Opioid Utilization Following Lumbar Arthrodesis

Trends and Factors Associated With Long-Term Use

Piyush Kalakoti, MD; Nathan R. Hendrickson, MD; Nicholas A. Bedard, MD; Andrew J. Pugely, MD

Disclosures

Spine. 2018;43(17):1208-1216. 

In This Article

Abstract and Introduction

Abstract

Study Design: A retrospective, observational cohort study.

Objective: In patients undergoing lumbar spine arthrodesis, we sought to establish perioperative trends in chronic versus naive opioid users (OUs) and identify modifiable risk factors associated with prolonged consumption.

Summary of Background Data: The morbidity associated with excessive opioid use for chronic conditions continues to climb and has been identified as a national epidemic. Limiting excessive perioperative opioid use after procedures such as lumbar fusion remains a national health strategy.

Methods: A national commercial claims dataset (2007–2015) was queried for all patients undergoing anterior lumbar interbody fusion (ALIF) and/or lumbar [posterior/transforaminal lumbar interbody fusion (P/TLIF) or posterolateral fusion (PLF)] spinal fusion procedures. Patients were labeled as either an OU (prescription within 3 months pre-surgery) or opioid naive (ON, no prescription). Rates of opioid use were evaluated preoperatively for OU, and longitudinally tracked up to 1-year postoperatively for both OU and ON. Multivariable regression techniques investigated factors associated with opioid use at 1-year following surgery. In addition, a clinical calculator (app) was created to predict 1-year narcotic use.

Results: Overall, 26,553 patients (OU: 58.3%) underwent lumbar surgery (ALIF: 8.5%; P/TLIF: 43.8%; PLF: 41.5%; ALIF+PLF: 6.2%). At 1-month postop, 60.2% ON and 82.9% OUs had a filled opioid prescription. At 3 months, prescription rates declined significantly to 13.9% in ON versus 53.8% in OUs, while plateauing at 6 to 12-month postoperative period (ON: 8.4–9.6%; OU: 42.1–45.3%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs than in ON (42.4% vs. 8.6%; P < 0.001). Preoperative opioid use was the strongest driver of 1-year narcotic use following ALIF [odds ratio (OR): 7.86; P < 0.001], P/TLIFs (OR: 4.62; P < 0.001), or PLF (OR: 7.18; P < 0.001).

Conclusion: Approximately one-third patients chronically use opioids before lumbar arthrodesis and nearly half of the pre-op OUs will continue to use at 1 year. Our findings serve as a baseline in identifying patients at risk for chronic use and alter surgeons to work toward discontinuation of opioids before lumbar spinal surgery.

Introduction

The United States (US) per-capita opioid consumption is highest compared with any other nation. Identified as a public health emergency, changes to national and local policies to curb the opioid epidemic are underway.[1,2] Between 1999 and 2008, opioid-related mortality exceeded that from unintentional use of cocaine and heroin combined.[3] National estimates suggest over 11 million misused prescription opioids in 2016, and the opioid-related deaths quadrupled since 1999.[4,5] Cumulative economic burden resulting from opioid abuse including health care costs, and those related to criminal justice and lost-work hours stood at $55.7 billion in 2007 alone.[6]

Although opioid therapy remains an effective treatment for chronic pain, the appropriateness for acute and chronic noncancer pain is increasingly controversial.[7,8] A recent randomized trial in patients presenting to the emergency department (ED) with acute extremity pain noted no difference in pain alleviation between those receiving a single dose of Ibuprofen and acetaminophen versus three different opioid and acetaminophen combinations.[7] In the past, campaigns such as "Pain as the 5th Vital Sign" have contributed to many patients being prescribed opioids for common musculoskeletal symptoms before formal orthopedic consultation.[9,10]

Furthermore, orthopedics as a specialty ranks third in the volume of opioid prescriptions.[9] Given the concerning rise and the associated deleterious effects due to long-term opioids use, the American Academy of Orthopedic Surgeons (AAOS) recently released practice recommendations for regulating inappropriate opiate use.[11] In the backdrop of these initiatives, identification of risk factors associated with opioids utilization is critical to direct strategies to mitigate abuse. Recent studies have identified presurgical opioid use (3 months before surgery) as a significant driver for prolonged postsurgical consumption and worse clinical outcomes following major orthopedic surgeries including joint replacement and trauma surgery.[12–18]

In patients with spinal conditions, limited data exist on the outcomes and risk factors associated with chronic consumption. Single institutional studies demonstrating the association of chronic narcotic use with poor functional outcomes following cervical or lumbar spine surgery[19–21] are limited by inherent selection bias. In the context of national concern, epidemiological trends and risk factors of opioids use in spine patients may guide practice surveillance, preventive strategies, and patient counseling and welfare, thereby warranting a comprehensive investigation using a population-based cohort.

Lumbar arthrodesis is a routinely performed procedure for discogenic low back pain, degenerative pathologies, deformities, traumatic fractures or dislocations, and spondylolisthesis. Opioid utilization rates and factors associated with long-term use in these patients can aid in presurgical risk-stratification and formulation of weaning strategies. Therefore, the current study seeks to investigate trends in perioperative opioid utilization in patients undergoing lumbar arthrodesis and assess risk factors associated with prolonged postoperative (1 year following surgery) opioids consumption using an administrative claims database. We hypothesize that insights from a national cohort containing data from diverse clinical practice settings could be generalized to US population to study perioperative opioid utilization trends and develop practice recommendations.

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