Perioperative Pain Control in the Era of Opioid Misuse
Pain is simultaneously one of life’s blessings and curses. At its core, pain is benevolent – it can protect us from harm and increase awareness of our surroundings. In times of physical endurance, pain even makes us feel “alive.” But day after day, unremitting, pain is devastating. Chronic pain robs individuals of mobility and livelihood, and in its extreme, one’s will to live. Many neurosurgical patients report such experiences, driving them towards surgery as an attempt to alleviate their suffering. But with surgery for chronic pain comes long-term pain management in the perioperative period, often in the form of opioid medications.
The explosion of both recreational and pharmaceutical opioid misuse in the United States has not spared the neurosurgical population, as clearly and dismayingly portrayed by several recent single-institution and national database studies. Most neurosurgical research surrounding opioid use has been performed in the spinal surgery arena, given that many spinal surgery patients suffer from chronic and debilitating pain. Opioid dependence among spinal surgery patients is growing, with an estimated prevalence of 8 in 1000 patients >50 years old.1 Some studies cite higher prevalence, with up to 10% of patients misusing opioids after spinal surgery.2 A significantly high percentage of spinal surgery patients, up to 14.7%, may use opioids without a prescription; this far exceeds the 2% average among all adults.3 Psychiatric comorbidities likely contribute to these patterns of opioid use in spinal surgery – in some reports, over 75% of patients with depression undergoing spinal fusion received chronic post-operative opioid therapy, compared to 50% of patients without depression.3
Alleviating pain after surgery is both an ethical obligation and a critical step towards postoperative recovery. But for patients with pre-existing opioid misuse disorders, adequate pain control is often difficult, if not impossible, without high-dose narcotic medications. The very prescriptions given by physicians as a wholesome attempt to improve the patient’s well-being may in fact be significantly harming their perioperative course. Simply prescribing post-operative opioids may be a risk factor for chronic opioid use.3 Several retrospective studies demonstrate links between opioid dependence and poorer outcomes of spinal surgery.1,4,5 These patients often have prolonged length of stay and increased complication rates, which imparts an exceptional socioeconomic burden to an already stressed cohort.
Exploring socioeconomic trends for neurosurgical patients who develop opioid dependence is vital in understanding the perioperative course for this at-risk population. Strikingly, opioid dependence imposes a significant financial burden on patients and the healthcare system, often greater than $10,000 of additional costs per operative course compared to patients without opioid dependence. Regional differences in opioid prescribing practices and rates of opioid dependence are key, with the South and Midwest potentially prescribing more opioids for spinal surgery.6 This correlates with the well-known higher incidence of opioid misuse and recreational narcotic abuse in these regions. It is no surprise that regions most at-risk of opioid misuse in general have a disproportionately high rate of opioid dependence among the neurosurgical patient population.
The literature is abundant with studies using national databases to characterize overall trends in opioid dependence in neurosurgical patients. Although such studies are extremely beneficial in highlighting areas for future study, it may be time to shift emphasis towards multi-institutional and micro-regional studies to better elucidate “hot-beds” of opioid dependence for this population. Such studies could permit correlation with the overall socioeconomic status in these smaller regions. Social determinants and health disparities are likely not identical among patients between regions, or even within the same region. Increased emphasis on micro-scale data could permit surgeons to better identify and address socioeconomic risk factors facing their patient population. Additionally, broadening the investigation of opioid dependence to other neurosurgical populations, such as traumatic brain injury or central nervous system malignancy, may identify key differences and correlations across the neurosurgical spectrum.
Determining what doesn’t work in perioperative pain control for spinal surgery patients is multi-faceted and multi-disciplinary. Can we appropriately achieve perioperative analgesia, especially among patients at high risk for opioid misuse, without significantly increasing complications and worsening outcomes? How should we best counsel this cohort of patients? Several recent studies have discussed incorporation of enhanced recovery after surgery (ERAS) techniques as an effort to explore solutions to these questions. Some evidence is emerging to support future roles of ERAS in treating postoperative pain among patients with a pre-existing opioid misuse disorder.7 Research for this vulnerable population is growing, and rightfully so. As recent literature suggests, the field is rapidly identifying problems and complications these patients face on a national scale. With increased emphasis on ERAS techniques, now may be the best time to identify what does work.
1. Tank, A., Hobbs, J., Ramos, E., & Rubin, D. S. (2018). Opioid Dependence and Prolonged Length of Stay in Lumbar Fusion. Spine, 43(24), 1739-1745.
2. Sharma, M., Ugiliweneza, B., Aljuboori, Z., & Boakye, M. (2018). Health care utilization and overall costs based on opioid dependence in patients undergoing surgery for degenerative spondylolisthesis. Neurosurgical Focus, 44(5).
3. Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic Opioid Use After Surgery. Anesthesia & Analgesia, 125(5), 1733-1740.
4. Jain, N., Phillips, F. M., Weaver, T., & Khan, S. N. (2018). Preoperative Chronic Opioid Therapy. Spine, 43(19), 1331-1338.
5. Walid, M., Hyer, L., Ajjan, M., Barth, A. C., & Robinson, J. S. (2007). Prevalence of opioid dependence in spine surgery patients and correlation with length of stay. Journal of Opioid Management, 3(3), 127-128.
6. Adogwa, O., Davison, M. A., Vuong, V. D., Desai, S. A., Lilly, D. T., Moreno, J., . . . Bagley, C. (2019). Regional Variation in Opioid Use After Lumbar Spine Surgery. World Neurosurgery, 121.
7. Martini ML, Nistal DA, Deutsch BC, Caridi JM. Characterizing the risk and outcome profiles of lumbar fusion procedures in patients with opioid use disorders: a step toward improving enhanced recovery protocols for a unique patient population. Neurosurgical Focus. 2019;46(4):E12
Kranzler Chicago Review Course in Neurosurgery
Jan. 24-31, 2020; Chicago
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Jan. 31-Feb. 3, 2020; Snowbird, Utah
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Feb. 14-16, 2020; Las Vegas
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Feb. 21-23, 2020; Lake Buena Vista, Fla.
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