Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study

Patterns and Outcomes of Opioid Use Before and After Hospitalization for Critical Illness: A Population-Based Cohort Study

Background: Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. Methods: This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. Results: Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, P < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, P < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], P < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], P < .001). Similar associations were observed across surgical and nonsurgical admissions. Conclusions: Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.

Association Between Early Surgery and Postoperative Opioid Use in Patients With Lumbar Disc Herniation: A Propensity Score-Matching Analysis Using an Administrative Claims Database in Japan

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to investigate whether early surgery shortens the duration of opioid use in patients who underwent surgery with lumbar disc herniation.

METHODS

We extracted patients who underwent surgery at least 2 weeks after they were diagnosed with lumbar disc herniation between April 2014 and May 2021. Opioid use after surgery was compared between patients who underwent surgery within 90 days (early surgery group) and 90 days or later (late surgery group). Propensity-score-matching analysis and multivariable Cox hazard regression analysis with a restricted cubic spline model were conducted to evaluate the association between the timing of surgery and termination of opioid use after surgery.

RESULTS

A total of 1597 eligible patients were identified, with 807 (51%) in the early surgery group. In the propensity-score-matched cohort, the early surgery group had a significantly lower proportion of opioid use than the control group (28% vs 48%, percent difference -20%, P < .001). Multivariable Cox hazard regression analysis showed that early surgery was significantly associated with the earlier termination of opioid use (HR, 3.13; 95% CI, 1.97-4.97; P < .001). Restricted cubic spline model showed a monotonically decreased hazard ratio and decreased hazard ratio of .50 in patients who underwent surgery 111 days or later after the diagnosis.

CONCLUSIONS

Early surgery, especially within 90 days, was associated with earlier opioid use termination after surgery. Regarding the duration of opioid use following surgery, surgical treatment may be preferable to perform within around 4 months after the diagnosis.

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 Current Status of Awake Endoscopic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the use of local anesthesia and/or conscious sedation in endoscopic spine procedures within the past decade.

METHODS

This systematic review abided by PRISMA guidelines. Embase, PubMed, Google Scholar, and Cochrane databases were searched for post-2011 articles with patients >18 years old, lumbar/cervical percutaneous endoscopic spine procedures using local/awake anesthesia, and patient/surgical outcomes. Reviews, book chapters, single case reports, or small case series (n ≤15 patients) were excluded. Scoring systems of the National Institutes of Health quality assessment tool, Newcastle-Ottawa Scale, and Cochrane Risk of Bias evaluated interventional case series, comparative studies, and randomized control trials, respectively.

RESULTS

Twenty-six articles were included, with 4 studies comparing general and local anesthesia. Of 2113 total patients, 1873 patients received local anesthesia. Significant improvements were seen in pain and disability scores. Studies that included MacNab scores showed that 96% of patients rated their postoperative satisfaction as excellent to good. Subanalysis of comparative studies showed a reduced risk of surgical/major medical complications and a slight increased risk for minor medical complications among awake spine patients. Length of stay was shorter for patients receiving local anesthesia.

CONCLUSIONS

The current systematic review and meta-analysis shows that use of local anesthesia is a safe and effective alternative to general anesthesia among different endoscopic spinal procedures. Although awake spine surgery is associated with a decreased risk of severe complications, lower revision rates, and higher postoperative satisfaction, more robust studies involving larger cohorts of patients are needed to evaluate the true impact of awake spine surgery on outcomes.

Mismatched opioid prescription in patients discharged after neurological surgeries: a retrospective cohort study

ABSTRACT

Although postsurgical overprescription has been well-studied, postsurgical opioid underprescription remains largely overlooked. This retrospective cohort study was to investigate the extent of discharge opioid overprescription and underprescription in patients after neurological surgeries. Six thousand nine hundred forty-nine adult opioid-naive patients who underwent inpatient neurosurgical procedures at the University of California San Francisco were included. The primary outcome was the discrepancy between individual patient's prescribed daily oral morphine milligram equivalent (MME) at discharge and patient's own inpatient daily MME consumed within 24 hours of discharge. Analyses include Wilcoxon, Mann-Whitney, Kruskal-Wallis, and χ 2 tests, and linear or multivariable logistic regression. 64.3% and 19.5% of patients were opioid overprescribed and underprescribed, respectively, with median prescribed daily MME 360% and 55.2% of median inpatient daily MME in opioid overprescribed and underprescribed patients, respectively. 54.6% of patients with no inpatient opioid the day before discharge were opioid overprescribed. Opioid underprescription dose-dependently increased the rate of opioid refill 1 to 30 days after discharge. From 2016 to 2019, the percentage of patients with opioid overprescription decreased by 24.8%, but the percentage of patients with opioid underprescription increased by 51.2%. Thus, the mismatched discharge opioid prescription in patients after neurological surgeries presented as both opioid overprescription and underprescription, with a dose-dependent increased rate of opioid refill 1 to 30 days after discharge in opioid underprescription. Although we are fighting against opioid overprescription to postsurgical patients, we should not ignore postsurgical opioid underprescription.

Surgical prescription opioid trajectories among state Medicaid enrollees

OBJECTIVE

The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy.

DESIGN

Retrospective cohort.

SETTING

Administrative claims data.

PATIENTS AND PARTICIPANTS

Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period.

RESULTS

More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported.

CONCLUSIONS

Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity

INTRODUCTION

Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD.

METHODS

A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost.

RESULTS

Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis.

CONCLUSION

Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.

Impact of Affective Disorders on Inpatient Opioid Consumption and Hospital Outcomes Following Open Posterior Spinal Fusion for Adult Spine Deformity

OBJECTIVE

Affective disorders (ADs) are common and have a profound impact on surgical recovery, though few have studied the impact of ADs on inpatient narcotic consumption. The aim of this study was to assess the impact of ADs on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity.

METHODS

A retrospective cohort study was performed using the 2016-2017 Premier Healthcare Database. Adults who underwent adult spinal deformity surgery were identified using International Classification of Disease, Tenth Revision, codes. Patients were grouped based on comorbid diagnosis of an AD. Demographics, comorbidities, intraoperative variables, complications, length of stay, admission costs, and nonroutine discharge rates were assessed. Increased inpatient opioid use was categorized by morphine milligram equivalents consumption greater than the 75th percentile. Multivariate regression analysis was used to identify predictors of increased healthcare recourse utilization.

RESULTS

Of the 1831 study patients, 674 (36.8%) had an AD. A smaller proportion of patients in the AD cohort were 65+ years of age (P = 0.001), while a greater proportion of patients in the AD cohort identified as non-Hispanic White (P < 0.001). A greater proportion of patients in the AD cohort had increased morphine milligram equivalents consumption (P < 0.001). The AD cohort also had a longer mean length of stay (P < 0.001). A greater proportion of patients in the AD cohort had nonroutine discharges (P = 0.039) and unplanned 30-day readmission (P = 0.041). On multivariate analysis, AD was significantly associated with increased cost (odds ratio: 1.61, P < 0.001) and nonroutine discharge (odds ratio: 1.36, P = 0.035).

CONCLUSIONS

ADs may be associated with increased inpatient opioid consumption and healthcare resource utilization.

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.