The authors of a recent study found that spine surgery patients who were on opioids prior to their surgery were most likely to use opioids for a year or longer after surgery.1
About 42% of preoperative opioid users were filling opioid prescriptions at one year postsurgery. This compares with 9% of opioid-naïve patients presurgery still taking opioids 12 months after their spine surgery. The authors used a patient sample of more than 17,000 people who underwent anterior cervical fusion or posterior cervical fusion between 2007 and 2015.
“Anyone with a spine fusion was included in the cohort,” says Andrew J. Pugely, MD, a co-author of the report. “Some patient comorbidities that could be associated with preop use of opioids, and continued use afterward, were a history of drug dependence, alcohol abuse, depression, fibromyalgia, and anxiety.”
The research findings suggest that surgeons should amend their prescribing practices. Surgeons should reduce the number of opioid pills prescribed. “Instead of giving everyone 80 pills of Percocet, tailor the subscription to the individual surgery,” Pugely advises.
A simple neck procedure would require fewer days on opioid medication than a spinal surgery. Some patients have medical conditions that might require more weeks on the painkiller after surgery. The next step is to require patients to wean off opioids prior to surgery.
“The big thing I do is use surgery itself as a time point to have patients wean off narcotics,” Pugely says. “I use the surgery as a reward for them, the same as with having them quit cigarettes.” Patients who are on opioids or who are smokers prior to surgery experience worse postoperative outcomes. Surgeons can reasonably ask patients to quit before the operation. Of course, there might be individual exceptions, such as the man who had a fused spine, broken rods, and was in horrific pain, Pugely says. “It’s not realistic for him to wean off opioids beforehand.”
Just as smokers might need a smoking cessation program, opioid users might need pain management help to quit. Pugely refers patients on opioids presurgery to a pain clinic that employs a pain psychologist with experience helping people handle pain as they wean off opioids.
“We have a woman who is a pharmacist and can look through patients’ medical records, discussing studies and outcomes, and come up with a weaning plan,” Pugely says. “I go much further than just telling people to go off opioids. I send them to people to help them develop coping mechanisms to get off the drug.”
Additionally, surgeons should examine opioid risk factors. Surgery centers can use an app that analyzes patients’ demographics, health, and other factors, or surgeons can go by their own experience.
For instance, Pugely has found that patients who are obese, present with chronic illnesses, and have a history of drug dependency and psychosocial issues are more likely to struggle ending their opioid habit. For some of these patients, it might be appropriate to find an alternative and nonaddictive pain medication. Surgeons should help patients develop realistic expectations for their pain after surgery, Pugely offers.
“Lay out expectations up front and pair it with educational material,” he suggests. “Some spine surgeries are not going to cure back pain, but they will help.”
- Pugely AJ, Bedard NA, Kalakoti P, et al. Opioid use following cervical spine surgery: Trends and factors associated with long-term use. Spine J 2018 Apr 10. pii: S1529-9430(18)30129-3. doi: 10.1016/j.spinee.2018.03.018. [Epub ahead of print].