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How Opioid Medications Effect Spine Surgery Outcomes

Dr. Anand Blog

August 6th, 2018

AS THE AMERICAN legislature and medical community continue efforts to stem the tide of the growing opioid crisis in our country, researchers are working diligently to highlight what a dangerous path doctors may be putting patients on when writing prescriptions for opioid medications to address chronic back pain as a result of a spinal condition. A new study published in the Journal of Bone & Joint Surgery indicates that the duration of pre-operative opioid usage was the strongest predictor of continued use after surgery. Other studies also paint an upsetting picture of spine surgery outcomes in patients who engaged in prolonged opioid use before surgery.

How Opioid Medications Effect Spine Surgery Outcomes

Opioid usage is on a steady rise in the United States over the last few decades, particularly among people who are affected by spinal conditions that result in severe or chronic back pain. Researchers have estimated that up to half of the people who undergo spine surgery are taking opioid medications at the time of surgery, with 20 percent possibly addicted to these medications. This is an essential topic for the medical community to pay significant attention to so we can help reduce patients' dependence on and misuse of powerful opioid narcotics that aren't intended for long-term usage.

The recent Journal of Bone & Joint Surgery study indicates that people who took prescription opioid medications for six months or longer before undergoing lumbar spine surgery were more likely to continue opioid usage after surgery. Nearly all of the patients studied had some exposure to opioid medications before surgery, and they were classified into four categories: exposed, acute exposed, intermediate sustained use and chronic sustained use.

The primary risk factor for continued opioid usage after surgery was the duration of opioid usage pre-surgery. The study authors referred to a "dose-response" effect, finding that patients who took opioids for six months or longer before surgery were 65 to 74 percent less likely to stop using them after surgery than the other study subjects who had not had as much exposure to opioid medications before surgery. The good news from the study indicated that most of the patients using prescription opioids before surgery stopped using them after surgery.

Opioid usage before surgery is also associated with a higher risk of surgical complications and unfavorable outcomes after spine surgery. In a Journal of Neurosurgery study published in 2017, researchers evaluated the one-year follow-up, postoperative outcomes of lumbar spinal fusion patients who had used opioid medications before surgery and compared them to those who hadn't. For the pre-surgery opioid user group, there was a higher reporting of continued back pain, greater disability and lower mental health scores (which study authors reported were also lower before surgery) than that of the non-user group 12-months after the operation had taken place. While the study did find that the health improved of all of the patients studied, whether or not they had used opioid medications before surgery, there was a significant difference in the quality of the improvement between opioid users and non-users.

The outcomes of these studies strongly suggest that patient care requires a multi-disciplinary approach between every member of a patient's health care team working together toward the patient's best health. We spine surgeons have a responsibility to treat our patients as whole people, not just as a spinal disorder. Because the research also indicates that other factors may contribute to continued opioid usage after surgery, it's crucial that doctors do our part to recognize and address those factors as well – including psychosocial issues, anxiety and depression.

In some cases, this could mean psychological counseling and an intentional period of weaning from opioid medications before surgery. Of course, this isn't to say we want to leave patients in pain. But the exploration of non-opioid methods for pain relief is gaining significant traction today and worth consideration. These alternatives can include physical therapy, massage, non-opioid medications and mindfulness meditation, to name a few. And of course, every member of a patient's care team must commit to closely monitoring any opioid medications being used after surgery.

As a spine surgeon, I've seen and heard the railing against spine surgery as a "treatment for back pain." However, as a medical community and society, what if we began to view prescription opioid medications as a dangerous treatment for back pain? While I've written extensively on the concept that spine surgery should neither be the first line of defense in addressing a spinal condition (unless a traumatic, catastrophic injury has been sustained) nor is it a "magic bullet" cure that will fix everyone's spinal concerns, it can save the right candidates' quality of life. A lifetime of opioid addiction is certainly not a better alternative. We doctors owe our patients a far better prognosis than that.


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