Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions

The Association Between Preoperative Cannabis Use and Anxiety, Pain Scores and Opioid Consumption in Patients Undergoing Spinal Fusion: A Retrospective Cohort Study

Study DesignRetrospective cohort study.ObjectiveDespite increasing cannabis use, its prevalence in specific surgical groups is unclear, and its impact on perioperative care and outcomes is understudied. This study estimates cannabis use incidence in patients undergoing lumbar spine surgery and explores associations between preoperative use and anxiety, pain scores, and postoperative opioid consumption. We hypothesized a correlation between cannabis use and decreased reliance on opioids for postoperative pain relief.MethodsThis single-center retrospective cohort study included 204 patients undergoing single or multilevel spinal fusion surgery between July 2022 and August 2023. Self-reported cannabis use, demographics, surgical characteristics, numeric rating scale (NRS) pain scores, anxiety, inpatient opioid consumption, and discharge prescribing (total morphine equivalent dose) were extracted from electronic medical records (EMR). Patients were categorized into cannabis users or non-cannabis users, and group differences were analyzed using bivariable and multivariable regression.ResultsOf 204 patients, 27 (13.2%) were cannabis users and 177 (86.8%) were non-users. Cannabis users were younger (P = 0.007), more likely male (P = 0.028), and Caucasian (P = 0.032) than non-users. Preoperative cannabis use correlated significantly with anxiety disorder (P = 0.023) and higher preoperative (P = 0.016) and postoperative (P = 0.002) NRS pain scores. Multivariable analysis showed cannabis use associated with higher preoperative (P = 0.015) but not postoperative (P = 0.073) pain scores. No significant differences were found in preoperative, discharge opioid prescribing or postoperative opioid consumption.ConclusionThe incidence of cannabis use was low, but positively associated with anxiety and higher preoperative NRS pain scores. Large, well-powered trials are needed to understand cannabis's impact on spine surgery outcomes.

Do Medical and Recreational Marijuana State Laws Impact Trends in Postoperative Opioid Prescriptions Among Patients Who Have Undergone TJA?

BACKGROUND

Total joint arthroplasty (TJA) is a painful procedure frequently managed with opioid medication, which puts patients at risk for chronic opioid use. Marijuana is a pain modifier and may be an effector of opioid-use reduction. Recently, many states have legalized the use of medical and recreational marijuana, and these legalization events have correlated with reductions in opioid prescriptions. This trend has not yet been demonstrated in the context of orthopaedic surgery, and there is limited evidence overall investigating the effect of marijuana on perioperative opioid use in TJA.

QUESTION/PURPOSES

(1) Is legalization of medical marijuana associated with changes in perioperative opioid use in patients who have undergone TJA? (2) Is legalization of recreational marijuana associated with changes in perioperative opioid use in patients who have undergone TJA? (3) Are these changes observed in any specific subpopulations of patients who have undergone TJA?

METHODS

The MarketScan Commercial and Medicare Supplemental Claims and Encounters Database was queried to assess the relative effect of marijuana legalization on perioperative opioid use in THA and TKA between May 1, 2017, and September 30, 2021, which was around and after the time that the opioid crisis was declared a public health emergency. We identified 129,132 inpatient TJA procedures (THA = 49,718, TKA = 79,414). The perioperative period was defined as 30 days before surgery and 90 days after surgery. We used the recreational and medical marijuana legalization effective dates in all 50 states and Washington, DC to conduct a difference-in-difference analysis to compare trends of outpatient opioid prescriptions among patients who underwent TJA in states with legalizations of medical or recreational marijuana with those among patients who underwent TJA in states without a change in marijuana legalization status.

RESULTS

We observed no impact of medical marijuana legalization on morphine milligram equivalent (MME)/day (difference-in-difference change 4.38 [95% confidence interval (CI) -4.49 to 13.22]). However, recreational marijuana legalization implementation was associated with an increase in MME/day (difference-in-difference change 8.83 [95% CI 0.22 to 17.43]). When we looked at specific patient groups, the implementations of medical and recreational marijuana laws were both associated with increases in perioperative opioid prescriptions in women, while recreational marijuana legalization was associated with increased opioid use in patients undergoing TKA and patients without prior use of opioids.

CONCLUSION

We did not identify differences with respect to medical marijuana legalization implementation. However, we found that recreational marijuana legalization was associated with an increase in perioperative MME/day for TJA. This is important because surgeons in states with the implementation of recreational marijuana law should be aware of the potential for increased marijuana availability for their patients and how this may impact their postoperative course, particularly with respect to pain and opioid utilization.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Impact of Preoperative Spinal Injection Timing on the Postoperative Complications of Lumbar Fusion

OBJECTIVE

To determine the impact of epidural spinal injections (ESIs) on postoperative surgical complications.

METHODS

This retrospective all-payer database analysis identified 202,181 adult patients undergoing one- to three-level transforaminal lumbar interbody fusion (TLIF) from 2010 to 2020. A 1:1 exact matching on comorbidities and demographics was performed, creating 2 cohorts: 1) patients who received an ESI within 90 days of surgery and 2) patients who did not receive an ESI. The primary outcome was surgical complication rates between groups at 30 days postoperatively. For the secondary outcome, patients were stratified based on injection time before surgery: 1-30, 31-45, 46-60, 61-75, and 76-90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. The P value was set to 0.05 for the primary analysis, and the Bonferroni correction was utilized for the secondary outcome.

RESULTS

Exact matching produced 12,491 pairs for analysis. Groups were well-matched on demographics, comorbidities, and fusion levels. The 30-day postoperative rates of surgical complications, hematomas, wound disruptions, or surgical site infections did not differ between groups (P > 0.05). The rate of cerebrospinal fluid (CSF) leak was increased in the ESI group (0.19% vs. 0.09%, P = 0.042). When temporally stratified, patients receiving an ESI within 30 days had significantly higher odds of CSF leak (odds ratio: 4.24, 95% confidence interval: 1.97-9.14).

CONCLUSIONS

Patients who receive an ESI within 30 days of transforaminal lumbar interbody fusion are at an increased risk for CSF leak. While the incidence of CSF leak remains small, it may be advisable to avoid ESIs at least 30 days before surgery for certain patients.

Effect of cannabis use history on postoperative opioid utilization in lumbar fusion patients: an American retrospective study

STUDY DESIGN

A retrospective cohort study.

PURPOSE

To examine the effect of cannabis use history on postoperative opioid utilization in patients undergoing one- to three-level lumbar fusion for degenerative spine disease.

OVERVIEW OF LITERATURE

Strategies to minimize dosing and chronic opioid use are needed for spine surgery given their widespread prescription for postsurgical pain management.

METHODS

In this database study, medical coding was used to identify patients who had undergone one- to three-level lumbar fusions between 2012 and 2021. Propensity score matching was used to create two equal cohorts with respect to cannabis use history. Opioid utilization rates (morphine milligram equivalents [MME]/day) and overuse rates at 6 months post-index procedure were assessed. All pvalues <0.05 were considered statistically significant.

RESULTS

Following examination of 153,500 patient records, 1,216 patients were matched into cannabis user and non-cannabis user cohorts. Cannabis users had lower rates of opioid utilization compared to non-cannabis users as early as 2 months after fusion (47.7% vs. 41.1%, p <0.05), a relationship which persisted at 6 months (46.2% vs. 37.7%, p <0.01). Additionally, cannabis users had lower rates of high-dose opioid utilization (≥100 MME per day) during the initial 14-30 days following surgery (6.91% vs. 3.79%, p <0.05).

CONCLUSIONS

Patients with a history of cannabis use were less likely to be using opioids as early as 2 months postoperatively and had lower rates of high-dose opioid utilization in the immediate postoperative period. Physicians operating on these patients should consider their cannabis use patterns to provide appropriate titration of pain medication over time.

Endogenous opiates and behavior: 2023

This paper is the forty-sixth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2023 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug and alcohol abuse (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Cannabis smoking and abdominal wall reconstruction outcomes: a propensity score-matched analysis

PURPOSE

Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR).

METHODS

Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared.

RESULTS

Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all).

CONCLUSION

Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers.

United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic

BACKGROUND

To determine if marijuana legalization was associated with reduced opioid mortality.

STUDY DESIGN

The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions.

METHODS

Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates.

RESULTS

The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01).

CONCLUSIONS

During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.