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MICHAEL VO
Sidney Kimmel Medical College
SUMMARY POINTS
There are a multitude of preoperative risk factors that are predictive of opioid
dependence.
Opioid use disorder is a financial and societal issue.
There is an increasing need for conscientious prescribing and guidelines for opioid
prescription.
Long term opioid use is correlated with poor clinical outcomes.
Background
Opioid use and opioid-related mortality have become a crisis in America, leading to
devastating financial, societal, and medical consequences. Historically, the opioid crisis started with Purdue Pharma pushing their new drug OxyContin. Purdue claimed that OxyContin was non-addictive in 1995, which was later proved to be false (1). Physicians were taught that pain was the fifth vital sign and OxyContin was a safe drug that could be freely prescribed.
Unknowingly, patients would become addicted, and the opioid epidemic began. Opioid
prescriptions quadrupled from 1999 to 2010 resulting in many cases of opioid overdoses. In 2015, roughly half of opioid-related mortality was linked to a prescription. (2). In 2017, it was estimated that the cost of opioid use disorder (OUD) exceeded $1.02 trillion (3).
Opioids are still prescribed to treat pain, most notably in the setting of spine surgeries (4). There are a multitude of risk factors that predispose individuals to postoperative OUD. For example, preoperative opioid use, depression, anxiety, drug abuse, female gender, fibromyalgia, lower back pain, tobacco use, and chronic pulmonary disease were statistically significant risk factors. (2). Preoperative opioid use is overwhelmingly associated with negative surgical and functional outcomes, including postoperative opioid use, prolonged hospitalization duration, increased healthcare costs, risk of surgical revision, and several other negative outcomes (5). Moreover, socioeconomic status is a significant predictor of surgical outcomes in spine surgery despite controlling for preoperative opioid and surgical intervention. Complications that have been associated with low socioeconomic status patients are OUD, longer length of stay (LOS),
and increased hospital emergency room revisits within 90 days postoperative spine surgery (6).
Due to OUD being a multifactorial issue, there seems to be no single effective treatment to displace opioid use or mitigate long-term opioid dependence.
Analysis
The opioid epidemic has been challenging to contain in the medical field. In some
respects, medicine may contribute to the opioid crisis through opioid prescription postoperatively in spine surgery. In several cases, patients may become addicted to opioids after spine surgery despite having never used opioids before. Unintended societal consequences of the opioid crisis have led to mental health disorders, rampant homelessness, and hazardous littered needles in local communities. It is reported that there are higher rates of bipolar disorder and schizophrenia among individuals with OUD experiencing homelessness compared to opioid users without homelessness (7). Opioids are the most prescribed drugs to treat postoperative pain. However, OUD has been associated with poor quality health metrics such as extended hospital LOS and
non-routine discharge (NRD). LOS and NRD have been correlated with higher healthcare
expenditure, clinical complications, and inferior long-term outcomes in spine surgery patients (8). Other risk factors that should be considered are chronic pain, or the history of neuromodulatory medications associated with post-operative opioid dependency. As a result, studies suggest spine surgeons consider several preoperative variables when determining postoperative opioid prescription (9).
The dilemma arises, that although opioids can be used to adequately treat post-operative pain, it has the unintended consequence of inducing tolerance and addiction. However, there are studies that are addressing this dilemma where conscientious prescribing can mitigate the effects of OUD. In postoperative spine surgeries, results suggest that opioid prescriptions should be shorter in duration to notice statistically significant 1-year patient-reported outcomes, and that opioid prescriptions with lower dosages leads to lower opioid dependence and increased cessation (10). Interestingly, patients undergoing lumbar spine surgery are twice as likely to experience OUD than cervical spine surgery (3). Additionally, studies suggest that postoperative patients with OUD after surgery were more dependent on health care resources than their counterparts who were no longer opioid dependent within 6 months. Health care resources include radiographs, computed tomography scans, magnetic resonance imaging, and emergency department visits. In addition, patients with OUD experienced more pain management referrals and received more epidural and spinal injections. One study suggests that there might be a threshold of postoperative opioid prescription with 225 morphine milligram equivalents (MME) or less correlated with increased patient satisfaction, physical function, and opioid cessation compared to their counterpart who had opioid prescription that were greater than 225 MME (11). Based on allocation of resources, studies suggest the patients with OUD result in significant healthcare burden yet not necessarily better outcomes or patient satisfaction (3,11). The opioid epidemic is an urgent concern that is threatening American public health and there is a growing need for spine surgeons to apply conscientious postoperative opioid prescribing.
Discussion
The opioid epidemic is a complex issue that warrants more media, research, and
governmental intervention to resolve. In addition to its consequences on medical outcomes, the epidemic has other harmful effects including homelessness.. Even if patients are treated medically and manage to stop using opioids, there could be relapse or a shift into different harmful drugs due to non-medical causes. At best, medicine can minimize and ameliorate whatever damage it can, and the rest comes down to the individual to combat their OUD. Lately, there have been some interesting findings in perioperative opioid use and spine surgery. Several examples include the discrepancy between postoperative OUD in cervical versus lumbar surgery (3), a threshold of 225 MME that has been associated with patient outcomes (11), with dosing and duration of opioid prescriptions effecting cessation (10). Overall, there needs to be more research in how healthcare can effectively treat OUD or find alternative treatments to displace opioid prescriptions.
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