to treat their pain, reduce their
anxiety, and improve satisfaction and also possibly the surgical
outcome," says Dr. Schechter.
This wider, broader view of pain management isn't for every
patient. "It should be tailored mostly for patients who are at risk,
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