The national opioid crisis the United States of America is currently facing has caused a Public Health Emergency and the field of spine surgery is working to fight back.
With an estimated two-million Americans being dependent on or abusing prescription pain medications, and a reported 63,600 drug-related overdoses resulting in death involving prescription or illegal opioids, it is becoming increasingly clear that a holistic and multidisciplinary approach is needed to impact the public health issue.
Opioids prescribed after spine surgery are the same medications commonly involved in prescription opioid related deaths (CDC, 2018); and when comparing prescription duration patterns in orthopedic surgery nationally, spine surgeons are amongst the highest (Boylan, Suchman, Slover, Bosco, 2018). Opioid related deaths in Kentucky in 2016 nearly double the national average and trends, demonstrating the problem is getting worse (NIH, 2016).
According to NIH, the national opioid prescription average was 70 prescriptions per 100 people; however, in Kentucky, the rate is alarmingly higher at 97 opioid prescriptions written per 100 people (NIH, 2015). The Norton Leatherman Spine Surgery team is making efforts to retaliate against the epidemic by conducting research to better understand drivers of opioid consumption and altering practice patterns accordingly.
It should be a universal responsibility of medical practitioners, especially those leading the nation’s spine research, in turning our attention toward decreasing opioids after spinal surgery. In 2017, Norton Leatherman Spine Center sought to evaluate how surgery invasiveness and preoperative opioid consumption effected opioid consumption after spinal surgery. Morphine Milligram Equivalents (MME) in patients with similar baseline characteristics undergoing 1-2 level minimally invasive lumbar fusion (MIDLIF) and open traditional lumbar fusion (TLIF) were compared, in the immediate in-hospital postoperative period.
We were surprised to find that surgery invasiveness alone was not associated with increased opioid consumption while in the hospital after surgery, and neither did being on opioids preoperatively. The research team felt that this outcome could have been related to the lack of consistent prescribing patterns immediately post spinal fusion surgery.
After seeing the study results, we created a prescriber driven protocol focused on providing pain medications to patients that were more specific to their individual needs after spinal surgery. We therefore developed a Standard Escalation Pain Protocol (SEPP) in efforts to more purposefully prescribe opioids postoperatively. After a year of protocol utilization, we evaluated if implementation of prescriber-driven SEPP changed the amount of opioids patients consumed in the acute in-hospital postoperative period and the results are in!
What the Study Showed
The study looked at the amount of pain medications required by patients who underwent 1-2 level minimally invasive lumbar fusions with similar baseline characteristics and preoperative opioid consumption, before and after implementation of the pain protocol, and found that patients using the protocol consumed 54% less opioids and had a statistically significant reduction in Length of Stay (LOS). The results of these studies demonstrate the importance of the prescriber’s role in battling opioid consumption in spinal fusion patients postoperatively.
Understanding the drivers of opioid consumption in the acute in-hospital postoperative period lead the team to further focus on identifying factors contributing to opioid use. In a single center study of 1,500 patients undergoing 1-2 level spinal fusion surgeries, we identified patient characteristics that were associated with higher opioid (MME) consumption. The factors that contributed to increased cumulative opioid consumption calculated on post-operative day (POD)#4 were younger age, opioid consumption prior to admission, current smokers, and more levels fused; factors with no association to opioid consumption included surgical approach, zip code, how sick the patients were pre-op, marital status, BMI, race, or insurance type. These results help surgeons identify modifiable risk factors for increased opioid consumption in patients undergoing lumbar spinal fusion surgery.
As we prepare to activate Enhanced Recovery After Surgery (ERAS) in Quarter 2 at Norton Leatherman, we have already begun to study the effectiveness of multimodal analgesia on opioid consumption and patient outcomes. Multimodal analgesia is the use of a variety of different types of pain medications which act on different pain blocking pathways, instead of just using opioid medications. In 2017, we began using Transverse Abdominis Plane (TAP) blocks and a “preoperative pain cocktail” given to patients prior to surgery, in efforts to decrease intra-operative and post-operative opioid consumption and decrease post-operative complications in patients undergoing Anterior Lumbar Interbody Fusion (ALIF).
In looking at patients with similar baseline characteristics and preoperative opioid use, before and after implementation of TAP blocks, we found patients were requiring 62% less opioids (MME) starting on POD#1. There was a reduction in length of stay (LOS) from 4.5 to 3.8 days, which was not statistically significant (p.0.246) by research standards; however, the loss of additional midnight stay is clinically relevant and effects hospital dashboard reporting. By decreasing the length of time patients are in the hospital after surgery, these patients are more quickly able to return to the comfort of their home for their recovery while also avoiding harmful infections that live in every hospital and decreasing the overall cost of their care.
Downstream effects of opioid use are sometimes overlooked, however, the Leatherman team is feeling the impact as the rates of Osteomyelitis related to intravenous drug use (IVDU) increased tenfold from 2013 to 2016 . Osteomyelitis is a serious, and sometimes life threatening, bone infection that occurs as a result of introducing bacteria into one’s blood stream through IV drug use outside of the hospital or from having a decreased immune system from other illnesses. Bacteria introduced into the bloodstream frequently infects the spine, causing severe back pain.
These patients require long-term IV antibiotics, and in severe cases where the bone has been destroyed by bacteria causing instability, major invasive spine surgery is needed. When looking at cost of care for these patients, the average cost for patients with history of IVDU requiring surgical intervention was $29,063; and $12,615 for the IVDU group treated non-operatively with antibiotics. Variable Direct Cost (VDC) of four diagnosis-related groups (DRG) were also evaluated, with three of the four having increased costs for patients with IVDU when compared to all-comers in the same DRGs. Overall it was found that while IV drug users with vertebral osteomyelitis have similar LOS, lower readmission rates, and similar hospital costs compared to those who do not use IV drugs; the average VDC based on DRG, the IV drug users cost more to care for.
There is still much work to be done to further understand the role of healthcare providers in fighting the opioid epidemic; this is just the beginning. As the Norton Leatherman team and other leaders in the spine community continue to study opioids in efforts to better understand ways to decrease opioid utilization in patients undergoing spine surgery, we are making progress. Research results and effective changes in provider practice patterns, like the implementation of the SEPP and ERAS protocols, in the field of spine surgery are transferable to other specialties and service lines as well. We invite you to create initiatives to continue to work toward progress, as winning the battle against opioids will take time and a multidisciplinary approach.
Read more in our Spine Health Journal here.
by Jeffrey Gum, M.D.
by Portia Steele, APRN
Norton Leatherman Spine Center