Preoperative Chronic Opioid Therapy Negatively Impacts Long-term Outcomes Following Cervical Fusion Surgery

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.

Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial (RCT).

OBJECTIVE

Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures.

SUMMARY OF BACKGROUND DATA

Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures.

METHODS

This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC).

RESULTS

Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively.

CONCLUSIONS

A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.

Influence of Anxiety and Depression on Opioid Use After Cervical Spine Fusion: An Analysis of a National Claims Database

Patients with spine pathology demonstrate an above average rate of active psychiatric disorders, which can influence their recovery. This study was designed to understand how mental health diagnoses (ie, anxiety and depression) influence a patient's postoperative need for opioids after a single level cervical spine fusion. The PearlDiver database was used to identify patients. Patients were placed into one of four groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. Chi-square tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days after their fusion. A total of 168,967 patients who underwent an elective cervical spine fusion in the United States between 2010 and 2021 were included in this study. The control group filled significantly more opioid prescriptions within the first 90 days after their cervical fusion (P<.001). There was no difference among the study groups regarding the need to fill additional opioid prescriptions. Patients with a diagnosis of depression and/or anxiety may present as complex patients; however, results suggest they do not need additional opioids for pain control after a single level cervical spine fusion. [Orthopedics. 2024;47(2):89-94.].

Preoperative opioid use and postoperative return to work following spinal surgery in workers' compensation settings: a systematic review and meta-analysis

BACKGROUND

Opioid use prior to spinal surgery is common among patients with workers' compensation (WC) claims. Extended opioid use for pain management in this population is associated with several adverse outcomes including delayed return to work (RTW).

OBJECTIVE

This systematic review and meta-analysis aim to assess the evidence on the association of preoperative opioid use with stable RTW and RTW within 1-year after spinal surgery.

MATERIAL AND METHODS

The authors searched MEDLINE, Embase, PsycINFO, Emcare, CINAHL Plus, Scopus, and Web of Science from inception to 14 January 2023. The authors included studies that compared any preoperative opioid use with no opioid use, and those that enabled a comparison of different durations of preoperative opioid use. The primary outcome was stable RTW after spinal surgery. Secondary outcomes were RTW within 1-year after surgery and cost of WC claims. A random effect model was assumed to pool the effect estimate. The GRADE approach was applied to evaluate the certainty of evidence.

RESULTS

From 2589 records, 10 studies were included, and of these, nine were considered for quantitative synthesis. All studies were observational with eight retrospective cohort and two case-control studies. Five studies each investigated cervical and lumbar disorders. With moderate certainty evidence, the odds of postoperative stable RTW reduced by half (OR: 0.51, 95% CI: 0.43-0.59; 5549 participants) in patients using opioids preoperatively. Similarly, moderate certainty evidence from 2348 participants demonstrated that the odds of RTW within 1-year after surgery were reduced by more than half in patients with preoperative opioid prescriptions (OR: 0.46, 95% CI: 0.36-0.59).

CONCLUSIONS

This systematic review and meta-analysis shows that preoperative opioid use is associated with a reduction in odds of postoperative RTW by half in patients with WC-funded spinal surgery.

Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis

BACKGROUND CONTEXT

Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting.

PURPOSE

To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures.

STUDY DESIGN

Retrospective analysis using national administrative claims database.

PATIENT SAMPLE

A total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery.

OUTCOME MEASURES

Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users.

METHODS

We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors.

RESULTS

A total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient.

CONCLUSION

Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification.

LEVEL OF EVIDENCE

Level III Prognostic Study.

MINI ABSTRACT

We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

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.

The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature

There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.

Perioperative Management of Comorbidities in Spine Surgery

The number of spinal operations performed in the United States has significantly increased in recent years. Along with these rising numbers, there has been a corresponding increase in the number of patient comorbidities. The focus of this article is to review comorbidities in Spine surgery patients and outline strategies to optimize patients and avoid complications.

Chronic Opioid Use Independently Increases Complications and Resource Utilization After Primary Total Joint Arthroplasty

BACKGROUND

Current literature suggests a link between the chronic use of opioids and musculoskeletal surgical complications. Given the current opioid epidemic, the need to elucidate the effects of chronic opioid use (OD) on patient outcomes and cost has become important. The purpose of this study was to determine if OD is an independent risk factor for inpatient postoperative complications and resource utilization after primary total joint arthroplasty.

METHODS

A total of 3,545,565 patients undergoing elective, unilateral, primary total hip (THA) and knee (TKA) arthroplasty for osteoarthritis from January 2016 to December 2019 were identified using a large national database. In-hospital postoperative complications, length of stay, and total costs adjusted for inflation in opioid + patients were compared with patients without chronic opioid use (OD). Logistic regression analyses were used to control for cofounding factors.

RESULTS

OD patients undergoing either THA or TKA had a higher risk of postoperative complications including respiratory (odds ratio (OR): 1.4 and OR: 1.3), gastrointestinal (OR: 1.8 and OR: 1.8), urinary tract infection (OR: 1.1 and OR: 1.2), blood transfusion (OR: 1.5 and OR: 1.4), and deep vein thrombosis (OR: 1.7 and OR: 1.6), respectively. Total cost ($16,619 ± $9,251 versus $15,603 ± $9,181, P < .001), lengths of stay (2.15 ± 1.37 versus 2.03 ± 1.23, P < .001), and the likelihood for discharge to a rehabilitation facility (17.8 versus 15.7%, P < .001) were higher in patients with OD.

CONCLUSION

OD was associated with higher risk for in-hospital postoperative complications and cost after primary THA and TKA. Further studies to find strategies to mitigate the impact of opioid use on complications are required.

Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study

OBJECTIVES

Opioids are commonly used to manage pain, despite an increased risk of adverse events and complications when used against recommendations. This register study uses data of osteoarthritis (OA) patients with joint replacement surgery to identify and characterize problematic opioid use (POU) prescription patterns.

METHODS

The study population included adult patients diagnosed with OA in specialty care undergoing joint replacement surgery in Denmark, Finland, Norway, and Sweden during 1 January 2011 to 31 December 2014. Those with cancer or OA within three years before the first eligible OA diagnosis were excluded. Patients were allocated into six POU cohorts based on dose escalation, frequency, and dosing of prescription opioids post-surgery (definitions were based on guidelines, previous literature, and clinical experience), and matched on age and sex to patients with opioid use, but not in any of the six cohorts. Data on demographics, non-OA pain diagnoses, cardiovascular diseases, psychiatric disorders, and clinical characteristics were used to study patient characteristics and predictors of POU.

RESULTS

13.7% of patients with OA and a hip/knee joint replacement were classified as problematic users and they had more comorbidities and higher pre-surgery doses of opioids than matches. Patients dispensing high doses of opioids pre-surgery dispensed increased doses post-surgery, a pattern not seen among patients prescribed lower doses pre-surgery. Being dispensed 1-4,500 oral morphine equivalents in the year pre-surgery or having a non-OA pain diagnosis was associated with post-surgery POU (OR: 1.44-1.50, and 1.11-1.20, respectively).

CONCLUSIONS

Based on the discovered POU predictors, the study suggests that prescribers should carefully assess pain management strategies for patients with a history of comorbidities and pre-operative, long-term opioid use. Healthcare units should adopt risk assessment tools and ensure that these patients are followed up closely. The data also demonstrate potential areas for further exploration in improving patient outcomes and trajectories.

Impact of Social Determinants of Health in Spine Surgery

PURPOSE OF REVIEW

Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity.

RECENT FINDINGS

Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.

Preoperative opiate use leads to increased postoperative opiate use and readmissions after anterior cervical discectomy and fusion

BACKGROUND

Determine effects of pre-operative opiate use on anterior cervical discectomy and fusion (ACDF) surgery outcomes.

METHODS

The study design was a single center retrospective cohort study. Patient records were reviewed from 2013 and 2018 for elective 1 to 2 level ACDF surgeries. Patients were classified as: opiate naive (ON: no history of opiate) use, acute opiate (AO: <6 months preoperatively) use, and chronic opiate (CO: 6-12 months preoperatively) use based on prescription history before surgery. Opiate use was quantified by milligram morphine equivalents (MME) at 6-12 months preop, 0-6 months preop, 0-6 months postop, and 6-12 months postop. Charts were reviewed for American Society of Anesthesiologists (ASA) physical status classification and smoking history.

RESULTS

Readmission rates were 9.8% for ON, 9.1% for AO, and 30% for CO (P value <0.05). Average opiate use measured in MME 6-12 months post-surgery was 5.76 for ON, 18.44 for AO, and 39.92 for CO (P value <0.05). Readmission rate between nonsmokers, former smokers, and active smokers was 4.4%, 0%, and 10.8% (P value <0.05) at 30-90 days post-surgery, and 1.1%, 14.5%, and 2.5% (P value <0.05) in the 91 days to 1-year post-surgery.

CONCLUSIONS

There is statistically significant relationship between CO and higher readmission rates after ACDF. Preoperative opiate use is also associated with increased opiate use 6-12 months after surgery. Smoking history is also associated with increased readmission rates.

Preoperative opioids before adult spinal deformity surgery associated with increased reoperations and high rates of chronic postoperative opioid use at 3-year follow-up

PURPOSE

To determine the association of preoperative opioid prescriptions with reoperations and postoperative opioid prescriptions after adult spina deformity (ASD) surgery. With the current opioid crisis, patients undergoing surgery for ASD are at particular risk for opioid-related complications due to significant preoperative disability and surgical morbidity. No previous studies consider preoperative opioids in this population.

METHODS

A retrospective cohort study of patients undergoing posterior spinal fusion (7 or more levels) for ASD was performed. All patients had at least 3 years of postoperative follow-up 3 years postoperatively. Prescriptions for 4 different opioid medications (hydromorphone, oxycodone, hydrocodone, and tramadol) were identified within 3 months preoperatively and up to 3 years postoperatively. Multivariate regression was utilized to determine the association of preoperative use with reoperations and with postoperative opioid use, controlling for both patient and surgery-related confounding factors.

RESULTS

A total of 743 patients were identified and 59.6% (443) had opioid prescriptions within 3 months preoperatively. Postoperative opioid prescriptions were identified in 66.9% of patients at 12 months postoperatively, and in 54.8% at 36 months postoperatively. The 3-year reoperation rate was 11.0% in patients without preoperative prescriptions, 16.0% in patients with preoperative any opioid prescriptions (P = 0.07), and 34.8% in patients with preoperative hydromorphone prescriptions (P < 0.01). In multivariate analysis, preoperative opioid prescriptions were associated with increased reoperations (odds ratio [OR]: 1.62, P = 0.04), and chronic postoperative opioid use (OR: 4.40, P < 0.01). Preoperative hydromorphone prescriptions had the strongest association with both reoperations (OR: 4.96; P < 0.01) and chronic use (OR: 5.19: P = 0.03).

CONCLUSION

In the ASD population, preoperative opioids are associated with both reoperations and chronic opioid use, with hydromorphone having the strongest association. Further investigation of the benefits of preoperative weaning programs is warranted.

New persistent opioid use after surgery in patients with a history of remote opioid use

BACKGROUND

Postoperative pain management is particularly challenging in patients using opioids preoperatively, but previous studies have not stratified patients not using opioids at the time of surgery according to history of opioid use. This study was designed to test the hypothesis that history of opioid use among patients not reporting opioid use at the time of surgery was independently associated with new persistent opioid use after surgery.

METHODS

Using prospective perioperative data from the Analgesic Outcomes Study, we assessed outcomes of patients 18 years of age or older who underwent elective surgery between December 2015 and January 2019 and were not using opioids at the time of surgery. Patient self-reported outcome measures were collected on the day of surgery and at 2 weeks, 1 month, and 3 months postoperatively. The primary outcome was new persistent opioid use, defined as continued opioid use 3 months after surgery. The primary explanatory variable was history of opioid use, which was categorized as no history of opioid use, history of non-continuous opioid use, or history of continuous opioid use (defined as daily or almost every day for 3 months or longer). Other covariates included demographics, validated measures (pain, mood), surgery type and approach, comorbidities, and use of tobacco, alcohol, cannabis, and benzodiazepines. Backward stepwise logistic regression models were used to determine patient factors associated with new persistent opioid use and refill after surgery.

RESULTS

A total of 1,249 patients not taking opioids preoperatively were included in the study cohort for new persistent opioid use. A total of 54 (4.3%) patients had continued use 3 months after surgery. New persistent opioid use after surgery was independently associated with non-continuous opioid use history (adjusted odds ratio 2.9, [95% confidence interval, 1.21 to 6.94]), continuous opioid use history (adjusted odds ratio 5.0, [95% confidence interval, 1.48 to 16.76]), and moderate to high alcohol use (adjusted odds ratio 2.5, [95% confidence interval, 1.24 to 4.93]). Similarly, opioid prescription refill at 1 month after surgery was independently associated with history of non-continuous opioid use (adjusted odds ratio 1.6, [95% confidence interval, 1.12 to 2.24]), history of continuous opioid use (adjusted odds ratio 2.2, [95% confidence interval, 1.15 to 4.06]), and moderate to high alcohol use (adjusted odds ratio 1.7, [95% confidence interval, 1.18 to 2.48]).

CONCLUSION

Among patients not using opioids preoperatively, a history of opioid use was independently associated with new persistent opioid use after surgery, especially those with a history of continuous 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.

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.

The opioid epidemic from the acute care hospital front line

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Association of Duration of Preoperative Opioid Use with Reoperation After One-level Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine that rates of preoperative opioid use in patients undergoing single-level anterior discectomy and fusion (ACDF) without myelopathy and determine the association with reoperations over 5 years.

SUMMARY OF BACKGROUND DATA

Preoperative opioid use before cervical spine surgery has been linked to worse postoperative outcomes. However, no studies have determined the association of duration and type of opioid used with reoperations after ACDF.

METHODS

Patients undergoing single-level ACDF without myelopathy between 2007 and 2016 with at least 5-year follow-up were identified in one private insurance administrative database. Preoperative opiate use was divided into acute (within 3 months), subacute (acute use and use between 3 and 6 months), and chronic (subacute use and use before 6 months) and by the opiate medication prescribed (tramadol, oxycodone, and hydrocodone). Postoperative rates of additional cervical spine surgery were determined at 5 years and multivariate logistic regression was used to determine the association of preoperative opiates with additional surgery.

RESULTS

Of 445 patients undergoing single-level ACDF without myelopathy, 66.3% were taking opioid medications before surgery. The most commonly used preoperative opioid was hydrocodone (50.3% acute use, 24.7% chronic use). Opioid-naïve patients had a 5-year reoperation rate of 4.7%, compared to 25.0%, 15.5%, and 23.3% with chronic preoperative use of tramadol, hydrocodone, and oxycodone. In multivariate analysis, controlling for age, sex, and Charlson Comorbidity Index, chronic use of hydrocodone (odds ratio [OR] = 2.08, P = 0.05), oxycodone (OR = 4.46, P < 0.01), and tramadol (OR = 4.01, P = 0.01) were all associated with increased reoperations. However, acute use of hydrocodone, oxycodone, and tramadol was not associated with reoperations (P > 0.05).

CONCLUSION

Both subacute and chronic use of common lower-dose opioid medications is associated with increased reoperations after single-level ACDF in nonmyelopathic patients. This information is critical when counseling patients preoperatively and developing preoperative opioid cessation programs.Level of Evidence: 3.

The influence of modifiable risk factors on short-term postoperative outcomes following cervical spine surgery: A retrospective propensity score matched analysis

BACKGROUND

Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs.

METHODS

Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented.

FINDINGS

We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p<0.0001 and p = 0.0037). However, those with substance abuse had the highest readmission rate and were more commonly readmitted for delayed procedure-related infections.

INTERPRETATION

A large proportion of patients who receive cervical spine surgery have potential MRFs that uniquely influence their postoperative outcomes. A thorough understanding of patient-specific MRF subgroups allows for improved preoperative risk stratification, tailored patient counseling, and postoperative management planning.

FUNDING

None.

Occurrence, Risk Factors, and Time Trends for Late Reoperations due to Degenerative Cervical Spine Disease: A Finnish National Register Study of 19 377 Patients Operated on Between 1999 and 2015

BACKGROUND

Surgery for degenerative cervical spine disease has escalated since the 1990s. Fusion has become the mainstay of surgery despite concerns regarding adjacent segment degeneration. The patient-specific trends in reoperations have not been studied previously.

OBJECTIVE

To analyze the occurrence, risk factors, and trends in reoperations in a long-term follow-up of all the patients operated for degenerative cervical spine disease in Finland between 1999 and 2015.

METHODS

The patients were retrospectively identified from the Hospital Discharge Registry. Reoperations were traced individually; only reoperations occurring >365 d after the primary operation were included. Time trends in reoperations and the risk factors were analyzed by regression analysis.

RESULTS

Of the 19 377 identified patients, 9.2% underwent a late reoperation at a median of 3.6 yr after the primary operation. The annual risk of reoperation was 2.4% at 2 yr, 6.6% at 5 yr, 11.1% at 10 yr, and 14.2% at 15 yr. Seventy-five percent of the late reoperations occurred within 6.5 yr of the primary operation. Foraminal stenosis, the anterior cervical decompression and fusion (ACDF) technique, male gender, weak opiate use, and young age were the most important risk factors for reoperation. There was no increase in the risk of reoperations over the follow-up period.

CONCLUSION

The risk of reoperation was stable between 1999 and 2015. The reoperation risk was highest during the first 6 postoperative years and then declined. Patients with foraminal stenosis had the highest risk of reoperation, especially when ACDF was performed.

Effect of Daily Dosage of Morphine Milligram Equivalents on Free Flap Complications: A Single-Institution Retrospective Study

INTRODUCTION

There appears to be an association between preoperative opioid use and postoperative complications. We sought to determine whether patients with a history of chronic opiate use (defined as 3 months or more of sustained use) prior to undergoing free flap surgery have higher rates of 30-day complications.

METHODS

A retrospective review of patients undergoing free flaps from 2015 to 2020 was performed. Patient characteristics were analyzed, including daily preoperative dose of opiates, which were then converted to morphine milligram equivalents; intra-operative variables such as estimated blood loss and operating room time; and 30-day outcomes, including wound and flap complications, return to the operating room, and readmissions.

RESULTS

One hundred fifty-five patients received 160 free flaps. Of these flaps, 50/160 (31%) were performed on patients with an opiate prescription for at least three months prior to surgery. Using multivariable analysis, morphine milligram equivalents, a surrogate for opioid dose, were significantly associated with flap complications (odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003-1.020, p<0.01), partial flap loss (OR 1.010, 95% CI 1.003-1.019, p<0.01), and surgical site infections (OR 1.017, 95% CI 1.007-1.027, p<0.01). Additionally, estimated blood loss was associated with partial flap loss (OR 4.838, 95% CI 1.589-14.728, p<0.006), and operating room time was also associated with flap complications (OR 1.337, 95% CI 1.152-1.150, p<0.01).

CONCLUSION

Chronic preoperative opioid use is common for free flap surgery, and according to our single-center experience, higher daily doses are a risk factor for flap complications and surgical site infections. These findings add to the growing body of evidence that opioid use is a modifiable risk factor that may increase surgical morbidity.

Impact of Preoperative Opioid Use on Postoperative Patient-reported Outcomes in Lumbar Spine Surgery Patients

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

Investigate the impact of preoperative opioid use on postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores in patients undergoing elective spine surgery.

BACKGROUND DATA

The PROMIS has demonstrated reliability and validity in conditions such as lumbar stenosis, disc herniation, and cervical spondylosis. Although previous studies have identified the negative impact of preoperative opioid use on legacy patient-reported outcome measures following lumbar spine surgery, no study to date has utilized PROMIS computer adaptive tests.

METHODS

Consecutive patients who underwent lumbar spine surgery at a single institution between 2014 and 2016 completed PROMIS PF and PI scores at baseline preoperatively and at 3, 12, and 24 months postoperatively. Preoperative opioid use was defined as >1 month before surgery. Univariate and linear mixed model multivariate analysis was performed to evaluate for correlation of preoperative opioid use, as well as patient risk factors, with postoperative PROMIS PI and PF scores at each time point.

RESULTS

Ninety-one patients met inclusion criteria with PROMIS scores at every time point. A total of 36 (39.6%) patients self-reported taking opioids at the time of surgery. Mean duration of opioid use among opioid users was 6.5±7.4 months. Patients taking preoperative opioids had significantly less improvement at all time points out to 24 months. At 24 months, patients in the nonopioid group had mean PI improvement of -13.0±14.2 versus -4.9±15.4 in the opioid group (P=0.014). The mean postoperative improvement in the opioid group did not achieve minimally clinically important difference (MCID) of 8 at any time point.

CONCLUSIONS

Patients who do not use opioids preoperatively show significant postsurgical improvement in PI scores compared with patients who use preoperative opioids. Mean improvement in PROMIS PI scores failed to meet an MCID of 8 in opioid users, whereas mean improvement exceeded this MCID in opioid naive patients. The results of this study help elucidate the deleterious impact of opioids, allowing surgeons to better set patient expectations.

LEVEL OF EVIDENCE

Level III.

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.

Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify an association between preoperative opioid use and reoperations rates.

SUMMARY OF BACKGROUND DATA

Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates.

METHODS

A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years.

RESULTS

A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05).

CONCLUSION

Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.

Risk Factors for Prolonged Opioid Use and Effects of Opioid Tolerance on Clinical Outcomes After Anterior Cervical Discectomy and Fusion Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to determine risk factors for prolonged opioid use and to investigate whether opioid-tolerance affects patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) surgery.

SUMMARY OF BACKGROUND DATA

There is a lack of consensus on risk factors that can affect continued opioid use after cervical spine surgery and the influence of opioid use on patient-reported outcomes.

METHODS

Ninety-two patients who underwent ACDF for degenerative cervical pathologies were retrospectively identified and their opioid usage before surgery was investigated using a state-sponsored prescription drug monitoring registry. Opioid-naïve and opioid tolerant groups were defined using criteria most consistent with the Federal Drug Administration (FDA) definition. Patient-reported outcomes were then collected, including the Short Form-12 (SF-12) Physical Component (PCS-12) and Mental Component (MCS-12), the Neck Disability Index (NDI), the Visual Analogue Scale Neck (VAS neck) and the Visual Analogue Scale Arm (VAS Arm) pain scores. Logistic regression was used to determine predictors for prolonged opioid use following ACDF. Univariate and multivariate analyses were conducted to compare change in outcomes over time between the two groups.

RESULTS

Logistic regression analysis demonstrated that opioid tolerance was a significant predictor for prolonged opioid use after ACDF (odds ratio [OR]: 18.2 [1.46, 226.4], P = 0.02). Duration of usage was also found to be a significant predictor for continued opioid use after surgery (OR: 1.10 [1.0, 1.03], P = 0.03). No other risk factors were found to be significant predictors. Both groups overall experienced improvements in patient-reported outcomes after surgery. Multiple linear regression analysis, controlling for patient demographics, demonstrated that opioid-tolerant user status positively affected change in outcomes over time for NDI (β = -13.7 [-21.8,-5.55], P = 0.002) and PCS-12 (β = 6.99 [2.59, 11.4], P = 0.003) but no other outcomes measured.

CONCLUSION

Opioid tolerance was found to be a significant predictor for prolonged opioid use after ACDF. Additionally, opioid-naïve and opioid-tolerant users experienced overall improvements across PROMs following ACDF. Opioid-tolerance was associated with NDI and PCS-12 improvements over time compared to opioid-naïve users.

LEVEL OF EVIDENCE

4.

Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies

There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.

The Impact of Preoperative Chronic Opioid Therapy in Patients Undergoing Decompression Laminectomy of the Lumbar Spine

STUDY DESIGN

Retrospective review of electronic medical records (EMR).

OBJECTIVE

This study aims to (1) characterize the pattern of opioid utilization in patients undergoing spine surgery and (2) compare the postoperative course between patients with and without chronic preoperative opioid prescriptions.

SUMMARY OF BACKGROUND DATA

Postoperative pain management for patients with a history of opioid usage remains a challenge for spine surgeons. Opioids are controversial in this setting due to side effects and potential for abuse and addiction. Given the increasing rate of opioid prescriptions for spine-related pain, more studies are needed to evaluate patterns and risks of preoperative opioid usage in surgical patients.

METHODS

EMR were reviewed for patients (age > 18) with lumbar spinal stenosis undergoing lumbar laminectomy in 2011 at our institution. Data regarding patient demographics, levels operated, pre/postoperative medications, and in-hospital length of stay were collected. Primary outcomes were length of stay and duration of postoperative opioid usage.

RESULTS

One hundred patients were reviewed. Fifty-five patients had a chronic opioid prescription documented at least 3 months before surgery. Forty-five patients were not on chronic opioid therapy preoperatively. The preoperative opioid group compared with the non-opioid group had a greater proportion of females (53% vs. 40%), younger mean age (63 yrs vs. 65 yrs), higher frequency of preoperative benzodiazepine prescription (20% vs. 11%), longer average in-hospital length of stay (3.7 d vs. 3.2 d), and longer duration on postoperative opioids (211 d vs. 79 d).

CONCLUSION

Patients on chronic opioids prior to spine surgery are more likely to have a longer hospital stay and continue on opioids for a longer time after surgery, compared with patients not on chronic opioid therapy. Spine surgeons and pain specialists should seek to identify patients on chronic opioids before surgery and evaluate strategies to optimize pain management in the pre- and postoperative course.

LEVEL OF EVIDENCE

3.