Editorial. Is the rise in spinal infections an unexpected consequence of the opioid epidemic?

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The opioid crisis began in the late 1990s due to unregulated and unscrupulous encouragement of opiate prescription by pharmaceutical companies for pain relief.6 It is widely known that due to the highly addictive nature of opioids, the increase in prescriptions led to an increase in dependence and abuse, making this a national epidemic in the United States.

Chronic abuse and dependence leads to illicit substance–seeking behaviors. An estimated 4%–6% of patients who were initially prescribed opioids misused them and then transitioned to using heroin.6 It has been reported that prior prescriptions of opioids for pain increases the risk of heroin use by 19-fold.5 The repercussions of the opioid prescription crisis are increasingly evident, as opioid-related deaths are now associated with a 0.21-year reduction in life expectancy in the US population as calculated for individuals living between the years 2011 and 2015.3 While state-based policies are needed to combat the opiate crisis, implementation of prescribing restrictions without concurrent rehabilitative programs may have unintended consequences.

This issue of Neurosurgical Focus includes a report by DiGiorgio et al., who examined clinical cases of spinal epidural abscesses and documented a doubling of intravenous drug abuse–related spinal epidural abscesses after state implementation of opioid-prescribing restrictions in 2017.2 The authors used a retrospective chart review to identify intravenous drug users at risk for spinal epidural abscess. In individuals characterized as high risk, the number of spinal epidural abscess cases that presented each month was compared before and after implementation of the opiate restriction policy in Louisiana, using Fisher’s exact test. In this panel of at-risk patients, the incidence of spinal epidural abscesses doubled from 0.54 cases per month in 2013–2017 to 1.15 cases per month in 2017–2018, following implementation of the new opiate prescribing restrictions. As such, the present study alludes to systemic failure in implementation of the opioid-prescribing restrictions that, without adequate implementation of drug rehabilitation programs, may have unexpectedly increased the risk of spinal infections by increasing use of intravenously administered illicit opioids.

Prior to this report, increased rates of intravenous drug abuse had been hypothesized as contributing to a rise in spinal infections requiring surgical intervention in Washington state.1,4 Blecher et al. surveyed a comprehensive statewide database to obtain medical records (based on ICD codes) for patients discharged after inpatient admission for spinal discitis, osteomyelitis, or intraspinal abscess.1 Alarmingly, the incidence of patients discharged for spinal infections nearly doubled during the survey period (2003–2017). Examination of factors contributing to spinal infection risk revealed that substance abuse was a top predictor of spinal infection. Of greater concern, the percentage of patients with concurrent spinal infections and substance abuse quadrupled during the 15-year survey period, rising to the second most prevalent risk factor, just below diabetes mellitus. Further probing of these data revealed that the rise in substance abuse among infected patients was due to an over 3-fold increase in substance dependence, rather than substance abuse, which remained relatively stable throughout the study period.

In general, while deaths associated with prescription opioid–related abuse remain high, the contribution of heroin and synthetic opioid–related deaths have increased relative to prescription-related opioid deaths in most states since 2010–2011. Regional trends in opioid-related deaths are tracked and made available by the CDC (Centers for Disease Control and Prevention) online (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state). In some states, such as Louisiana, deaths associated with heroin abuse have surpassed those related to prescription opioid use. Of the states with the highest opioid-related deaths (West Virginia, New Hampshire, Ohio, and Maryland, including the District of Columbia), deaths due to synthetic opioid use versus heroin use have risen nonuniformly. These data reveal regional patterns in opioid-related deaths. In the Northeastern states of New Hampshire, Maine, Rhode Island, and Massachusetts, the rise in opioid-related deaths is largely attributable to synthetic opioid use. Conversely, in other states such as Washington and Louisiana, heroin rather than synthetic opioid–related deaths, have surged. Statewide differences in illicit opioid–related deaths may reflect a difference in regional access to illicit substances and warrants a need for regionally targeted interventions.

In context of the DiGiorgio et al. and Blecher et al. studies, regional differences in illicit opioid abuse patterns may require the development of specific educational and medical-based prevention methods. This is especially true when considering differential trends in illicit opioid administration routes, as intravenous administration of opioids undoubtedly increases the risk of systemic infections. This opinion agrees with a recent Morbidity and Mortality Report by the CDC, which states that a limitation in prevention of opioid-related deaths is knowledge of contributing substances and other factors attributable to overdose.4 As such, enhancing our knowledge of the root cause of opioid-related deaths is critical to developing targeted interventional strategies to reduce opioid-related morbidity and mortality.

The DiGiorgio et al. study highlights a need for better methods of diagnosing and treating intravenous substance abuse–related infections. Nearly half of all patients treated for epidural abscesses were Medicaid recipients, and approximately 29% did not receive follow-up after an average hospital stay of 27.6 days. This suggests that intravenous drug users progressing to systemic infections are likely underserved and under-resourced for the provision of proper preventative and rehabilitative care. Encouragement of substance abuse reporting and follow-up practices may better serve this community to reduce the risk of acquiring intravenous drug–related infections.

In the DiGiorgio et al. study, more than half of infected patients tested positive for methicillin-resistant Staphylococcus aureus, suggesting a public healthcare need to target the spread of this organism regionally and through campaigns and prevention strategies, such as public outreach and needle exchange programs.

Based on access to care and confidentiality concerns, providing safe patient-injection facilities is considered by many to be an important approach to combating intravenous drug use–associated infections. Developing needle exchange programs that provide education on the risks of intravenous drug use, early signs of infections, and emphasis of the importance of follow-up, may also help promote risk reduction. For example, educating users that back pain, radiculopathy, and/or myelopathy are risk factors for debilitating and life-threatening spinal infections may help reduce needle sharing and advanced infections among users. However, to truly combat this epidemic, research is needed to optimize education, prevention, and treatment methods. Questions such as “How do opioid-abuse patterns affect opioid-related morbidity and mortality?” and “How do opioid prescribing restrictions impact abuse patterns?” should be asked.

The current literature additionally elucidates a need for future community-based research tailored to regional patterns of drug abuse. As surgeons, we have a responsibility to do what we can to help this at-risk population, which is currently experiencing an opioid-related crisis and needs medical care champions. Methods such as early diagnosis and treatment of intravenous drug use–related infections, expanding regional needle exchange programs, and education on the risks and side effects of opioid abuse are warranted. Such strategies should be implemented at the local, regional, and national levels and facilitated by physician advocates for opioid policy research and reform.

Together, these studies uncover and report a potentially new and alarming epidemic of spinal infections among drug users, while suggesting that the rise in spinal infections may be a consequence of the current opioid prescription crisis in the United States.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Blecher RYilmaz EDrazin DOskouian RJChapman JR: Recent increase in the rate of spinal infections may be related to growing substance-use disorder in the state of Washington: wide population-based analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) database. Spine (Phila Pa 1976) [epub ahead of print] 2018

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  • 2

    DiGiorgio AMStein RMorrow KDRobichaux JMCrutcher CL IITender GC: The increasing frequency of intravenous drug abuse–associated spinal epidural abscesses: a case series. Neurosurg Focus 46(1):E42019

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  • 3

    Dowell DArias EKochanek KAnderson RGuy GP JrLosby JL: Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000–2015. JAMA 318:106510672017

    • Crossref
    • PubMed
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  • 4

    Mattson CLO’Donnell JKariisa MSeth PScholl LGladden RM: Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016–June 2017. MMWR Morb Mortal Wkly Rep 67:9459512018

    • Crossref
    • PubMed
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    • Export Citation
  • 5

    Muhuri PKGfroerer JCDavies MC: Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. (https://www.samhsa.gov/data/report/associations-nonmedical-pain-reliever-use-and-initiation-heroin-use-united-states) [Accessed November 9 2018]

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    • Export Citation
  • 6

    National Institutes of Health: Opioid overdose crisis. National Institute on Drug Abuse. (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis) [Accessed November 9 2018]

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Article Information

Correspondence Doniel Drazin: ddrazin@gmail.com.

ACCOMPANYING ARTICLE DOI: 10.3171/2018.10.FOCUS18449.

INCLUDE WHEN CITING DOI: 10.3171/2018.10.FOCUS18576.

Disclosures The authors report no conflict of interest.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Blecher RYilmaz EDrazin DOskouian RJChapman JR: Recent increase in the rate of spinal infections may be related to growing substance-use disorder in the state of Washington: wide population-based analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) database. Spine (Phila Pa 1976) [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    DiGiorgio AMStein RMorrow KDRobichaux JMCrutcher CL IITender GC: The increasing frequency of intravenous drug abuse–associated spinal epidural abscesses: a case series. Neurosurg Focus 46(1):E42019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Dowell DArias EKochanek KAnderson RGuy GP JrLosby JL: Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000–2015. JAMA 318:106510672017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Mattson CLO’Donnell JKariisa MSeth PScholl LGladden RM: Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016–June 2017. MMWR Morb Mortal Wkly Rep 67:9459512018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Muhuri PKGfroerer JCDavies MC: Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. (https://www.samhsa.gov/data/report/associations-nonmedical-pain-reliever-use-and-initiation-heroin-use-united-states) [Accessed November 9 2018]

    • Search Google Scholar
    • Export Citation
  • 6

    National Institutes of Health: Opioid overdose crisis. National Institute on Drug Abuse. (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis) [Accessed November 9 2018]

    • Search Google Scholar
    • Export Citation

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