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Arciero E, Coury JR, Dionne A, Reyes J, Lombardi JM, Sardar ZM. Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients: A Narrative Review of Outcomes with Opioid and Adjuvant Pain Therapies. JBJS Rev 2023; 11:01874474-202312000-00006. [PMID: 38100612 DOI: 10.2106/jbjs.rvw.23.00156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
» Chronic preoperative opioid use negatively affects outcomes after spine surgery, with increased complications and reoperations, longer hospital stays, decreased return-to-work rates, worse patient-reported outcomes, and a higher risk of continued opioid use postoperatively.» The definition of chronic opioid use is not consistent across studies, and a more specific and consistent definition will aid in stratifying patients and understanding their risk of inferior outcomes.» Preoperative weaning periods and maximum dose thresholds are being established, which may increase the likelihood of achieving a meaningful improvement after surgery, although higher level evidence studies are needed.» Spinal cord stimulators and intrathecal drug delivery devices are increasingly used to manage chronic back pain and are equivalent or perhaps even superior to opioid treatment, although few studies exist examining how patients with these devices do after subsequent spine surgery.» Further investigation is needed to determine whether a true mechanistic explanation exists for spine-related analgesia related to spinal cord stimulators and intrathecal drug delivery devices.
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Affiliation(s)
- Emily Arciero
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
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Abul K, Yilgor C, Yucekul A, Alanay NA, Yavuz Y, Zulemyan T, Boissiere L, Bourghli A, Obeid I, Pizones J, Kleinstueck F, Perez-Grueso FJS, Pellise F, Alanay A. Long-term opioid medication profile of European adult spinal deformity patients: minimum five years follow-up study. Spine J 2023; 23:209-218. [PMID: 36336253 DOI: 10.1016/j.spinee.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT There remains significant variability in the use of postoperative opioids. On one end, it is proven that appropriate pain control is a critical aspect of patient management; on the other end, past few decades have been associated with major increases in opioid-related overdoses and addiction treatment. We hypothesized that several pre- and postoperative risk factors affecting long-term opioid use could be identified. PURPOSE Evaluation of factors associated with minimum 5-year postoperative opioid use following adult spinal deformity surgery. STUDY DESIGN/SETTING Prospectively followed study group database. PATIENT SAMPLE Adult spinal deformity patients who underwent elective spine surgery between 2009 and 2016 were included. OUTCOME MEASURES Opioid usage or otherwise at minimum 5 years follow-up. Use of nonopioid analgesics, weak and strong opioids METHODS: Retrospective analysis of patients undergoing elective spinal deformity surgery. A total of 37 factors comprising patient characteristics, radiographic measurements, operative details, preoperative and early postoperative opioid use, and mechanical complications and revisions were analyzed. Details on identified factors were provided. RESULTS A total of 265 patients (215F, 50M) from five sites were included. The mean follow-up duration was 68.4±11.7 (60-102) months. On average, 10.6±3.5 levels were fused. Preoperatively, 64 (24.2%) patients were using opioids. The rate of opioid users increased to 33.6% at 6 weeks and decreased to 21.5% at 6 months. During follow-up, there were patients who discontinued opioids, while others have started and/or restarted using opioids. As a result, 59 (22.3%) patients were still on opioids at the latest follow-up. Multivariate analyses showed that factors independently affecting opioid use at an average of 68 months postoperatively, in order of significance, were opioid use at sixth weeks, preoperative opioid use and opioid use at sixth months with the odds ratios of 2.88, 2.51, and 2.38 respectively. At these time points, factors such as age, number of comorbidities, tobacco use, the time of the last prior spine surgery and postoperative sagittal plane alignment affected opioid usage rates. CONCLUSIONS Opioid usage at 6 weeks was found to be more predictive of long-term opioid use compared to preoperative use. Patients should be well informed to have realistic expectations regarding opioid use when considering adult spinal deformity surgery.
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Affiliation(s)
- Kadir Abul
- Clinic of Orthopedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Olimpiyat Bulvarı Yolu, 34480 Basaksehir, Istanbul, Turkey
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Altug Yucekul
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Nezih Arin Alanay
- Lycée Français Notre Dame de Sion, Cumhuriyet Cad 127, 34373 Sisli, Istanbul, Turkey
| | - Yasemin Yavuz
- Department of Biostatistics, Ankara University School of Medicine, Adnan Saygun Cad., 06230 Altindag, Ankara, Turkey
| | - Tais Zulemyan
- Comprehensive Spine Center, Acibadem University Maslak Hospital, Buyukdere Cad 40, 34457 Sariyer, Istanbul, Turkey
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Al Mathar Ash Shamali, 11564 Riyadh, Saudi Arabia
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Frank Kleinstueck
- Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland
| | | | - Ferran Pellise
- Spine Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey.
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Elsamadicy AA, Sandhu MRS, Reeves BC, Sherman JJZ, Craft S, Williams M, Shin JH, Sciubba DM. Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity. Clin Neurol Neurosurg 2022; 224:107532. [PMID: 36436433 DOI: 10.1016/j.clineuro.2022.107532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity. METHODS A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD). RESULTS Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077). CONCLUSION Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States.
| | - Mani Ratnesh S Sandhu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Mica Williams
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, United States; Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Mo KC, Sachdev R, Zhang B, Vadhera A, Ren M, Andrade NS, Kebaish KM, Skolasky RL, Neuman BJ. Preoperative duration of pain is associated with chronic opioid use after adult spinal deformity surgery. Spine Deform 2022; 10:1393-1397. [PMID: 35750987 DOI: 10.1007/s43390-022-00531-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Few studies have explored the association between preoperative patient-reported measures and chronic opioid use following adult spinal deformity (ASD) surgery. We sought to explore the association between preoperative duration of pain, as well as other patient-reported factors, and chronic opioid use after ASD surgery. METHODS We retrospectively reviewed our U.S. academic tertiary care hospital's database of ASD patients. We included patients 18 years or older who underwent arthrodesis of four or more spinal levels from January 2008 to February 2018, with 2-year follow-up. The primary outcome variable was chronic opioid use, defined as opioid use at both 1 and 2 years postoperatively. We analyzed patient characteristics; duration of preoperative pain (<4 years or ≥4 years); radiculopathy; preoperative Scoliosis Research Society-22r (SRS-22r) score; Oswestry Disability Index (ODI) value; and surgical characteristics. RESULTS Of 119 patients who met the inclusion criteria, 93 (78%) were women, and mean ± standard deviation age was 59 ± 13. Sixty patients (50%) reported preoperative opioid use, and 35 (29%) reported chronic opioid use. Preoperative opioid use was associated with higher odds of chronic use (adjusted odds ratio, 5.9; 95% confidence interval 1.6-21), as was preoperative pain duration of ≥4 years (adjusted odds ratio, 3.3; 95% confidence interval 1.1-9.8). Patient characteristics, surgical variables, ODI value, and SRS-22r score were not significantly associated with chronic postoperative opioid use. CONCLUSION Preoperative opioid use and duration of pain of ≥4 years were associated with higher odds of chronic opioid use after ASD surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Rahul Sachdev
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Amar Vadhera
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Mark Ren
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Nicholas S Andrade
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA.
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Arndt KB, Schrøder HM, Troelsen A, Lindberg-Larsen M. Opioid and Analgesic Use Before and After Revision Knee Arthroplasty for the Indications "Pain Without Loosening" Versus "Aseptic Loosening" - A Danish Nationwide Study. J Arthroplasty 2022; 37:1618-1625.e3. [PMID: 35378235 DOI: 10.1016/j.arth.2022.03.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND It is uncertain if patients undergoing revision knee arthroplasty for "pain without loosening" are relieved of pain. This study aimed to compare pre- and postoperative analgesic consumption by patients undergoing revision for "pain without loosening" versus "aseptic loosening" and to determine predictors for postoperative long-term opioid use. METHODS A retrospective nationwide study of 1,037 revisions for "pain without loosening" and 2,317 revisions for "aseptic loosening" during 1997-2018 from the Danish Knee Arthroplasty Register was carried out. Analgesic use was defined by prescription reimbursement, and long-term opioid use by prescription reimbursement in 4 consecutive quarters. RESULTS In the preoperative year, 37% and 29% of patients revised for "pain without loosening" and "aseptic loosening" were opioid users compared to 32% and 30% in the postoperative year. Non-steroidal anti-inflammatory drug (NSAID) use was significantly lower postoperatively for both indications (35% versus 28% for "pain without loosening" and 33% versus 25% for "aseptic loosening"). Use of other analgesics was unchanged. Long-term opioid use increased postoperatively by 4% for patients with "pain without loosening" (P = .029) and by 3% for "aseptic loosening" (P = .003). New long-term opioid users (without preoperative long-term use) were 9% for "pain without loosening" and 8% for "aseptic loosening". Predictors of new long-term opioid use were other opioid-requiring diagnoses or procedures within the first postoperative year, Charlson Comorbidity Index (CCI) ≥3, and preoperative long-term NSAID use. CONCLUSION The consumption of opioids decreased slightly after knee arthroplasty revision for the indication "pain without loosening", but not for "aseptic loosening". The amount of new long-term opioid users increased for both indications.
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Affiliation(s)
- Kristine Bollerup Arndt
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik M Schrøder
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Orthopaedic Surgery, Naestved Hospital, Naestved, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Samuel AM, Morse KW, Pompeu YA, Vaishnav AS, Gang CH, Kim HJ, Qureshi SA. Preoperative opioids before adult spinal deformity surgery associated with increased reoperations and high rates of chronic postoperative opioid use at 3-year follow-up. Spine Deform 2022; 10:615-623. [PMID: 35066794 PMCID: PMC9063716 DOI: 10.1007/s43390-021-00450-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the association of preoperative opioid prescriptions with reoperations and postoperative opioid prescriptions after adult spina deformity (ASD) surgery. With the current opioid crisis, patients undergoing surgery for ASD are at particular risk for opioid-related complications due to significant preoperative disability and surgical morbidity. No previous studies consider preoperative opioids in this population. METHODS A retrospective cohort study of patients undergoing posterior spinal fusion (7 or more levels) for ASD was performed. All patients had at least 3 years of postoperative follow-up 3 years postoperatively. Prescriptions for 4 different opioid medications (hydromorphone, oxycodone, hydrocodone, and tramadol) were identified within 3 months preoperatively and up to 3 years postoperatively. Multivariate regression was utilized to determine the association of preoperative use with reoperations and with postoperative opioid use, controlling for both patient and surgery-related confounding factors. RESULTS A total of 743 patients were identified and 59.6% (443) had opioid prescriptions within 3 months preoperatively. Postoperative opioid prescriptions were identified in 66.9% of patients at 12 months postoperatively, and in 54.8% at 36 months postoperatively. The 3-year reoperation rate was 11.0% in patients without preoperative prescriptions, 16.0% in patients with preoperative any opioid prescriptions (P = 0.07), and 34.8% in patients with preoperative hydromorphone prescriptions (P < 0.01). In multivariate analysis, preoperative opioid prescriptions were associated with increased reoperations (odds ratio [OR]: 1.62, P = 0.04), and chronic postoperative opioid use (OR: 4.40, P < 0.01). Preoperative hydromorphone prescriptions had the strongest association with both reoperations (OR: 4.96; P < 0.01) and chronic use (OR: 5.19: P = 0.03). CONCLUSION In the ASD population, preoperative opioids are associated with both reoperations and chronic opioid use, with hydromorphone having the strongest association. Further investigation of the benefits of preoperative weaning programs is warranted.
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Affiliation(s)
- Andre M Samuel
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kyle W Morse
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Yuri A Pompeu
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Avani S Vaishnav
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Catherine Himo Gang
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Han Jo Kim
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
- Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, USA.
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Line B, Bess S, Gum JL, Hostin R, Kebaish K, Ames C, Burton D, Mundis G, Eastlack R, Gupta M, Klineberg E, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Opioid use prior to surgery is associated with worse preoperative and postoperative patient reported quality of life and decreased surgical cost effectiveness for symptomatic adult spine deformity; A matched cohort analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 9:100096. [PMID: 35141660 PMCID: PMC8819939 DOI: 10.1016/j.xnsj.2021.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022]
Abstract
Multi-center, matched analysis of surgically treated SASD patients demonstrated preoperative opioid users reported greater pain, worse physical function, worse self-image preoperatively and at minimum 2-years postoperative and reported lower treatment satisfaction compared to opioid nonusers (p<0.05). Preoperative opioid users had longer ICU (40.8 vs 21.4 hours) and hospital stay (10.5 vs 8.0 days) than nonusers following SASD surgery, respectively (p<0.05). Preoperative opioid users demonstrated worse one and two-year postoperative cost/QALY following SASD surgery than nonusers (p<0.05). Preoperative opioid users reported greater opioid use at two-years following SASD surgery than preoperative nonusers (41.2% vs. 12.9%; odds ratio=4.5; 95% confidence interval=2.7-8.3; p<0.05).
Background Preoperative opioid is associated with poor postoperative outcomes for several surgical specialties, including neurosurgical, orthopedic, and general surgery. Patients with symptomatic adult spinal deformity (SASD) are among the highest patient populations reporting opioid use prior to surgery. Surgery for SASD has been demonstrated to improve patient reported quality of life, however, little medical economic data exists evaluating impact of preoperative opioid use upon surgical cost-effectiveness for SASD. The purpose of this study was to evaluate the impact that preoperative opioid use has upon SASD surgery including duration of intensive care unit (ICU) and hospital stay, postoperative complications, patient reported outcome measures (PROMs), and surgical cost-effectiveness using a propensity score matched analysis model. Methods Surgically treated SASD patients enrolled into a prospective multi-center SASD study were assessed for preoperative opioid use, and divided into two cohorts; preoperative opioid users (OPIOID) and preoperative opioid non-users (NON). Propensity score matching (PSM) was used to control for patient age, medical comorbidities, spine deformity type and magnitude, and surgical procedures for OPIOID vs NON. Preoperative and minimum 2-year postoperative PROMs, duration of ICU and hospital stay, postoperative complications, and opioid use at one and two years postoperative were compared for OPIOID vs NON. Preoperative, one year, and minimum two-year postoperative SF6D values were calculated, and one- and two-year postoperative QALYs were calculated using SF6D change from baseline. Hospital costs at the time of index surgery were calculated and cost/QALY compared at one and two years postop for OPIOID vs NON. Results 261/357 patients (mean follow-up 3.3 years) eligible for study were evaluated. Following the PSM control, OPIOID (n=97) had similar preoperative demographics, smoking and depression history, spine deformity magnitude, and surgery performed as NON (n=164; p>0.05). Preoperatively, OPIOID reported greater NRS back pain (7.7 vs 6.7) and leg pain (5.2 vs 3.9), worse ODI (50.8 vs 36.9), worse SF-36 PCS (28.8 vs 35.6), and worse SRS-22r self-image (2.3 vs 2.5) than NON, respectively (p<0.05). OPIOID had longer ICU (41.2 vs 21.4 hours) and hospital stay (10.6 vs 8.0 days) than NON, respectively (p<0.05). At last postoperative follow up, OPIOID reported greater NRS back pain (4.1 vs 2.3) and leg pain (2.9 vs 1.7), worse ODI (32.4 vs 19.4), worse SF-36 PCS (37.4 vs 47.0), worse SRS-22r self-image (3.5 vs 4.0), and lower SRS-22r treatment satisfaction score (2.5 vs 4.5) than NON, respectively (p<0.05). At last follow-up postoperative Cost/QALY was higher for OPIOID ($44,558.31) vs NON ($34,304.36; p<0.05). At last follow up OPIOID reported greater postoperative opioid usage than NON [41.2% vs. 12.9%, respectively; odds ratio =4.7 (95% CI=2.6-8.7; p<0.05)]. Conclusions Prospective, multi-center, matched analysis demonstrated SASD patients using opioids prior to SASD surgery reported worse preoperative and postoperative quality of life, had longer ICU and hospital stay, had less cost effectiveness of SASD surgery. Preoperative opioid users also reported lower treatment satisfaction, and reported greater postoperative opioid use than non-users. These data should be used to council patients on the negative impact preoperative opioid use can have on SASD surgery.
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Mohan S, Lynch CP, Cha EDK, Jacob KC, Patel MR, Geoghegan CE, Prabhu MC, Vanjani NN, Pawlowski H, Singh K. Baseline Risk Factors for Prolonged Opioid Use Following Spine Surgery: Systematic Review and Meta-Analysis. World Neurosurg 2021; 159:179-188.e2. [PMID: 34971835 DOI: 10.1016/j.wneu.2021.12.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To conduct a comprehensive systematic review and meta-analysis of current retrospective cohort studies to identify significant preoperative risk factors for prolonged postoperative opioid use following spine surgery. METHODS Studies were identified according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) through a search of the PubMed, Google Scholar, Scopus, Cochrane databases. Unique articles were screened by two independent reviewers. Primary research articles reporting odds ratios (OR) of risk factors for prolonged opioid use as following spine surgery were included. Prolonged opioid use was defined as continued use ≥ 3 months following surgery, and study quality was evaluated using the Newcastle-Ottawa Scale (NOS). Random effects meta-analysis was performed to calculate pooled OR and confidence intervals. RESULTS 648 studies were returned upon initial search. Following duplicate removal, 492 titles and abstracts were screened. After full-text review of 68 studies, 19 final studies including 168,961 patients were eligible for meta-analysis. NOS scores ranged from 6-9. Seventeen risk factors for long-term opioid use were assessed by meta-analysis. Preoperative opioid use, depression, depression and/or anxiety, drug abuse or dependency, female gender, fibromyalgia, lower back pain, tobacco use, and chronic pulmonary disease were found to be statistically significant risk factors for prolonged opioid use. CONCLUSION These results suggest that several patient-level factors may play a role in the tendency to persistently utilize opioids following spine surgery. By preoperatively identifying these characteristics, clinicians may be better able to identify patients that are at-risk and employ methods to mitigate potential long-term opioid use.
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Affiliation(s)
- Shruthi Mohan
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Conor P Lynch
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Kevin C Jacob
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Madhav R Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Michael C Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Nisheka N Vanjani
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Hanna Pawlowski
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612.
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Bastawrous AL, Brockhaus KK, Chang MI, Milky G, Shih IF, Li Y, Cleary RK. A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use. Surg Endosc 2021; 36:701-710. [PMID: 33569727 PMCID: PMC8741658 DOI: 10.1007/s00464-021-08338-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
Background Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. Methods Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90–180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. Results Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of ‘any opioids’ (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90–180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. Conclusion Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08338-9.
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Affiliation(s)
| | - Kara K Brockhaus
- Inpatient Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Melissa I Chang
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA
| | - Gediwon Milky
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA.,Department of Pharmacy Practice, Purdue University, West Lafayette, IN, USA
| | - I-Fan Shih
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Yanli Li
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Robert K Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA.
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Samuel AM, Lovecchio FC, Premkumar A, Louie PK, Vaishnav AS, Iyer S, McAnany SJ, Albert TJ, Gang CH, Qureshi SA. Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery. Spine (Phila Pa 1976) 2021; 46:E203-E212. [PMID: 33079910 DOI: 10.1097/brs.0000000000003751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to identify an association between preoperative opioid use and reoperations rates. SUMMARY OF BACKGROUND DATA Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates. METHODS A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years. RESULTS A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05). CONCLUSION Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Steven J McAnany
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Todd J Albert
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
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