Nancy A. Melville

May 10, 2017

LOS ANGELES — The preoperative use of opioid analgesics is associated with worse clinical postoperative outcomes at 12-month follow-up of lumbar fusion surgery for degenerative lumbar conditions, new research shows.

"The results suggest the use of opioid medication is a potentially modifiable factor that could be controlled to maximize clinical outcomes," said first author, Alan T. Villavicencio, MD, from Boulder Neurosurgical Associates, Colorado.

He presented the findings here at the American Association of Neurological Surgeons (AANS) 2017 Annual Meeting.

While a high number of patients with low back pain can be expected to have been prescribed opioid medications for pain, research on the relationship between use of the medications before surgery and lumbar fusion surgery outcomes is lacking.

For the prospective study, Dr Villavicencio and colleagues enrolled 93 patients receiving one- to two-level transforaminal lumbar interbody fusion surgeries for degenerative low back conditions.

Of the patients, who had an average age of 59 years, 60 (64.5%) had preoperatively used prescribed opioids, with an average preoperative dose of 64.4 mg (range, 10 to 270 mg).

Demographic and surgical characteristics did not significantly differ between patients who did and didn't have preoperative opioid use, with the exception of average symptom duration, which was longer in nonusers (113 months vs 56 months; P = .008).

In the opioid use group, preoperative disability was higher than in nonusers (average Oswestry Disability Index, 40.3 vs 33.7; P = .04) and measures of mental health were lower (Short Form-36 [SF-36] Mental Component Summary [MCS], 42.7 vs 49.2; P = .01).

However, other clinical scores of back and leg pain visual analogue scale and SF-36 Physical Component Summary (PCS) were not statistically different.

The results in postoperative clinical outcomes at a 12-month follow-up showed that patients with preoperative opioid use had significantly higher low back pain in visual analogue scale measures (P = .01), greater disability (P = .01), and lower health-related SF-36 PCS scores (P = .03).

Mental health-related SF-36 MCS scores remained lower (P = .03), likely because of the significantly lower baseline scores, the authors noted.

"In general, we found that the patients all got better whether they used opioids or not, but there was a statistically significant difference in the amount of improvement based on whether they used opioids preoperatively or not," Dr Villavicencio said.

"This is the first study that has demonstrated this association in a homogeneous population of patients, which should be studied further to confirm these conclusions," he said.

The study  was also published in the AANS's Journal of Neurosurgery in February.

The findings are consistent with previous research on preoperative opioid use and surgical outcomes, including a 2014 study  of patients undergoing spine surgery. That study concluded that increased preoperative opioid consumption, in addition to preoperative Modified Somatic Perception Questionnaire score and Zung Depression Scale scores, predicted worse patient-reported outcomes.

"This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively," the authors said.

Dr Villavicencio said he does typically try to take patients off of opioids before surgery.

"It's clear that it's better to try to get patients off of pain narcotics before surgery," he said. "When patients come in and they're on a high dose of OxyContin, for instance, you know it's probably going to be a bad outcome, so I always try to wean off or at least get them on much lower doses of narcotics."

Causes of the worse outcomes are likely multifactorial, Dr Villavicencio said, noting other research that has pointed to a potential role of opioid-induced hyperalgesia.

The findings underscore that "healthcare providers should use a multimodal approach or alternative means of pain control when possible to reduce patients' consumption of opioids," Dr Villavicencio said.

Jason M. Schwalb, MD, surgical director of the Movement Disorder & Comprehensive Epilepsy Centers at Henry Ford Medical Group, West Bloomfield, Michigan, said the issue of preoperative opioid use is highly relevant in the management of spine surgery patients.
"We are very interested in this," he told Medscape Medical News. "The association between preoperative opioids and worsened outcomes is becoming more established, [and] we know that patients on chronic opioids have increased length of stay and more complications."

"Not surprisingly, since they have no open opioid receptors, dealing with postop pain is more difficult," he noted.

Efforts to better understand the relationship — and effects of trying to take patients off the drugs preoperatively — are ongoing, Dr Schwalb added.

"Many groups, including ours and the University of Michigan, are trying to determine if preoperative opioid weans make a difference in short- and long-term outcome."

"The counterargument is that patients who are on preoperative opioids have worse pain and disease and that their opioid use is a sign of that," he said. "It could definitely be a correlation and not a cause."

The authors disclosed research support from Globus, Grifols, Integra, LifeScience, Pfizer, and Leading Edge Implants. Dr Schwalb has disclosed no relevant financial relationships.

American Association of Neurological Surgeons (AANS) 2017 Annual Meeting. Abstract 822. Presented April 24, 2017.

J Neurosurg. 2017 ;26:144-149. Abstract  

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