Chapter 11: Guidelines for the Provision of Anaesthesia Services for Inpatient Pain Management 2019

Published: 31/01/2019

Introduction

Inpatient pain services (IPS) consist of a multidisciplinary team including appropriately trained acute pain physicians and anaesthetists along with nurses specialised in pain management. Other allied health professionals such as applied psychologists, addiction medicine specialists, physiotherapists and pharmacists may also be part of the IPS team.

After the publication of the joint working party of the Royal College of Surgeons and Royal College of Anaesthetists report ‘Pain after surgery’ document in 1990, the provision of IPS in UK hospitals expanded rapidly.1 The percentage of UK hospitals with an IPS increased from 44% in 1995 to >80% in 2004. However, further progress has been difficult to sustain, particularly in terms of quality and consistency.2,3 Recent UK and European surveys of IPS demonstrate a wide variation in service provision, with many IPSs not meeting minimal quality standards (for example, 45% of German IPSs met the specified standards in 2016).4,5 A British survey in 2004 revealed that 69% of respondants thought that IPSs were ‘struggling’ or ‘non-existent’.3 Clinicians agree that most of the reasons for the failure of IPSs to meet standards are organisational rather than technical; financial constraints were cited as being the major reason for failure in 53% of cases.2,3  It has proved difficult to implement early recommendations despite support from the Chief Medical Officer in his report of 2009.6

The Faculty of Pain Medicine (FPM) of the Royal College of Anaesthetists produced the document Core Standards for Pain Management Services in the UK in 2015 (CSPMSUK).7 This chapter should be read with reference to CSPMSUK, which informs part of the requirements detailed below. CSPMSUK provides a detailed model for IPSs to emulate. Recent national audit has revealed that most IPSs do not meet the standards recommended in CSPMSUK in terms of staffing provision.8

Where benchmarking against national standards has identified shortcomings, organisational change is difficult to achieve in most UK hospitals. The particular challenges faced by IPSs have been investigated in three case studies and include: ‘doubts and disagreements about the nature of the changes required to improve inpatient pain management; challenging local organisational contexts; and the beliefs, attitudes and responses of health professionals and managers’.9 In order to provide an adequate IPS these, challenges need to be addressed simultaneously at a local level. Embracing continuous quality improvement as a core value of the IPS and utilising change management techniques may increase the likelihood of success in the longer term.3

The relief of acute pain is primarily a humanitarian matter, but effective pain management may also result in improved clinical outcomes and reduced complication rates, particularly in high risk patients undergoing major surgery.10

Providing safe and effective analgesia for an increasingly elderly surgical patient population with complex medical problems is a significant challenge for IPSs.

Patients’ expectations of surgical outcome and pain relief are high, and it is difficult to meet these expectations with limited IPS resources.

Advances in minimally invasive surgery have resulted in a significant reduction in post surgical pain in some cases. However, these new surgical techniques present challenges of their own, particularly when combined with enhanced recovery after surgery (ERAS) programmes in which the expectation is of early mobilisation and accelerated discharge from hospital.11,12 Meeting the goals of ERAS has led to rapid and significant changes in pain management techniques, which must be supported by well trained and informed IPSs.13,14 However, it is important that we recognise that ERAS protocols are not a replacement for IPSs.15 Patients with complex medical problems, opioid tolerance or chronic pain account for 20-30% of all inpatients and cannot be effectively managed using rigid post surgical pain management protocols.16 There is evidence from a Danish survey to suggest that a steady rise in the adoption of ERAS protocols from 40% of all hospitals in 2000 to 80% in 2009 was paralleled by the almost complete loss of IPSs outside teaching hospitals over the same period.17

The traditional role of IPSs was to manage acute pain after surgery. This remit is expanding in many hospitals to include the care of medical inpatients and patients with complex pain problems such as acute-on-chronic pain or opioid misuse.18

As part of a growing emphasis on perioperative medicine by anaesthetists in the UK, IPSs are increasingly involved at all stages of the patient pathway, from the decision to operate to full recovery after discharge from hospital. The potential for preoperative optimisation of pain management, both in terms of analgesic drugs and pain coping strategies, is being evaluated as part of wider prehabilitation programmes.19,20 Preassessment programmes now include preoperative prediction of those who are likely to suffer severe acute pain and those at risk of developing persistent post surgical pain (PPSP).21,22 IPSs may be involved in developing these programmes and devising enhanced analgesic strategies for high risk patients.23,24

IPSs therefore have the potential to evolve into Transitional Pain Services involving acute pain physcians, applied psychologists, physiotherapists and occupational therapists to identifiy risk factors for persistent pain, implement preventative strategies and avoid potential opioid dependency.25,26 The use of opioid risk scores such as the Opioid Risk Tool should be considered to assess risk of opioid abuse when continuing opioid therapy beyond the immediate postoperative period.

The development of risk stratification tools for PPSP and opioid dependence, together with improved communication with surgical teams and primary care have the potential to reduce the risk of developing inappropriate long term opioid use. This intervention should be led by IPSs and has the potential to prevent an ‘opioid crisis’ occurring in the UK. IPSs can help to develop and support analgesic techniques to minimise opioid use without worsening post surgical pain and without increasing the risk of developing PPSP.27

The combination of IPSs with other teams, such as critical care outreach, is taking place in some hospitals, and there is evidence that this approach may reduce adverse events and improve analgesia in complex patients, albeit at the expense of an increased workload.12,28  However, there is also a risk of dilution of pain management skills and the loss of highly trained clinical nurse specialists in pain management.

1. Staffing requirements

1.1

Inpatient pain services (IPS) should be staffed by multidisciplinary teams led by appropriately trained consultant or SAS anaesthetists. The minimum training requirement for new appointments to IPS lead roles is Royal College of Anaesthetists higher pain training.29  Advanced pain training, or its equivalent, should be considered optimal.

C Strong
1.2

Anaesthetists in an IPS post need to demonstrate an ongoing significant interest in acute pain management by involvement in continuing professional development (CPD), appraisal and job planning.

C Strong
1.3

Adequate time should be made available for IPS provision in job plans. Two clinical sessions for the lead(s) and one session for all other anaesthetists involved in the IPS is recommended per week.  

C Strong
1.4

Adequate staff and systems should be in place to provide timely pain management to all inpatients. Out of usual working hours, this may be delivered by appropriately trained IPS nursing staff or anaesthetic staff (having received intermediate pain training as a minimum standard). A clear point of contact for expert advice should be available at all times.

C Strong
1.5

Patients under the care of an IPS should be reviewed by the IPS regularly, with patients receiving epidural analgesia or other continuous local anaesthetic infusions being seen at least once daily.

C Strong
1.6

Adequate numbers of clinical nurse specialists in pain medicine should be available to fulfil the following roles within working hours:

  • review of patients in pain with appropriate frequency to provide a safe and effective service
  • provision of advice to ward staff and other healthcare teams regarding all aspects of pain management
  • liaise with an appropriate pain medicine specialist to highlight clinical or systematic problems
  • ensuring that systems are in place to support non specialist heathcare staff to safely and effectively manage acute pain overnight and at weekends if the IPS is not immediately available.
C Strong
1.7

The IPS should aim to provide multidisciplinary assessment and management of pain where needed. This should involve collaborative working with allied health professionals including pharmacists, physiotherapists, applied psychologists, liaison psychiatrists and addiction medicine specialists.

C Moderate
1.8

Outpatient (chronic) pain management teams should be available to provide advice to the IPS during working hours. This activity should be supported through job planning. If possible, the inpatient and outpatient (chronic) pain services should be integrated, with team members working in both environments, to ensure coordinated care for patients with complex pain while in hospital and also for those recently discharged to the community.

C Moderate

2. Equipment, services and facilities

Equipment

2.1

All equipment and disposables must be compliant with local and national safety policies. There should be an adequate supply of the following:32,33,34,35

  • infusion pumps for neuraxial analgesia (epidural infusion/patient controlled epidural analgesia (PCEA) and potentially intrathecal infusions)
  • infusion pumps for use with continuous regional analgesia catheters
  • patient controlled analgesia infusion pumps
  • infusion pumps for other analgesic drugs
  • disposables for the above, including neuraxial and regional block devices e.g. NRFit.
C Moderate
2.2

Ultrasound scanning, nerve stimulators and all equipment and drugs necessary to perform local and regional analgesic techniques should be available.30

C Strong
2.3

Pumps and infusion lines should be single purpose and appropriately coloured or labelled.31,32,33,34

C Strong
2.4

Drugs for epidural use or for continuous regional anaesthesia infusions should be prepared and stored in compliance with local and national medicines management policies.32,33,34,35

C Strong
2.5

Controlled drugs must be stored and audited in compliance with current legislation.35,36,37

M Mandatory
2.6

Efforts should be made to minimize drug administration errors, and these should be compliant with local medicines management policies, which incorporate relevant national policy and frameworks, including the avoidance of ‘Never Events’.38,39,40,41

C Strong
2.7

Clinical areas caring for patients receiving analgesic techniques which may result in cardiovascular, respiratory or neurological impairment should have appropriate facilities and adequately trained staff to provide appropriate monitoring.42

C Strong
2.8

Drugs and equipment for the management of the complications associated with analgesic techniques should be readily available.39

GPP Strong

Facilities

2.9

There should be adequate office space, informatics and administrative support for the IPS.

GPP Strong
2.10

There should be appropriate storage facilities for analgesic devices and drugs.

GPP Strong

3. Areas of special requirement

Children

Recommendations on the provision of anaesthesia services for children are comprehensively described in chapter 10.

3.1

The standard of care for neonates, infants, children and young people should be the same as that for adults, with specific arrangements made for the management of pain in neonates, infants, children and young people.43

C Strong
3.2

The service should be delivered by an appropriately trained team, with specific skills in paediatric pain management and paediatric anaesthesia. Paediatric pain management services may be provided by paediatricians or anaesthetists.

C Strong
3.3

All tertiary paediatric centres should have access to paediatric chronic pain services to assist  in managing complex cases. Other centres should develop a network to provide access to paediatric chronic pain services for advice and guidance.

GPP Strong

Emergency department

3.4

Specialist acute pain management advice and intervention should be available in the emergency department (ED).

B Strong
3.5

Inpatient pain services should also provide assistance in developing management plans for groups or individuals who attend ED frequently with pain. This should be in the context of a wider multidisciplinary team including chronic pain services, primary care and clinical psychology.

C Strong

Other patient groups

Specific arrangements and guidelines should be available, where applicable, for the management of subgroups of vulnerable adult patients, including:

  • critically ill patients
  • elderly and/or frail patients44,45
  • non-native English speakers
  • patients with chronic pain
  • patients with coexisting mental health problems
  • patients with dementia
  • patients with multiple trauma or significant blunt chest wall trauma
  • patients with opioid tolerance46
  • patients with physical or learning disability
  • patients with problem drug and alcohol use47
  • patients with significant organ dysfunction
  • pregnant and breastfeeding patients.

4. Training and education

Inpatient pain services should actively contribute to a hospital environment in which education, training and staffing levels ensure the safe care of patients being treated for pain.

4.1

Inpatient pain services should provide education delivered by appropriately trained individuals.48 Training should include the recognition, assessment and treatment of pain. This includes using a management plan.

C Strong
4.2

Training should be provided at induction and regularly thereafter for anaesthetists, ward staff, doctors in training and allied health professionals.

GPP Strong
4.3

All staff should know how to obtain expert advice when required. This includes being able to access guidelines and protocols.

GPP Strong
4.4

Members of the IPS should have access to internal and external CPD appropriate to their roles. Funding and time should be available for staff to attend this training.49

C Strong
4.5

Training for anaesthetists to attain basic, intermediate and higher level competencies in pain medicine, as specified by the Faculty of Pain Medicine of the Royal College of Anaesthetists, should be provided. Where higher or advanced pain training is not feasible within an individual hospital, it should be available within the region.50

C Strong
4.6

Inpatient pain nurse specialists providing education on the wards should have dedicated time for this role distinct from direct clinical duties.

GPP Strong
4.7

Training should include consideration of the use of simulation where feasible. For example role play with the pain team simulating a patient with a failed epidural.

GPP Aspirational
4.8

Members of the IPS should engage in outpatient (chronic) pain CPD.

GPP Strong

5. Organisation and administration

5.1

Clear lines of communication and close working with other services such as surgical and medical colleagues, outpatient (chronic) pain, palliative care, emergency medicine and primary care should be in place.

GPP Strong
5.2

Advice for the management of step down analgesia should be provided for primary care doctors, where required.

GPP Moderate
5.3

Inpatient pain services should engage with critical incident reporting, root cause analysis and mortality and morbidity meetings as part of the local hospital reporting structure.51

C Strong
5.4

There should be processes in place for learning from critical incidents and from excellent care.

GPP Strong
5.5

There should be mechanisms to disseminate national safety alerts from groups such as the Safe Anaesthesia Liaison Group (SALG).52

C Strong

Guidelines

5.6

Analgesic guidelines, including those for specifc analgesic techniques, should be widely disseminated and easily accessible.

GPP Strong
5.7

All guidelines should be dated and regularly reviewed. All guidelines should have a clearly documented author and review date and be published in line with local clinical governance policies with appropriate oversight.

GPP Strong
5.8

Guidelines for side effect and complication management including inadequate analgesia should be available.

GPP Strong
5.9

Where good evidence exists, consideration should be given to procedure specific analgesic techniques.

GPP Aspirational
5.10

Where possible, guidelines should be shared locally, between hospitals and nationally.

GPP Aspirational

Assessment and record keeping

Pain and its management should be regularly recorded in the patient notes and/or observation chart using validated tools for each clinical setting. Consistent tools should be used throughout the patient pathway.

6. Financial considerations

Part of the methodology used in this chapter in making recommendations is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.

The vast majority of the recommendations are not new recommendations, but are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.

7. Research, audit and quality improvement

7.1

Inpatient pain services should keep a prospective database of activity and outcome data and this should be used for quality improvement and early recognition of potential harm.53

C Strong
7.2

The IPS should actively engage in benchmarking against national standards e.g. GPAS, CSPMSUK, ACSA, RCoAaudit recipe book.54,55,56,57

C Strong
7.3

Where possible, the IPS should encourage engagement in research in acute pain medicine, including recruitment into well designed national and international multicentre studies.

GPP Moderate

8. Implementation Support

The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication, to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations, so that departments can refer to them while working through their gap analyses.

Departments of anaesthesia can subscribe to the ACSA process for an appropriate fee. Once subscribed, departments are provided with a ‘college guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.

The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.

One of the outcomes of the ACSA process is to test the standards, and by extension the GPAS recommendations, to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.

9. Patient Information

Recommendations for the provision of patient information and obtaining consent are comprehensively described in chapter 2. Specific recommendations for inpatient pain services are listed below.

9.1

Patient information leaflets should be made available to provide information on analgesia in general, and on specialised analgesic techniques such as epidural analgesia, nerve blocks, specialist drug infusions and patient controlled analgesia.58

B Strong
9.2

Patient information should be available in formats that take into account the information needs of patients listed in 3.6 and they should be accessible electronically.

GPP Strong
9.3

Leaflets should explain pain management after discharge, including a step down analgesic plan and how further supplies of medicine can be obtained. Patient information should emphasise the need to avoid harm from long term strong opioid use and give clear advice on the impact of analgesics on driving, acknowledging the current DVLA guidance.59,60

C Strong
9.4

Patients should provide informed consent for invasive analgesic procedures, and this must be documented following the GMC advice on informed consent.61,62

C Strong
9.5

Patient education regarding expectation of pain and analgesia after surgery should be given to all patients in the preoperative period.

GPP Strong

Areas for future development

Following the systematic review of the evidence, the following areas of research are suggested:

  • transitional pain management63
  • psychological interventions64,65
  • establish a national database (organisational and patient level data)
  • opioid minimisation and long term abuse
  • persistent post surgical pain
  • pre-emptive and preventive analgesic strategies
  • safe analgesia for older people and those with cognitive dysfunction

Glossary

Clinical lead - Staff grade, associate specialist and specialty (SAS) doctors undertaking lead roles should be autonomously practicing doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.

References

1. Royal College of Surgeons of England and Royal College of Anaesthetists. Pain after surgery. Report of a working party of the commission on the provision of surgical services, London 2009
2. Harmer M, Davies KA, Lunn JN. A survey of acute pain services in the United Kingdom. BMJ 1995;311:360
3. Powell AE, Davies HT, Bannister J, Macrae WA. Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey. Br J Anaesth 2004; 92: 689-93
4. Erlenwein J, Koschwitz R, Pauli-Magnus D et al. A follow-up on Acute Pain Services in Germany compared to international survey data. Eur J Pain 2016; 20: 874-83
5. Duncan F, Day R, Haigh C et al. First steps toward understanding the variability in acute pain service provision and the quality of pain relief in everyday practice across the United Kingdom. Pain Med 2014; 15: 142-53
6. Donaldson L. 150 Years of the Annual Report of the Chief Medical Officer: on the state of public health 2008. London: Department of Health, 2009
8. Rockett M, Vanstone R, Chand J, Waeland D. A survey of acute pain services in the UK. Anaesthesia 2017; 72: 1237-42
9. Powell AE, Davies HT, Bannister J, Macrae WA. Understanding the challenges of service change - learning from acute pain services in the UK. J R Soc Med 2009; 102: 62-8
10. Kooij FO, Schlack WS, Preckel B, Hollmann MW. Does regional analgesia for major surgery improve outcome? Focus on epidural analgesia. Anesth Analg, 2014; 119: 740-4
11. Nimmo SM, Foo ITH, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol 2017; 116: 583-91
12. Werner MU, Nielson PR. The acute pain service: Present and future role. Curr Anaesth Crit Care 2007; 18: 135-9
13. Tilleul P, Aissou M, Bocquet F et al. Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery, in Br J Anaesth 2012; 108: 998-1005
14. Paiste J, Simmons JW, Vetter TR. Enhanced Recovery After Surgery in the Setting of the Perioperative Surgical Home. Int Anesthesiol Clin 2017; 55: 135-47
15. Romundstad L, Breivik H. Accelerated recovery programmes should complement, not replace, the acute pain services. Acta Anaesthesiol Scand 2012; 56: 672-4
16. Rockett MP, Simpson G, Crossley R, Blowey S. Characteristics of pain in hospitalized medical patients, surgical patients, and outpatients attending a pain management centre. Br J Anaesth 2013; 110: 1017-23
17. Nielsen PR, Christensen PA, Meyhoff CS, Werner MU. Post-operative pain treatment in Denmark from 2000 to 2009: a nationwide sequential survey on organizational aspects. Acta Anaesthesiol Scand, 2012; 56: 686-94
18. Chang SH, Maney KM, Mehta V, Langford RM. Pain assessment and management in medical wards: an area of unmet need. Postgrad Med J, 2010; 86: 279-84
19. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin 2015; 33: 17-33
20. Kaye AD, Helander EM, Vadivelu N et al. Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions. Pain Ther 2017; 6: 129-41
21. Boezaart AP, Munro AP, Tighe PJ. Acute pain medicine in anesthesiology. F1000Prime Rep 2013; 5: 54
22. Clarke H, Poon M, Weinrib A, Katznelson R, Wentlandt K, Katz J. Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain. Drugs 2015; 75: 339-51
23. Janssen KJ, Kalkman CJ, Grobbee DE, Bonsel GJ, Moons KG, Vergouwe Y. The risk of severe postoperative pain: modification and validation of a clinical prediction rule. Anesth Analg, 2008; 107: 1330-9
24. Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain, 2011; 152: 566-72
25. Huang A., Azam A, Segal S et al. Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service. Pain manag 2016; 6: 435-43
26. Vetter TR, Kain ZN. Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids. Anesth Analg 2017; 125: 1653-7
27. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg 2017; 125: 1733-40
28. Story DA, Shelton AC, Poustie SJ, Colin-Thome NJ, McIntyre RE, McNicol PL. Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events. Anaesthesia, 2006; 61: 24-8
32. National Patient Safety Agency. Design for patient safety: A guide to the design of electronic infusion devices, 2013
33. National Patient Safety Agency. Safer spinal (intrathecal), epidural and regional devices – Part B, 2009
34. National Patient Safety Agency. Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with Incompatible Connectors, 2011
42. Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery 2015. Anaesthesia 2016; 71: 85-93
44. Helfand M. Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. Pain Med 2009; 10: 1183-99
45. Schofield, P.A. The assessment and management of peri-operative pain in older adults. Anaesthesia 2014; 69(S1): 54-60
46. Huxtable CA, Roberts LJ, Somogyi AA, MacIntyre PE. Acute pain management in opioid-tolerant patients: a growing challenge. Anaesth Intensive Care 2011; 39: 804-23
47. Krashin D, Murinova N, Ballantyne J. Management of pain with comorbid substance abuse. Curr Psychiatry Rep 2012; 14: 462-68
48. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012; 116: 248-73
53. Bibby, P. Auditing your acute pain service - a UK NHS model. Acute pain 2004; 5: 109-12
58. Kumar G, Howard SK, Kou A, Kim TE, Butwick AJ, Mariano ER. Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management. Pain Med 2017; 18: 2027-32
63. Katz J, Weinrib A, Fashler SR et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. Journal of pain research 2015; 8: 695-702
64. Childs SR, Casely EM, Kuehler BM et al. The clinical psychologist and the management of inpatient pain: a small case series. Neuropsychiatr Dis Treat 2014; 10: 2291-7
65. Weinrib AZ, Azam MA, Birnie KA, Burns LC, Clarke H, Katz J. The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management. Br J Pain 2017; 11: 169-77