New retrospective studies led by Charla Fischer, associate professor of orthopaedic surgery and director of quality and patient safety at NYU Langone’s Spine Center (New York, USA), show that the number of opioids taken before and during hospital stays by patients who need a transforaminal lumbar interbody fusion (TLIF) surgery may predict long-term risk of opioid abuse.
“With spine surgery, patients often experience a lot of pain before surgery and may come in after taking opioids for a prolonged period of time. As orthopaedic surgeons, we need to better understand how spine surgery may affect their pain levels and ultimately impact their overall outcomes” says Fischer. “In light of the current opioid epidemic, prudent prescriptions of opioids by orthopedic surgeons is necessary now more than ever.”
The first study looked at 53 consecutive patients who underwent a one, two, or three- level primary TLIF at NYU Langone’s Orthopedic Hospital between 2014–2017. Questionnaires were given to patients before surgery, and three months after, to determine patient reported outcomes such as pain intensity, in order to evaluate the effectiveness of the surgeries and their medication usage.
Thirty-two patients had not taken opioids prior to surgery for back pain, while 21 had. The researchers found that patients with a history of preoperative opioid use had worse baseline scores for pain and disability and greater functional improvement postoperatively compared to opioid-naïve patients. Nevertheless, the patients on preoperative opioids experienced a longer length of stay, were prescribed more opioids as inpatients following surgery, and continued taking opioids for a longer duration postoperatively.
“Spine surgeons may want to take a multidisciplinary approach, and work closely with pain and addiction medicine specialists to address the prolonged utilisation of opioids at six months after TLIF surgery in patients who took opioids preoperatively,” says Fischer.
In a separate study, Fischer’s team looked at the number of opioids taken in the hospital following TLIF, and whether that might impact usage rates following surgery. They retrospectively reviewed the medical records of TLIF procedures between 2014–2017, and identified 172 patients. They were separated into groups based on how many opioids they took during their inpatient hospital stays: 44 percent received less than 250 total morphine milligram equivalents (MMEs), 26% received between 250 and 500 MMEs, and 27 percent exceeded 500 MMEs during their hospital stay.
Patients who underwent a TLIF and received fewer than 250 MMEs of opioids had a 3.73 times smaller probability of requiring opioids at 6 month follow-up, compared to people who received 500 MMEs or more, who had a 4.84 times greater of requiring opioids at 6 months. A sub-analysis looking at the role of presurgical showed that patients with preoperative opioid use who received <250 total MME’s had a 7.09 times smaller of requiring opioids at 6 month follow-up while those who received >500 total MME’s had a 5.43 times greater probability of taking the medications at 6-month follow-ups. Patients who did not take opioids prior to surgery and were given <250 total MME’s or >500 total MME’s in the hospital did not have a statistically significant probability of requiring opioids at six month follow-up.
This is the first study to date that assesses the thresholds for postoperative opioid dosages that can predict continued long-term opioid use, according to the researchers.
“If your patient is requiring a lot of pain medication in the hospital, that’s a flag to get them into a pain medicine or addiction specialist as soon as possible,” says Fischer.