Opioid use following cervical spine surgery: trends and factors associated with long-term use

Opioid Prescription Trends Among Orthopaedic, Primary Care, and Pain Management Providers in Spine Surgery Patients

OBJECTIVE

To determine prescription trends across specialties in the perioperative care of patients undergoing spine surgery from 2018 to 2021.

SUMMARY OF BACKGROUND DATA

A range of measures, including implementation of state prescription drug monitoring programs, have been instituted to combat the opioid epidemic. Considering the continued presence of opioids for spine-related pain management, a better understanding of the patterns of opioid prescription practices may be important for future intervention.

METHODS

All patients aged 18 years and older who underwent elective posterior lumbar decompression and fusion, transforaminal lumbar interbody fusion, and anterior cervical diskectomy and fusion from 2018 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through a Structured Query Language search and manual chart review. Opioid prescription data were collected through Pennsylvania's Prescription Drug Monitoring Program (PDMP) database and grouped into the following prescriber categories: primary care, pain management, physiatry, and orthopaedic surgery.

RESULTS

Of the 1,062 patients, 302 (28.4%) underwent anterior cervical diskectomy and fusion, 345 (32.4%) underwent posterior lumbar decompression and fusion, and 415 (39.1%) underwent transforaminal lumbar interbody fusion. From 2018 to 2021, there were no significant differences in total opioid prescriptions from orthopaedic surgery ( P = 0.892), primary care ( P = 0.571), pain management ( P = 0.687), or physiatry ( P = 0.391) providers. Pain management providers prescribed the most opioids between 1 year and 2 months preoperatively ( P = 0.003), between 2 months and 1 year postoperatively ( P = 0.018), and overall ( P < 0.001).

CONCLUSION

Despite increasing national awareness of the opioid epidemic and the establishment of statewide prescription drug monitoring programs, prescription rates have not changed markedly in spine patients. Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery, likely in part because of longitudinal relationships with these patients.

LEVEL OF EVIDENCE

III.

STUDY DESIGN

Retrospective Cohort Study.

Opioid Use Following Spine Surgery in Ambulatory Surgical Centers Versus Hospital Outpatient Departments

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess the association between undergoing spine surgery in an ambulatory surgical center (ASC) vs a hospital outpatient department (HOPD) and (a) perioperative opioid prescription patterns and (b) prolonged opioid use.

METHODS

Data from the Merative MarketScan Database included patients aged 18-64 who underwent single-level or multilevel anterior cervical discectomy and fusion (ACDF) or lumbar decompression between January 2017 and June 2021. Primary outcomes included receipt of a perioperative opioid prescription, perioperative oral morphine milligram equivalents (MMEs), and prolonged opioid use (defined as opioid prescription 91-180 days post-surgery). Secondary outcomes included the number of perioperative opioid prescriptions filled (single/multiple) and type of initial perioperative opioid filled (potent/weak). Analysis of prolonged opioid use was limited to opioid-naive patients. Propensity score matching (1 ASC to 3 HOPD cases) and logistic regression models were used for analysis.

RESULTS

The study included 11,654 ACDF and 26,486 lumbar decompression patients. For ACDF, ASCs had higher odds of an initial potent opioid prescription (OR = 1.18, 95% CI 1.08-1.30, P < .001) and higher total adjusted mean MMEs (+21.14, 95% CI 3.08-39.20, P = .02). For lumbar decompression, ASCs had increased odds of an initial potent opioid (OR = 1.23, 95% CI 1.16-1.30, P < .001) but lower odds of multiple opioid prescriptions (OR = 0.90, 95% CI 0.85-0.96, P < .001). There was no significant association between the surgery setting and prolonged opioid use.

CONCLUSION

Differences in perioperative opioid prescribing were observed between ASCs and HOPDs, but there was no increase in prolonged opioid use in ASCs. Further research is needed to optimize postoperative pain management in different outpatient settings.

Osteoporosis is not associated with reoperation or pseudarthrosis after anterior cervical discectomy and fusion through 4-years' follow-up: a retrospective cohort study of US academic health centers

BACKGROUND CONTEXT

Osteoporosis has been proposed as a risk factor for reoperation after anterior cervical discectomy and fusion (ACDF), yet this potential association has been understudied, with conflicting results to date.

PURPOSE

This study examines the hypothesis that adults with osteoporosis would have an increased risk of reoperation after ACDF compared to matched adults without osteoporosis.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Two matched cohorts (mean age: 62 years; 75% female), each with 1,019 patients, who underwent primary ACDF. Cohorts were determined by the presence or absence of a diagnosis of osteoporosis.

OUTCOME MEASURES

Incidence of reoperation occurring over 4 years postoperatively, with our primary outcome being the risk ratio (RR) of reoperation with 95% confidence intervals (CI). Secondary outcomes included risk and mean count of oral opioid prescriptions and risk of pseudoarthrosis.

METHODS

We utilized the TriNetX network to identify adults undergoing their first ACDF from 2004 to 2020, excluding those with serious pathology, and divided patients into 2 cohorts: osteoporosis and nonosteoporosis. Patients were propensity matched according to key risk factors for reoperation.

RESULTS

Patients with osteoporosis had no statistically significant or meaningful difference in risk of reoperation compared to nonosteoporotic patients over 4-years' follow-up [95% CI] (17.3% vs. 16.5%; RR: 1.05 [0.86, 1.27]; p=.6361). Similarly, there were no significant differences in the risk of pseudoarthrosis (26.5% vs. 29.1%; RR: 0.91 [0.79, 1.05]; p=.1820), oral opioid prescription (75.0% vs. 76.0%; RR: 0.99 [0.94, 1.04]; p=.6067), or mean oral opioid prescription count (11.5 vs. 11.8; p=.7040).

CONCLUSION

Compared to matched nonosteoporosis controls, osteoporosis was not associated with a statistically significant or clinically meaningful increase in risk of reoperation in adults over 4 years after ACDF. Furthermore, osteoporosis was not associated with a significant or meaningful risk of pseudoarthrosis or oral opioid prescription after ACDF, although more research is needed for corroboration. Additional research is needed to clarify whether those with osteoporosis have meaningful differences in pain and function compared to those without osteoporosis following ACDF.

Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion

BACKGROUND CONTEXT

Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated.

PURPOSE

The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF.

OUTCOME MEASURES

Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day.

METHODS

A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use.

RESULTS

A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs 10.4%, p=.040) and take more MMEs per day (0.70 vs 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs 52.1%, p<.001) and took more MMEs per day (3.73 vs 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: -1.63 p=.022).

CONCLUSION

Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

Prescription Trends of Opioid and Nonopioid Controlled Prescription Adjunctive Analgesics Before and After Cervical Spinal Surgery: A Retrospective Cohort Study

OBJECTIVE

Cervical spine surgery may be needed in those with refractory pain or neurologic deficits to improve outcomes in patients with cervical spine disease. However, consensus varies in the literature on the effect of surgery on opioid use. The objectives of this study were to analyze prescription rates of multiple controlled substances before and after cervical spine surgery and distinguish factors that may have contributed to opioid use after surgery.

DESIGN

This is a retrospective cohort study analyzing prescription trends of various controlled substances in 632 patients who underwent cervical spine surgery from 2019 to 2021.

RESULTS

Opioids have the largest rise in prescriptions at 3- and 6-mo time points after cervical spine surgery. A significant association ( P < 0.001) was found between opioid use 1 yr before and 1 yr after cervical spine surgery. Exposure to opioids before surgery (odds ratio = 2.77, 95% confidence interval = 1.43-5.51, P = 0.003) and higher morphine milligram equivalent dose (odds ratio = 1.02, 95% confidence interval =1.01-1.04, P = 0.012) were found to be associated with opioid use after surgery. Significantly more females were prescribed controlled substances ( P = 0002).

CONCLUSIONS

Higher morphine milligram equivalent dose and opioid exposure before surgery are important factors in predicting postsurgical opioid use.

Functional Somatic Syndromes Are Associated With Varied Postoperative Outcomes and Increased Opioid Use After Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and clinical outcomes after spine surgery.

METHODS

A systematic review of online databases (PubMed and Web of Science) through December 2021 was conducted via PRISMA guidelines to identify all studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches/migraines, interstitial cystitis, chronic fatigue syndrome, multiple chemical sensitivity) on outcomes after spine surgery. Outcomes of interest included patient reported outcome measures (PROMs), postoperative opioid use, cost of care, complications, and readmission rates.

RESULTS

A total of 207 records were identified. Seven studies (n = 40,011 patients) met inclusion criteria with a mean MINORS score of 16.6 out of 24. Four studies (n = 21,086) reported postoperative opioid use; fibromyalgia was a strong risk factor for long-term opioid use after surgery whereas the association with chronic migraines remains unclear. Two studies (n = 233) reported postoperative patient reported outcome measures (PROMs) with mixed results suggesting a possible association between fibromyalgia and less favorable PROMs. One study (n = 18,692) reported higher postoperative complications in patients with fibromyalgia.

CONCLUSION

Patients with fibromyalgia and possibly migraines are at higher risk for prolonged postoperative opioid use and less favorable PROMs after spine surgery. There is limited research on the relationship between other Functional somatic syndromes (FSSs) and outcomes following spine surgery. Growing evidence suggests the variation in outcomes after spine procedures may be attributed to non-identifiable organic patient factors such as FSSs.

Postoperative Opioid Use and Prescribing Patterns among Patients Undergoing Cervical Laminectomy with Instrumented Fusion versus Cervical Laminoplasty with Reconstruction

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare patterns in opioid usage and prescriptions between patients who undergo cervical laminectomy with instrumented fusion (LF) vs cervical laminoplasty with reconstruction (LP) within single surgeon and national database cohorts.

METHODS

We identified patients with cervical myelopathy undergoing primary LF or LP in both a single-surgeon series cohort (2004-2018) and a nationally representative cohort drawn from the IBM® Marketscan® database (2014-2016). We recorded opioid usage within 6 months of surgery and identified differences in unadjusted opioid use rates between LF and LP patients. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative opioid use.

RESULTS

Without adjusting for covariates, LF patients had a higher rate of 6-month opioid use in the single-surgeon cohort (15.7% vs 5.1%, P = .02). After adjusting for covariates, LF patients had higher odds of 6-month postoperative opioid use (OR 2.8 [95% CI 1.0-7.7], P = .04). In the national cohort, without adjusting for covariates, there was no significant difference in 6-month opioid use between LF and LP patients. Even after adjusting for covariates, we found no significant difference in odds.

CONCLUSIONS

Findings from a single-surgeon cohort reveal that LF is associated with a higher rate of 6-month opioid use than LP. This is at odds with findings from a national database cohort, which suggested that LP and LF patients have similar rates of opioid usage at 6-months postoperatively. To prevent overuse of narcotics, surgeons must consider the distinct pain requirements associated with different procedures even in treatment of the same condition.

The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population.

METHODS

Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups.

RESULTS

583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003).

CONCLUSIONS

Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.

The impact of perioperative opioid use on postoperative outcomes following spinal surgery: a meta-analysis of 60 cohort studies with 13 million participants

BACKGROUND CONTEXT

An important factor for the prognosis of spinal surgery is the perioperative use of opioids. However, the relationship is not clear.

PURPOSE

The purpose of this study was to evaluate the effect of perioperative opioid use on the prognosis of patients following spinal surgery.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

OUTCOME MEASURES

A meta-analysis was conducted using the random-effects method to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched to find relevant articles that were published until September 2, 2022. The primary outcome was prolonged postoperative opioid use, and secondary outcomes included the length of stay (LOS), reoperation, the time to return to work (RTW), postoperative complications, gastrointestinal complications, new permanent disability, central nervous system events and infection. In addition, subgroup analysis of the primary outcome was conducted to explore the main sources of heterogeneity, and sensitivity analysis of all outcomes was performed to evaluate the stability of the results.

RESULTS

A total of 60 cohort studies involving 13,219,228 individuals met the inclusion criteria. Meta-analysis showed that perioperative opioid use was specifically related to prolonged postoperative opioid use (OR 6.91, 95% CI 6.09 to 7.84, p<.01). Furthermore, the results also showed that perioperative opioid use was significantly associated with prolonged LOS (OR 1.74, 95% CI 1.39 to 2.18, p<.01), postoperative complications (OR 1.72, 95% CI 1.26 to 2.36, p<.01), reoperation (OR 2.38, 95% CI 1.85 to 3.07, p<.01), the time to RTW (OR 0.45, 95% CI 0.39 to 0.52, p<.01), gastrointestinal complications (OR 1.39, 95% CI 1.30 to 1.48, p<.01), central nervous system events (OR 1.99, 95% CI 1.21 to 3.27, p=.07) and infection (OR 1.22, 95% CI 1.09 to 1.36, p=.01). These results were corroborated by the trim-and-fill procedure and leave-one-out sensitivity analyses.

CONCLUSIONS

Based on the current evidence, patients with perioperative opioid use, in comparison to controls, appear to have prolonged postoperative opioid use, which may increase the risk of poor outcomes including prolonged LOS, complications, reoperation, RTW and so on. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous. These findings may help clinicians to realize the harmfulness of perioperative use of opioids, reduce the use of prescription opioids, necessarily withdraw before operation or significantly wean to the lowest tolerable preoperative amount, and provide some inspiration for standardizing the use of opioids in the future.

Recovery Kinetics After Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively maintained multisurgeon registry.

OBJECTIVE

To study recovery kinetics and associated factors after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Few studies have described return to activities cervical spine surgery. This is a big gap in the literature, as preoperative counseling and expectations before surgery are important.

MATERIALS AND METHODS

Patients who underwent either anterior cervical discectomy and fusion (ACDF) or cervical disk replacement (CDR) were included. Data collected included preoperative patient-reported outcome measures, return to driving, return to working, and discontinuation of opioids data. A multivariable regression was conducted to identify the factors associated with return to driving by 15 days, return to working by 15 days, and discontinuing opioids by 30 days.

RESULTS

Seventy ACDF patients and 70 CDR patients were included. Overall, 98.2% of ACDF patients and 98% of CDR patients returned to driving in 16 and 12 days, respectively; 85.7% of ACDF patients and 90.9% of CDR patients returned to work in 16 and 14 days; and 98.3% of ACDF patients and 98.3% of CDR patients discontinued opioids in a median of seven and six days. Though not significant, minimal (odds ratio (OR)=1.65) and moderate (OR=1.79) disability was associated with greater odds of returning to driving by 15 days. Sedentary work (OR=0.8) and preoperative narcotics (OR=0.86) were associated with decreased odds of returning to driving by 15 days. Medium (OR=0.81) and heavy (OR=0.78) intensity occupations were associated with decreased odds of returning to work by 15 days. High school education (OR=0.75), sedentary work (OR=0.79), and retired/not working (OR=0.69) were all associated with decreased odds of discontinuing opioids by 30 days.

CONCLUSIONS

Recovery kinetics for ACDF and CDR are comparable. Most patients return to all activities after ACDF and CDR within 16 days. These findings serve as an important compass for preoperative counseling.

Chronic obstructive pulmonary disease is an independent risk factor for increased opioid use in total hip arthroplasty: A retrospective PearlDiver study

Background

Total hip arthroplasty (THA) has become an incredibly common procedure due to its' predictability and high success rate. The success of surgery is related to strict indications and careful optimization of medical comorbidities to decrease risk and improve outcomes. Chronic obstructive pulmonary disease (COPD) has been associated with increased medical and surgical complications. A regulatory focus on opioid utilization does not usually consider COPD as a risk factor, but limited research exists on the impact of COPD on outcomes and risks after THA.

Methods

Retrospective all-inclusive database analysis of Medicare patients who had undergone THA between 2007 and 2017 included in the PearlDiver Database were studied. Postoperative opioid usage was examined at 1-, 3-, 6-, and 12 months, along with surgical infection, implant complications, and revisions. Post-operative complications within 30 days, either medical or implant related, were identified. Controlling for comorbidities, age, and sex, odds ratios were calculated using multivariable logistic regression with a significant α value of 0.05.

Results

COPD patients had significantly higher rates of opioid usage postoperatively. COPD patients also had an increased rate of readmissions, medical/implant complications, and revision surgeries.

Discussion

This is the only study raising concern regarding opioid use in COPD patients after total hip arthroplasty, which may be critical considering the associated respiratory depression further exacerbating the COPD. Considering the evidence of poor outcomes associated with COPD in arthroplasty, appropriately screening for COPD and counseling or planning for post-operative pain control and complications is paramount.

Odontoid fracture in geriatric patients - analysis of complications and outcome following conservative treatment vs. ventral and dorsal surgery

BACKGROUND

Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures.

METHODS

Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed.

RESULTS

A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications.

CONCLUSION

Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages.

An individualised tapering protocol reduces opioid use 1 year after spine surgery: A randomised controlled trial of patients with preoperative opioid use

BACKGROUND

Persistent opioid use following surgery is common especially in patients with preoperative opioid use. This study aims to determine the long-term effect of an individualised opioid tapering plan versus standard of care in patients with a preoperative opioid use undergoing spine surgery at Aarhus University Hospital, Denmark.

METHODS

This is the 1-year follow-up of a prospective, single-centre, randomised trial of 110 patients who underwent elective spine surgery for degenerative disease. The intervention was an individualised tapering plan at discharge and telephone counselling 1 week after discharge, compared to standard of care. Postoperative outcomes after 1 year include opioid use, reasons for opioid use and pain intensity.

RESULTS

The overall response rate to the 1-year follow-up questionnaire was 94% (intervention group 52/55 patients and control group 51/55 patients). Forty-two patients (proportion = 0.81, 95% CI 0.67-0.89) in the intervention group compared to 31 (0.61, 95% CI 0.47-0.73; p = .026) patients in the control group succeeded in tapering to zero 1 year after discharge (p = .026). One patient (0.02, 95% CI 0.01-0.13) in the intervention group compared to seven patients (0.14, 95% CI 0.07-0.26) in the control group were unable to taper to their preoperative dose 1 year after discharge (p = .025). Back/neck and radicular pain intensity was similar between study groups.

CONCLUSION

These results suggest that an individualised tapering plan at discharge combined with telephone counselling 1 week after discharge can reduce opioid use 1 year after spine surgery.

Comparison of Postoperative Opioid Use After Anterior Cervical Diskectomy and Fusion or Posterior Cervical Fusion

INTRODUCTION

Posterior cervical fusion (PCF) and anterior cervical diskectomy and fusion (ACDF) are two main surgical management options for the treatment of cervical spondylotic myelopathy. Although ACDF is less invasive than PCF which should theoretically reduce postoperative pain, it is still unknown whether this leads to reduced opioid use. Our objective was to evaluate whether PCF increases postoperative opioid use compared with ACDF.

METHODS

We retrospectively identified all patients undergoing 2-level to 4-level ACDF or PCF at a single center from 2017 to 2021. Our state's prescription drug-monitoring program was queried for filled opioid prescriptions using milligrams morphine equivalents (MMEs) up to 1 year postoperatively. In-hospital opioid use was collected from the electronic medical record. Bivariate statistics compared ACDF and PCF cohorts. Multivariate linear regression was done to assess independent predictors of in-hospital opioid use and short-term (0 to 30 days), subacute (30 to 90 days), and long-term (3 to 12 months) opioid prescriptions.

RESULTS

We included 211 ACDF patients and 91 PCF patients. Patients undergoing PCF used more opioids during admission (126.7 vs. 51.0 MME, P < 0.001) and refilled more MMEs in the short-term (118.2 vs. 86.1, P = 0.001) but not subacute (33.6 vs. 19.7, P = 0.174) or long-term (85.6 vs. 47.8, P = 0.310) period. A similar percent of patients in both groups refilled at least one prescription after 90 days (39.6% vs. 33.2%, P = 0.287). PCF (β = 56.7, P = 0.001) and 30-day preoperative MMEs (β = 0.28, P = 0.041) were associated with greater in-hospital opioid requirements. PCF (β = 26.7, P = 0.039), C5 nerve root irritation (β = 51.4, P = 0.019), and a history of depression (β = 40.9, P < 0.001) were independently associated with 30-day postoperative MMEs.

CONCLUSIONS

PCF is initially more painful than ACDF but does not lead to persistent opioid use. Surgeons should optimize multimodal analgesia protocols to reduce long-term narcotic usage rather than change the surgical approach.Level of Evidence:III.

Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery

STUDY DESIGN

Retrospective case control.

OBJECTIVES

The purpose of the current study is to determine risk factors associated with chronic opioid use after spine surgery.

METHODS

In our single institution retrospective study, 1,299 patients undergoing elective spine surgery at a tertiary academic medical center between January 2010 and August 2017 were enrolled into a prospectively collected registry. Patients were dichotomized based on renewal of, or active opioid prescription at 3-mo and 12-mo postoperatively. The primary outcome measures were risk factors for opioid renewal 3-months and 12-months postoperatively. These primarily included demographic characteristics, operative variables, and in-hospital opioid consumption via morphine milligram equivalence (MME). At the 3-month and 12-month periods, we analyzed the aforementioned covariates with multivariate followed by bivariate regression analyses.

RESULTS

Multivariate and bivariate analyses revealed that script renewal at 3 months was associated with black race (P = 0.001), preoperative narcotic (P < 0.001) or anxiety/depression medication use (P = 0.002), and intraoperative long lumbar (P < 0.001) or thoracic spine surgery (P < 0.001). Lower patient income was also a risk factor for script renewal (P = 0.01). Script renewal at 12 months was associated with younger age (P = 0.006), preoperative narcotics use (P = 0.001), and ≥4 levels of lumbar fusion (P < 0.001). Renewals at 3-mo and 12-mo had no association with MME given during the hospital stay or with the usage of PCA (P > 0.05).

CONCLUSION

The current study describes multiple patient-level factors associated with chronic opioid use. Notably, no metric of perioperative opioid utilization was directly associated with chronic opioid use after multivariate analysis.

Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?

OBJECTIVE

The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF).

METHODS

A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use.

RESULTS

A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions.

CONCLUSIONS

High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.

Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study

OBJECTIVE

This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery.

METHODS

Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis.

RESULTS

Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56).

CONCLUSIONS

The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty

Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.

Factors Associated With Total Discharge Opioid Prescription Morphine Milligram Equivalent Amounts Following Primary Anterior Cervical Spine Surgery

BACKGROUND

Opioid overuse is a substantial cause of morbidity and mortality in the United States, and orthopaedic surgeons are the third highest prescribers of opioids. Postoperative prescribing patterns vary widely, and there is a paucity of data evaluating patient and surgical factors associated with discharge opioid prescribing patterns after elective anterior cervical surgery (ACS). The purpose of this study was to evaluate the volume of postoperative opioids prescribed and factors associated with discharge opioid prescription volumes after elective ACS.

METHODS

We retrospectively identified patients aged 18 years and older who underwent elective primary anterior cervical diskectomy and fusion (ACDF), cervical disk arthroplasty (CDA), or hybrid procedure (ACDF and CDA at separate levels) at a single institution between 2015 and 2021. Demographic, surgical, and opioid prescription data were obtained from patients' electronic medical records. Univariate and multivariate analyses were conducted to assess for independent associations with discharge opioid volumes.

RESULTS

A total of 313 patients met inclusion criteria, including 226 (72.2%) ACDF, 69 (22.0%) CDA, and 18 (5.8%) hybrid procedure patients. Indications included radiculopathy in 63.6%, myelopathy in 19.2%, and myeloradiculopathy in 16.3%. The average age was 57.2 years, and 50.2% of patients were male. Of these, 88 (28.1%) underwent one-level, 137 (43.8%) underwent two-level, 83 (26.5%) underwent three-level, and 5 (1.6%) underwent four-level surgery. Younger age (P = 0.010), preoperative radiculopathy (P = 0.029), procedure type (ACDF, P < 0.001), preoperative opioid use (P = 0.012), and discharge prescription written by a midlevel provider (P = 0.010) were independently associated with greater discharge opioid prescription volumes.

CONCLUSION

We identified wide variability in prescription opioid discharge volumes after ACS and patient, procedure, and perioperative factors associated with greater discharge opioid volumes. These factors should be considered when designing protocols and interventions to reduce and optimize postoperative opioid use after ACS.

Patients With Functional Somatic Syndromes-Fibromyalgia, Irritable Bowel Syndrome, Chronic Headaches, and Chronic Low Back Pain-Have Lower Outcomes and Higher Opioid Usage and Cost After Shoulder and Elbow Surgery

PURPOSE

To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery.

METHODS

A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs.

RESULTS

The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs.

CONCLUSIONS

Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline.

LEVEL OF EVIDENCE

Level III, systematic review of Level II-III studies.

Determinants of long-term opioid use in hospitalized patients

BACKGROUND

Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital.

DESIGN

To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days.

RESULTS

Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40-2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22-8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12-1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31-0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17-3.69).

CONCLUSIONS AND RELEVANCE

Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.

Preoperative duration of pain is associated with chronic opioid use after adult spinal deformity surgery

PURPOSE

Few studies have explored the association between preoperative patient-reported measures and chronic opioid use following adult spinal deformity (ASD) surgery. We sought to explore the association between preoperative duration of pain, as well as other patient-reported factors, and chronic opioid use after ASD surgery.

METHODS

We retrospectively reviewed our U.S. academic tertiary care hospital's database of ASD patients. We included patients 18 years or older who underwent arthrodesis of four or more spinal levels from January 2008 to February 2018, with 2-year follow-up. The primary outcome variable was chronic opioid use, defined as opioid use at both 1 and 2 years postoperatively. We analyzed patient characteristics; duration of preoperative pain (<4 years or ≥4 years); radiculopathy; preoperative Scoliosis Research Society-22r (SRS-22r) score; Oswestry Disability Index (ODI) value; and surgical characteristics.

RESULTS

Of 119 patients who met the inclusion criteria, 93 (78%) were women, and mean ± standard deviation age was 59 ± 13. Sixty patients (50%) reported preoperative opioid use, and 35 (29%) reported chronic opioid use. Preoperative opioid use was associated with higher odds of chronic use (adjusted odds ratio, 5.9; 95% confidence interval 1.6-21), as was preoperative pain duration of ≥4 years (adjusted odds ratio, 3.3; 95% confidence interval 1.1-9.8). Patient characteristics, surgical variables, ODI value, and SRS-22r score were not significantly associated with chronic postoperative opioid use.

CONCLUSION

Preoperative opioid use and duration of pain of ≥4 years were associated with higher odds of chronic opioid use after ASD surgery.

LEVEL OF EVIDENCE

III.

Postoperative Physical Therapy Program Focused on Low Back Pain Can Improve Treatment Satisfaction after Minimally Invasive Lumbar Decompression

Patient satisfaction is crucial in pay-for-performance initiatives. To achieve further improvement in satisfaction, modifiable factors should be identified according to the surgery type. Using a prospective cohort, we compared the overall treatment satisfaction after microendoscopic lumbar decompression between patients treated postoperatively with a conventional physical therapy (PT) program (control; n = 100) and those treated with a PT program focused on low back pain (LBP) improvement (test; n = 100). Both programs included 40 min outpatient sessions, once per week for 3 months postoperatively. Adequate compliance was achieved in 92 and 84 patients in the control and test cohorts, respectively. There were no significant differences in background factors; however, the patient-reported pain score at 3 months postoperatively was significantly better, and treatment satisfaction was significantly higher in the test than in the control cohort (−0.02 ± 0.02 vs. −0.03 ± 0.03, p = 0.029; 70.2% vs. 55.4%, p = 0.045, respectively). In the multivariate logistic regression analysis, patients treated with the LBP program tended to be more satisfied than those treated with the conventional program, independent of age, sex, and diagnosis (adjusted odds ratio = 2.34, p = 0.012). Postoperative management with the LBP program could reduce pain more effectively and aid spine surgeons in achieving higher overall satisfaction after minimally invasive lumbar decompression, without additional pharmacological therapy.

Liposomal bupivacaine in posterior spine surgery: A piece of the puzzle for postoperative pain

Background

Liposomal bupivacaine (LB) is a local analgesic that may be used at the time of surgery to limit postoperative pain around the surgical site. Its efficacy in decreasing pain, decreasing narcotic consumption, decreasing length of stay, and improving mobility is an area of intense research. The purpose of this study was to determine whether LB use was associated with improved patient-reported pain scores in the first 72 h following posterior spinal surgery, decreased postoperative narcotic need, and decreased length of stay.

Methods

One hundred and five patients undergoing elective posterior cervical or lumbar surgery were included in retrospective analysis. Forty-eight patients who received LB intraoperatively were compared with a historical cohort of 56 patients who underwent similar procedures and did not receive postsurgical infiltration with local analgesia. The same pain medication protocol was utilized postoperatively.

Results

Demographics, clinical characteristics, and total morphine milligram equivalents did not differ significantly between the groups. The treatment group averaged a decreased length of stay (1.85 days treatment, 2.68 days control, p = 0.057). Treatment with LB was associated with lower pain levels at 24 h (5.2 treatment, 6.4 control, p = 0.04) and 48-72 h (4.9 treatment, 6.6 control, p = 0.007) after surgery.

Conclusions

LB improved patient perception of pain in the acute postoperative time period.Intraoperative LB injection, coupled with focused early mobilization efforts and multimodal pain control, may lead to improved patient-reported outcomes, shorter length of stay, and decreased risk of perioperative complications.

Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF?

The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.

Utilizing previous patient opioid experiences for pain plan implementation: Role of opioid use categorization on inpatient and outpatient opioid use, length of stay, pain scores, and clinic resource utilization following elective spine surgery

Background

A Pain Plan was formulated for all patients undergoing elective spine surgery at our institution. It was based on prior opioid experiences and developed collaboratively between the patient and the surgeon at a preoperative clinic visit. Category 1 patients had no previous opioid experience, Category 2 patients had remote previous opioid experience with acceptable pain control and no side effects, Category 3 patients had remote previous opioid experience with unacceptable pain control and/or side effects, and Category 4 patients had opioid use leading up to surgery.

Methods

This is a retrospective cohort study comparing adult patients within four different pain plan categories over one year (n = 313) to determine if categorization is predictive. Demographic data collected included age, gender, ASA class, BMI, smoking status, insurance status, substance abuse, and comorbid psychiatric diagnoses. Demographic factors between categories were compared and controlled for as covariates within analyses. Outcomes measures comprised self-reported pain scores and functional measurements, including inpatient opioid use, outpatient opioid prescription quantities, and postoperative healthcare utilization.

Results

Inpatient and outpatient opioid use were statistically significant amongst the categories, with prescription quantities greatest in Category 4, followed by Categories 2, 3, and 1, respectively. There was no difference in LOS or complexity of communication encounters amongst any of the groups. Patient-reported pain scores showed statistically significant differences and followed the same trend as opioid quantities, 4, 2, 3, and 1. The number of communication encounters was significant exclusively for Category 3 vs. 4.

Conclusions

The use of categorization in Pain Plan formation has been a helpful tool for postoperative pain management at our institution. Categorization is predictive of pain scores and opioid use after surgery, allowing the surgical team to tailor their care and counseling towards individual patients. In addition, the plan's collaborative nature enables patients to be involved in their pain management decisions while also setting limits and expectations.

The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty

Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.

SRS-22r question 11 is a valid opioid screen and stratifies opioid consumption

PURPOSE

To validate the Scoliosis Research Society-22r (SRS-22r) question 11 (Q11) response as a measure to assess and quantify opioid consumption.

METHODS

A post hoc analysis of a prospective study regarding opioid use during ASD surgery was performed. Data were collected at enrollment and 2-year follow-up including the SRS-22r and a standardized data collection form (CRF) for self-reported opioid consumption. Responses to Q11 of the SS-22r were compared with responses to the opioid consumption CRF (as measured by morphine equivalent dose (MED)). Inter-rater agreement was calculated. Sensitivity and specificity for the Q11 (+) responses were calculated using MED reports as the "true" value.

RESULTS

Cohen's kappa indicated almost perfect agreement between the MED CRF and Q11 (k = 0.878, p < 0.001). Mean daily MED consumption for patients reporting "Daily Narcotic" use was 62.0 (Median: 38.7, SD 87.5) mg; for patients reporting "Narcotics weekly or less", mean daily MED consumption was 21.6 (15.0, 29.0) mg. The positive Q11 responses were 96% sensitive and 92% specific for opioid users.

CONCLUSION

SRS-22r Q11 exhibits almost perfect agreement with an independent questionnaire designed to assess opioid consumption in this cohort. "Daily narcotic" users report nearly three times the mean daily MED of "Weekly or less" users (62.0 ± 87.5 mg vs 21.6 ± 29 mg, p = 0.037). Q11 exhibited excellent sensitivity and specificity for determining opioid users and non-users. Given the need for opioid research in ASD, Q11 may be useful to use existing registries and observational cohorts to design more definitive studies regarding opioid consumption.

LEVEL OF EVIDENCE

III.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Anterior vs Posterior Approach in Multilevel Cervical Spondylotic Myelopathy: A Nationwide Propensity-Matched Analysis of Complications, Outcomes, and Narcotic Use

BACKGROUND

There is unclear evidence regarding the optimal surgical approach for multilevel cervical spondylotic myelopathy (CSM). The objective of this study was to compare complications, outcomes, and narcotic use in anterior discectomy and fusion (ACDF) vs posterior decompression and fusion (PCDF) in CSM patients.

STUDY DESIGN

Registry-based retrospective cohort analysis.

METHODS

Patients undergoing 3-level ACDF or PCDF for CSM between 2007 and 2017 were identified from the Humana Claims Database using relevant procedure codes. Propensity score-matched groups were compared in regards to complications, outcomes, and narcotic use.

RESULTS

Propensity score matching generated equal cohorts of 6124 patients. The posterior fusion group had a higher rate of urinary tract infection (OR 2.47, P < 0.0001), deep vein thrombosis (OR 1.90, P < 0.0001), and pulmonary embolism (OR 1.75, P < 0.0001). In regards to 30-day outcomes, the posterior approach demonstrated higher rates of stroke (OR 1.68, P < 0.0001), wound dehiscence (OR 5.59, P < 0.0001), Surgical site infection (SSI) (OR 4.76, P < 0.0001), wound revision surgery (OR 3.02, P < 0.0001), and all-cause readmission (OR 2.01, P < 0.0001). One-year outcomes revealed higher rates of pseudarthrosis (4.7% vs 2.0%, OR 2.43, P < 0.0001) and revision or extension surgery (OR 2.33, P < 0.0001) in the posterior fusion cohort. These patients also demonstrated significantly higher mean morphine milligram equivalent used at 30 days (OR 1.19, P < 0.0001), as well as 60 (OR 1.20, P < 0.0001), 90 (OR 1.21, P < 0.0001), and 120 (OR 1.21, P < 0.0001) days.

CONCLUSIONS

This nationwide propensity-matched analysis of multilevel CSM patients found the posterior approach to be associated with increased rates of inpatient complications, wound complications, 30-day readmission, 1-year pseudarthrosis, and 1-year revision or extension surgery. These patients also demonstrated higher levels of narcotic use up to 120 days after surgery.

CLINICAL RELEVANCE

The posterior approach for treatment of CSM may be associated with increased rates of short- and long-term complications in addition to increased narcotic consumption in comparison to the anterior approach.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial

BACKGROUND CONTEXT

Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.

PURPOSE

We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.

STUDY DESIGN/SETTING

This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.

PATIENT SAMPLE

Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).

OUTCOME MEASURES

Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.

METHODS

A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.

RESULTS

Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.

CONCLUSIONS

Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Baseline Risk Factors for Prolonged Opioid Use Following Spine Surgery: Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of current retrospective cohort studies to identify significant preoperative risk factors for prolonged postoperative opioid use following spine surgery.

METHODS

Studies were identified according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) through a search of the PubMed, Google Scholar, Scopus, Cochrane databases. Unique articles were screened by two independent reviewers. Primary research articles reporting odds ratios (OR) of risk factors for prolonged opioid use as following spine surgery were included. Prolonged opioid use was defined as continued use ≥ 3 months following surgery, and study quality was evaluated using the Newcastle-Ottawa Scale (NOS). Random effects meta-analysis was performed to calculate pooled OR and confidence intervals.

RESULTS

648 studies were returned upon initial search. Following duplicate removal, 492 titles and abstracts were screened. After full-text review of 68 studies, 19 final studies including 168,961 patients were eligible for meta-analysis. NOS scores ranged from 6-9. Seventeen risk factors for long-term opioid use were assessed by meta-analysis. Preoperative opioid use, depression, depression and/or anxiety, drug abuse or dependency, female gender, fibromyalgia, lower back pain, tobacco use, and chronic pulmonary disease were found to be statistically significant risk factors for prolonged opioid use.

CONCLUSION

These results suggest that several patient-level factors may play a role in the tendency to persistently utilize opioids following spine surgery. By preoperatively identifying these characteristics, clinicians may be better able to identify patients that are at-risk and employ methods to mitigate potential long-term opioid use.

An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery

Opioids are commonly prescribed postoperatively for pain control, especially in spine surgery. Not only does this pose concerns for potential abuse, but it also has been shown to worsen certain outcomes. Risk factors for increased use include preoperative opioid use, female sex, psychiatric diagnoses, and drug and alcohol use. Over the past few decades, there have been increasing efforts mostly spearheaded by governmental agencies to decrease postoperative opioid use via opioid prescription limitation laws regulating the number of days and amounts of analgesics prescribed and promotion of the use of enhanced recovery after surgery (ERAS) protocols, multimodal pain regimens, epidural catheters, and ultrasound-guided peripheral nerve blocks. These strategies collectively have been efficacious in decreasing overall opioid use and better controlling patients' postoperative pain while simultaneously improving other outcomes such as postoperative nausea, vomiting, and length of stay. With an aging population undergoing an increasing number of spinal surgeries each year, it is now more important than ever to continue these efforts to improve the quality and safety of pain control methods after spinal surgery and limit the transition of acute management to the development of opioid dependence and addiction long-term.

Persistent Opioid Use After Spine Surgery: A Prospective Cohort Study

STUDY DESIGN

Single-center, investigator-initiated, prospective cohort study.

OBJECTIVE

This study aimed to determine patient-reported reasons for persistent opioid use following elective spine surgery, assess the frequency of withdrawal symptoms, and characterize pain-related care sought after discharge.

SUMMARY OF BACKGROUND DATA

Patients are often prescribed opioids at discharge from hospital following surgery. Several studies have shown that a large number of patients fail to discontinue opioid treatment and use opioids even months to years after surgery. Spine surgery has proven to be a high-risk procedure in regard to persistent opioid use. There is, however, limited evidence on why patients continue to take opioids.

METHODS

Three hundred patients, scheduled to undergo spine surgery at Aarhus University Hospital, Denmark, were included. Baseline characteristics and discharge data on opioid consumption were collected. Data on opioid consumption, patient-reported reasons for opioid use, withdrawal symptoms, and pain-related care sought were collected at 3- and 6-month follow-up via a REDCap survey.

RESULTS

Before surgery, opioid use was reported in 53% of patients. Three months after surgery, opioid use was reported in 60% of preoperative opioid-users and in 9% of preoperative opioid non-users. Patients reported the following reasons for postoperative opioid use: treatment of surgery-related pain (53%), treatment of surgery-related pain combined with other reasons (37%), and reasons not related to spine surgery (10%). Withdrawal symptoms were experienced by 33% of patients during the first 3 months after surgery and were associated with failure to discontinue opioid treatment (P < 0.001). Half of patients (52%) contacted health care after discharge with pain-related topics the first 3 months.

CONCLUSION

Patients use opioids after spine surgery for reasons other than surgery-related pain. Withdrawal symptoms are frequent even though patients are given tapering plans at discharge. Further studies should address how to facilitate successful and safe opioid tapering in patients undergoing spine surgery.Level of Evidence: 3.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Opioid Evaluation

BACKGROUND

Opioid use disorders in the United States have rapidly increased, yet little is known about the relationship between preoperative opioid duration and dose and patient outcomes after spine surgery. Likewise, the utility of preoperative opioid weaning is poorly understood.

OBJECTIVE

The purpose of this evidence-based clinical practice guideline is to determine if duration and dose of preoperative opioids or preoperative opioid weaning is associated with patient-reported outcomes or adverse events after elective spine surgery for degenerative conditions.

METHODS

A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to opioid use among adult patients undergoing spine surgery. Clinical studies evaluating preoperative duration, dose, and opioid weaning and outcomes were selected for review.

RESULTS

A total of 41 of 845 studies met the inclusion criteria and none were Level I evidence. The use of any opioids before surgery was associated with longer postoperative opioid use, and longer duration of opioid use was associated with worse outcomes, such as higher complications, longer length of stay, higher costs, and increased utilization of resources. There is insufficient evidence to support the efficacy of opioid weaning on postoperative opioid use, improving outcome, or reducing adverse events after spine surgery.

CONCLUSION

This evidence-based clinical guideline provides Grade B recommendations that preoperative opioid use and longer duration of preoperative opioid use are associated with chronic postoperative opioid use and worse outcome after spine surgery. Insufficient evidence supports the efficacy of an opioid wean before spine surgery (Grade I).The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/1-preoperative-opioid-evaluation.

Opioid Utilization in Geriatric Patients After Operation for Degenerative Spine Disease

BACKGROUND

Few studies have investigated opioid utilization by geriatric patients after spinal surgery, a population in whom degenerative spine disease (DSD) is highly prevalent. We aimed to quantify rates of chronic, continuous opioid utilization by geriatric patients following spine surgery for DSD-related diagnoses.

MATERIALS AND METHODS

Utilizing a national 5% Medicare sample database, we investigated individuals aged above 66 years who underwent spinal surgery for a DSD-related diagnosis between the years of 2008 and 2014. The outcomes of interest were the rate of and risk factors for continuous opioid utilization at 1-year following anterior cervical discectomy and fusion, posterior cervical fusion, 360-degree cervical fusion, lumbar microdiscectomy, lumbar laminectomy, posterior lumbar fusion, anterior lumbar fusion, or 360-degree lumbar fusion for a DSD-related diagnosis.

RESULTS

Of the 14,583 Medicare enrollees who met study criteria, 6.0% continuously utilized opioids 1-year after spinal surgery. When stratified by preoperative opioid utilization (with the prior year divided into 4 quarters), the rates of continuous utilization at 1-year postsurgery were 0.3% of opioid-naive patients and 23.6% of patients with opioid use in all 4 quarters before surgery. Anxiety, benzodiazepine use within the year before surgery, and Medicaid dual-eligibility were associated with prolonged opioid utilization.

CONCLUSIONS

Of opioid-naive geriatric patients who underwent surgery for DSD, 0.3% developed chronic, continuous opioid use. Preoperative opioid use was the strongest predictor of prolonged utilization, which may represent suboptimal use of nonopioid alternatives, pre-existing opioid use disorders, delayed referral for surgical evaluation, or over-prescription of opioids for noncancer pain.

Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection

BACKGROUND CONTEXT

Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection.

METHODS

The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%.

RESULTS

A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients.

CONCLUSIONS

We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.

Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) After Primary Spinal Fusion: An Analysis of Outcomes and Risk Factors from 2005 to 2014

BACKGROUND

Ogilvie syndrome (OS) is a rare but serious condition seen in the postoperative period. This was an epidemiologic study using data from the National Inpatient Sample from 2005 to 2014 to look at incidence, risk factors, and outcomes associated with OS after primary spine fusion.

METHODS

International Classification of Diseases, Ninth Revision codes were used to identify patients who underwent spine fusion surgery. Patients were separated into 2 cohorts based on the diagnosis of OS. Outcome measures and risk factors for cohorts were analyzed using multivariate logistic regression and compared.

RESULTS

Over the 10-year study period, 3,884,395 patients underwent primary spine fusion surgery. Among these, 0.04% developed OS during the index hospitalization. The greatest incidence seen in primary fusion involved the thoracic spine (0.15%). OS was more common after spine fusion for spine deformity (P < 0.001). Patients with OS were more likely to be men (P < 0.001), older (P < 0.0001), and have more comorbidities (P < 0.0001). Patients with OS were more likely to require postoperative blood transfusions (odds ratio [OR], 3.39; 95% confidence interval [CI], 2.51-4.59; P < 0.001) and sustain any complication (OR, 4.20; 95% CI, 3.17-5.57; P < 0.001). Patients with OS had a longer length of stay (15.7 vs. 3.9 days; P < 0.001) and increased average hospitalization cost ($63,037.03 vs. $26,792.19; P < 0.001). The development of OS was associated with fluid electrolyte disorder (OR, 4.06; 95% CI, 2.99-5.51; P < 0.001).

CONCLUSIONS

OS is a rare but serious complication of primary spine fusion surgery. Identifying the specific risk factors, symptoms, and potential complications related to OS is critical to aid in decreasing the significant morbidity associated with its development.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform

OBJECTIVE

On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery.

METHODS

This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery.

RESULTS

A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform.

CONCLUSIONS

Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

BACKGROUND

The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.

METHODS

A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.

RESULTS

There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.

CONCLUSIONS

We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The impact of preoperative motor weakness on postoperative opioid use after ACDF

This study aims to determine if preoperative weakness is an isolated risk factor for prolonged postoperative opioid use after anterior cervical discectomy and fusion (ACDF). Patients with preoperative weakness were significantly more likely to have prolonged and inappropriate opioid use and have a single prescription mean morphine equivalent (MME) ≥ 200. Logistic regression isolated preoperative weakness, opioid tolerance, depression, and VAS Neck pain as independent predictors of extended opioid use. High postoperative opioid dose (MME ≥ 90) correlated with opioid tolerance, younger age, male sex, greater CCI, prior cervical surgery, and preoperative VAS Neck pain on regression.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge

OBJECTIVE

To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors.

METHODS

We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05).

RESULTS

Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95).

CONCLUSIONS

Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

Postoperative opioid utilization associated with revision risk following primary shoulder arthroplasty

INTRODUCTION

With a substantial increase in utilization of primary shoulder arthroplasty, it is important to understand risk factors that may signal early failure and need for revision. Recent studies have reported that sustained postoperative opioid use is associated with a higher revision risk after total hip or knee arthroplasty. In this study, we evaluated postoperative opioid utilization as a risk factor for revision after primary shoulder arthroplasty.

METHODS

We conducted a cohort study using data from a United States integrated health care system's Shoulder Arthroplasty Registry. Patients who had a primary elective shoulder arthroplasty were identified (2009-2017); those with cancer or who underwent other arthroplasty procedures (either shoulder, hip, or knee) within the preceding year were excluded. Cumulative daily opioid utilization during the first year postoperative, calculated as oral morphine equivalents (OME), was categorized into 3 exposure groups: high user (≥15 mg OME daily), moderate user (<15 mg OME daily), and no opioid use (reference group). The exposure window was stratified into 2 time periods: postoperative days 1-90 and postoperative days 91-360. Multivariable Cox proportional-hazards regression was used to evaluate the association between postoperative opioid use and aseptic revision risk.

RESULTS

The final study sample included 8325 shoulder arthroplasty procedures. Of these individuals, 3707 (45%) received some opioid within the 1 year before the index procedure. We failed to observe a difference in aseptic revision risk between opioid utilization in the first 90 days postoperatively, regardless of dose. After the first 90 days, a higher revision risk was observed for high opioid users compared with nonusers (hazard ratio = 1.62, 95% confidence interval = 1.10-2.41), and no association was observed for moderate users (hazard ratio = 1.25, 95% confidence interval = 0.82-1.91).

CONCLUSIONS

We found a positive association between opioid consumption and aseptic revision risk after primary shoulder arthroplasty. This study cannot determine if opioids have a direct physiological cause that increases the risk of revision; rather it is likely that opioid consumption is a marker of chronic pain, poor function, and/or poor coping mechanisms. Further study is needed to determine if programs designed to decrease opioid use may impact revision risk after shoulder arthroplasty.

Comparison of Postoperative Opioid Utilization in an ACDF Cohort: Narcotic Naive Patients Versus Preoperative Opioid Users

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To compare the postoperative opioid utilization rates and costs after anterior cervical discectomy and fusion (ACDF) procedures between groups of patients who were preoperative opioid users versus opioid naive.

SUMMARY OF BACKGROUND DATA

Opioid medications are frequently prescribed after ACDF procedures. Given the current opioid epidemic, there is increased emphasis on early identification of patients at risk for prolonged postoperative opioid use.

METHODS

Records from patients diagnosed with cervical stenosis who underwent a ≤3-level index ACDF surgery between 2007 and 2017 were collected from a large insurance database. International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes were used to search clinical records. Two cohorts were established: a group of patients who utilized opioids preoperatively and a group of patients who were opioid naive at the time of surgery. The 1-year utilization and costs of postoperative therapies were documented for each group.

RESULTS

The preoperative opioid use cohort contained 4485 patients (61.6%), whereas the opioid-naive cohort included 2799 patients (38.4%). Postoperatively, 86.6% of the preoperative opioid use group continued to use opioids, whereas 59.0% of the opioid-naive group began using opioids. Patients who utilized opioids preoperatively were 4.48 times more likely (95% confidence interval, 3.99-5.02, P<0.001) to use opioids postoperatively and 4.30 times more likely (95% confidence interval, 3.10-5.94, P<0.001) to become opioid dependent compared with opioid-naive patients. In addition, after normalization, patients in the preoperative opioid use group utilized 3.7 times more opioid units/patient and billed for 5.3 times more dollars/patient than opioid-naive patients.

CONCLUSIONS

In patients with cervical stenosis who undergo an ACDF procedure, the postoperative utilization and costs of opioids seem to be substantially higher in patients with preoperative opioid use compared with opioid-naive patients. Efforts should be made to avoid opioid use as a component of conservative management before surgery.

LEVEL OF EVIDENCE

Level III.

Preoperative and Postoperative Opioid Dependence in Patients Undergoing Anterior Cervical Diskectomy and Fusion for Degenerative Spinal Disorders

BACKGROUND

 Anterior cervical diskectomy and fusion (ACDF) is a procedure for effectively relieving radiculopathy. Opioids are commonly overprescribed in postsurgical settings and prescriptions vary widely among providers. We identify trends in opioid dependence before and after ACDF.

METHODS

 We used the Truven Health MarketScan data to identify adult patients undergoing ACDF for degenerative cervical spine conditions between 2009 and 2015. Patients were segregated in four cohorts of preoperative and postoperative opioid nondependence (ND) or dependence (D) with 15 months of postoperative follow-up.

RESULTS

 A total of 25,403 patients with median age of 52 years (18-92) who underwent ACDF met the inclusion criteria. Breakdown of the four cohorts was as follows: prior nondependent who remain nondependent (NDND): 62.76% (n = 15,944); prior nondependent who become dependent (NDD): 4.6% (n = 1,168); prior dependent who become nondependent (DND): 14.03% (n = 3,564); and prior dependent who remain dependent (DD): 18.61% (n = 4,727). Opioid dependence decreased 9.43% postoperatively. Overall payments and 30-day readmissions increased 1.96 and 1.79 times for opioid dependent versus nondependent cohorts, respectively. Adjusted payments at 3 to 15 months were significantly increased for dependent cohorts with 3.56-fold increase for the DD cohort when compared with the NDND cohort. Length of stay, complications, medication refills, outpatient measures, and hospital admissions were also higher in those groups with postoperative opioid dependence when compared with those who were not opioid dependent.

CONCLUSIONS

 Opioid dependence after ACDF is associated with increased hospital readmissions, complication rates at 30 days, and payments within 3 months and 3 to 15 months postdischarge. Overall opioid dependence was decreased after ACDF procedure, however, a smaller number of opioid-dependent and opioid-naive patients became dependent postoperatively and should be followed carefully.

Postdischarge Opioid Use after Total Hip and Total Knee Arthroplasty

BACKGROUND

As America's third highest opioid prescribers, orthopedic surgeons have contributed to the opioid abuse crisis. This study evaluated opioid use after primary total joint replacement. We hypothesized that patients who underwent total hip arthroplasty (THA) use fewer opioids than patients who underwent total knee arthroplasty (TKA) and that both groups use fewer opioids than prescribed.

METHODS

A prospective study of 110 patients undergoing primary THA or TKA by surgeons at an academic center during 2018 was performed. All were prescribed oxycodone 5 mg, 84 tablets, without refills. Demographics, medical history, and operative details were collected. Pain medication consumption and patient-reported outcomes were collected at 2 and 6 weeks postoperatively. Analysis of variance was performed on patient and surgical variables.

RESULTS

Sixty-one patients scheduled for THA and 49 for TKA were included. THA patients consumed significantly fewer opioids than TKA patients at 2 weeks (28.1 tablets vs 48.4, P = .0003) and 6 weeks (33.1 vs 59.3, P = .0004). Linear regression showed opioid use decreased with age at both time points (P = .0002). A preoperative mental health disorder was associated with higher usage at 2 weeks (58.3 vs 31.4, P < .0001) and 6 weeks (64.7 vs 39.2, P = .006). Higher consumption at 2 weeks was correlated with worse outcome scores at all time points.

CONCLUSIONS

TKA patients required more pain medication than THA patients, and both groups received more opioids than necessary. In addition, younger patients and those with a preexisting mental health disorder required more pain medication. These data provide guidance on prescribing pain medication to help limit excess opioid distribution.

Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis

Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60 mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24 h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48 h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60 mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.

Preoperative Opioid Weaning Before Major Spinal Fusion: Simulated Data, Real-World Insights

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To identify gaps in opioid prescription immediately prior to spinal fusion and to study the effect of such simulated "opioid weaning/elimination" on risk of long-term postoperative opioid use.

SUMMARY OF BACKGROUND DATA

Numerous studies have described preoperative opioid duration and dose thresholds associated with sustained postoperative opioid use. However, the benefit and duration of preoperative opioid weaning before spinal fusion has not been elaborated.

METHODS

Humana commercial insurance data (2007-Q1 2017) was used to study primary cervical and lumbar/thoracolumbar fusions. More than 5000 total morphine equivalents in the year before spinal fusion were classified as chronic preoperative opioid use. Based on time between last opioid prescription (<14-days' supply) and spinal fusion, chronic opioid users were divided as; no gap, >2-months gap (2G) and >3-months gap (3G). Primary outcome measure was long-term postoperative opioid use (>5000 total morphine equivalents between 3 and 12-mo postoperatively). The effect of "opioid gap" on risk of long-term postoperative opioid use was studied using multiple-variable logistic regression analyses.

RESULTS

17,643 patients were included, of whom 3590 (20.3%) had chronic preoperative opioid use. Of these patients, 41 (1.1%) were in the 3G group and 106 (3.0%) were in the 2G group. In the 2G group, 53.8% patients ceased to have long-term postoperative use as compared with 27.8% in NG group. This association was significant on logistic regression analysis (OR 0.30, 95% CI: 0.20-0.46, P < 0.001).

CONCLUSIONS

Chronic opioid users whose last opioid prescription was >2-months prior to spinal fusion and less than 14-days' supply had significantly lower risk of long-term postoperative opioid use. We have simulated "opioid weaning" in chronic opioid users undergoing major spinal fusion and our analysis provides an initial reference point for current clinical practice and future clinical studies.Level of Evidence: 3.