Sustained use of opioids before spine surgery increases risk of continued use after surgery

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Research finds duration of opioid use before surgery is the main risk factor for continued postoperative use

Patients who take prescription opioids for a longer period before spinal surgery are more likely to continue opioid use several months after surgery, reports a study in The Journal of Bone & Joint Surgery

According to the new research, led by Andrew J Schoenfeld (Brigham and Women’s Hospital, Harvard Medical School, Boston, USA), nearly 9% of patients were still taking opioids six months after spinal surgery, and duration of opioid use before surgery was the main risk factor for continued use.

Sustained preoperative opioid use predicts continued use after spine surgery

Using insurance claims data, the researchers identified more than 27,000 patients who underwent various types of lumbar spine surgery between 2006 and 2014. Most of the patients underwent a discectomy or spinal fusion procedure. Although the data came from the US Department of Defence’s Tricare insurance program, most of the patients in the study were civilians (such as retired military personnel or dependents of active-duty or retired personnel).

Nearly all patients had at least some opioid exposure before spinal surgery. They were classified into four groups:

  • Exposed: 60% had used opioids in the past, but were not actively using them at the time of surgery.
  • Acute exposure: 34% had their first opioid prescription within one month before surgery.
  • Intermediate sustained use: 2% had uninterrupted opioid use for less than six months before surgery.
  • Chronic sustained use: 3% had uninterrupted opioid use for six months or longer before surgery.

After surgery, 67% of the patients stopped taking opioids within 30 days, and 86% discontinued opioids by 90 days. Six months after surgery, 8.8% of patients were still taking prescription opioids.

Longer duration of opioid use before spinal surgery was an independent risk factor for continued use after surgery. After adjustment for other patient characteristics, the authors found that the likelihood of discontinuing opioid use within six months was 65% lower for patients in the “intermediate sustained” and 74% lower in the “chronic sustained” groups, compared to the “acute exposure” group. Somewhat surprisingly, even the patients who were “exposed” but not actively using opioids before surgery were 29% less likely than those in the “acute exposure” group to discontinue opioids after surgery.

Several other factors were associated with long-term opioid use after surgery: spinal fusion surgery, preoperative depression or anxiety, preoperative spinal fracture, a longer hospital stay, and junior enlisted rank (suggesting lower socioeconomic status).

The ongoing opioid crisis in the USA has prompted increased attention to the use of pain medications prescribed before and after surgery. Previous opioid use has been linked to an increased risk of complications and adverse outcomes after spinal surgery. This new study focuses on how preoperative opioid use affects continued opioid use after lumbar spine surgery, and finds evidence of a “dose-response” effect: patients taking opioids for a longer period before surgery are less likely to discontinue opioid use after surgery.

“Our results indicate that the majority of patients who are using prescription opioids prior to spine surgery discontinue these medications following surgical intervention,” Schoenfeld and co-authors write. However, because close to one out of 10 patients are still taking opioids at six months after spinal surgery, the researchers highlight the need for surgeons to recognise the “biopsychosocial” factors contributing to chronic opioid use.

Since nearly all patients receive opioids before spinal surgery, Schoenfeld believes it’s “reasonable” for surgeons to discuss risk factors for sustained opioid use with patients at the time of surgery.  He adds, “Expectation management—defining shared goals of post-surgical pain control and a suspense date when the surgeon and patient agree opioids should likely no longer be necessary—could go a long way toward smoothing the opioid cessation process following surgery.”

Additionally, a recent Spine study presented at the 18th annual conference of the International Society for the Advancement of Spine Surgery (ISASS; 11–13 April 2018, Toronto, Canada) found that patients who have been taking opioids as pain relievers for several months before spinal fusion surgery are at increased risk of complications after their surgery.

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