Opioid use after adult spinal deformity surgery: patterns of cessation and associations with preoperative use

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  • Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

METHODS

Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5–82), high-dose use (aOR 7.3, 95% CI 1.1–48), and long-term use (aOR 17, 95% CI 2.2–123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8–10,546) but not long-term use (aOR 4.0, 95% CI 0.18–91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8–261) but not at 6 months (aOR 4.3, 95% CI 0.95–24).

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

ABBREVIATIONS

aOR = adjusted odds ratio; ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; BMI = body mass index; MMED = morphine milligram equivalents daily; ON = opioid naïve; OU = opioid using.

OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

METHODS

Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5–82), high-dose use (aOR 7.3, 95% CI 1.1–48), and long-term use (aOR 17, 95% CI 2.2–123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8–10,546) but not long-term use (aOR 4.0, 95% CI 0.18–91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8–261) but not at 6 months (aOR 4.3, 95% CI 0.95–24).

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

ABBREVIATIONS

aOR = adjusted odds ratio; ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; BMI = body mass index; MMED = morphine milligram equivalents daily; ON = opioid naïve; OU = opioid using.

In Brief

The study is important to gauge the long-term implications of opioid use for pain control at a time in history when opioid abuse is a national crisis. The authors retrospectively analyzed a cohort of adult spinal deformity (ASD) patients to assess the pattern and timeline of opioid use following surgery and to identify the effects of preoperative opioid use, dose, and duration on patient-reported outcomes and long-term postoperative opioid use. The study helps identify risk factors for long-term postoperative opioid use and may allow clinicians to better understand and counsel patients on the likelihood of opioid use after ASD surgery.

Opioid medications are frequently prescribed to treat back pain.1 However, preoperative and perioperative opioid use is associated with poorer function after spine surgery, poorer patient-reported outcomes, higher complication rates, and longer hospital stays.2–6 Patients who take opioids preoperatively are more likely to continue taking them after undergoing spine surgery, and patients who use opioids for longer than 3 months after spine surgery tend to have worse outcomes and to incur greater healthcare costs.7–13 Therefore, reducing preoperative opioid use has been suggested as a way to improve postoperative outcomes and to reduce costs.14,15 Reported rates of opioid use before spine surgery range from 34% to 57%.3,12,16–19

Adult spinal deformity (ASD), which comprises a group of diseases that have a reported prevalence of up to 68% in adults older than 65 years,20–23 can impair function, decrease quality of life, and cause severe back and radicular pain.24,25 Patients often seek opioid analgesics and spinal arthrodesis to treat these symptoms,25,26 and the frequency of ASD surgery more than doubled among those 70 years or older from 2004 to 2011.27,28

ASD differs from other conditions treated with spinal arthrodesis in that it is often more complex and more likely to be chronic.29 We are aware of no studies that have investigated how preoperative dose and duration of opioid use are related to long-term (2-year) postoperative use. In addition, we do not believe the timeline of opioid cessation after ASD surgery has been described. An understanding of these factors may help when counseling patients regarding preoperative opioid weaning and setting patient expectations for opioid cessation after surgery.

Our objectives were threefold. First, we assessed how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose at 2 years after ASD surgery. Second, we assessed how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years after ASD surgery. Third, we assessed whether opioid use at 6 months and 1 year after ASD surgery predicts opioid use at 2 years. We hypothesized the following: 1) higher preoperative opioid dose and longer duration of use would be associated with higher rates of opioid use, as well as high-dose opioid use at the 2-year follow-up; 2) any preoperative opioid use would be associated with higher rates of opioid use starting 3 months after ASD surgery; and 3) opioid use at 6 months and 1 year would predict opioid use at 2 years.

Methods

Patient Selection and Data Collection

After approval by our institutional review board, we retrospectively analyzed a single-center, longitudinally maintained patient registry to identify adults aged 18 years or older who were diagnosed with ASD (scoliosis, kyphosis, or proximal or distal junctional kyphosis) and who underwent spinal arthrodesis involving the lumbar and/or sacral spine between January 1, 2013, and December 31, 2017. Of 238 patients who underwent surgery, we included 87 patients who had opioid use data at the 2-year follow-up mark, defined as 21–27 months after surgery (Table 1).

TABLE 1.

Characteristics of 87 patients who underwent ASD surgery from 2013 to 2017

CharacteristicNo. of Cases (%)
Age, yrs
 18–446 (6.9)
 45–5921 (24)
 60–7450 (57)
 ≥7510 (11)
Female sex54 (62)
Race
 Caucasian76 (87)
 African American7 (8.0)
 Other4 (4.6)
BMI, kg/m2
 <2523 (26)
 25–29.929 (33)
 ≥3035 (40)
Smoking history
 Never39 (45)
 Former42 (48)
 Current6 (6.9)
Anxiety or depression15 (17)
Diabetes14 (16)
Primary diagnosis
 Kyphosis42 (48)
 Degenerative scoliosis39 (45)
 PJK/DJK6 (6.9)
No. of levels fused
 ≤512 (14)
 6–1046 (53)
 ≥1129 (33)

DJK = distal junctional kyphosis; PJK = proximal junctional kyphosis.

We extracted the following data from the registry: patient age, sex, race, diagnosis, and number of spinal levels fused. We also retrospectively extracted the following data from medical records: American Society of Anesthesiologists (ASA) physical status classification; body mass index (BMI); history of smoking, diabetes, and anxiety or depression; and any opioid medications and their doses at 4 preoperative time points (6 months, 3 months, 1 month, and preoperative evaluation within 2 weeks before surgery) and 5 standard postoperative time points (6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery). At each visit, a medication review, including all pain medications, was documented by a member of the surgical team. The opioid dose at each time point was abstracted from these notes and prescription records. State prescription databases were unavailable for use in this study.

Preoperative Opioid Use

On the basis of patient-reported preoperative opioid use, we assigned each patient to either the opioid-using (OU) group (if they reported taking opioid medications at the time of the preoperative evaluation) or the opioid-naïve (ON) group (if they reported no preoperative opioid use). All opioid doses were converted into morphine milligram equivalents daily (MMED) uses. Prescriptions ≥ 90 MMED30 were considered high dose, and prescriptions < 90 MMED were considered low dose. Preoperative opioid use for ≥ 6 months2,31 was considered long-term, and use for < 6 months was considered short-term. Patients in the OU group who reported opioid use at the 6-month preoperative visit, defined as 5–7 months before surgery, were considered to have long-term opioid use, and patients who reported no opioid use at the 6-month preoperative visit or any subsequent visit, but did report use at the 2-week preoperative evaluation, were considered to have short-term preoperative use.

Patient Characteristics

Fifty-nine patients reported preoperative opioid use and were classified as OU cases. Among these patients, the median reported dosage was 45 MMED (range 3.75–1080 MMED). The remaining 28 patients reported no preoperative opioid use and were classified as ON cases. Among the OU group, 37 patients reported low-dose prescriptions and 22 reported high-dose prescriptions. Forty-four patients had long-term use, and 15 had short-term use.

We found no significant differences in the distribution of age, sex, race, smoking status, history of diabetes, history of anxiety or depression, primary diagnosis, or the number of levels fused between the OU and ON groups or between patients reporting high-dose versus low-dose or long-term versus short-term preoperative opioid use. Patients in the OU group had a higher mean BMI than patients in the ON group (p = 0.03). Compared with patients with low preoperative opioid doses, those reporting high doses had a higher mean ASA class (p = 0.048) (Table 2).

TABLE 2.

Characteristics of 87 patients who underwent ASD surgery from 2013 to 2017 stratified by preoperative opioid use, dose, and duration of use

Opioid UseOpioid Dose*Duration of Opioid Use
CharacteristicNo (n = 28)Yes (n = 59)p ValueLow (n = 37)High (n = 22)p ValueShort-Term (n = 15)Long-Term (n = 44)p Value
Age, yrs63 ± 1363 ± 110.9864 ± 1159 ± 110.0965 ± 1362 ± 100.42
Female sex16 (57)38 (64)0.6826 (70)12 (55)0.3510 (67)28 (64)>0.99
Race
 Caucasian22 (79)54 (92)33 (89)21 (95)12 (80)42 (95)
 African American4 (14)3 (5.1)0.233 (8.1)0 (0)0.312 (13)1 (2.3)0.16
 Other2 (7.1)2 (3.4)1 (2.7)1 (4.5)1 (6.7)1 (2.3)
Current/former smoker14 (50)34 (58)0.6621 (57)13 (59)>0.9910 (67)24 (55)0.60
BMI, kg/m228 ± 6.131 ± 6.00.0330 ± 5.532 ± 6.50.1932 ± 6.030 ± 6.00.87
Anxiety or depression5 (18)10 (17)>0.996 (16)4 (18)>0.990 (0)10 (23)0.10
Diabetes6 (21)8 (14)0.536 (16)2 (9.1)0.702 (13)6 (14)>0.99
Primary diagnosis
 Degenerative scoliosis12 (43)30 (51)18 (49)12 (55)7 (47)23 (52)
 Kyphosis15 (54)24 (41)0.4616 (43)8 (36)0.877 (47)17 (39)0.85
 PJK/DJK1 (3.6)5 (8.5)3 (8.1)2 (9.1)1 (6.7)4 (9.1)
 No. of levels fused8.9 ± 3.59.3 ± 4.00.619.9 ± 4.18.4 ± 3.60.149.3 ± 4.19.4 ± 4.00.94
 ASA class2.6 ± 0.562.6 ± 0.490.952.5 ± 0.502.8 ± 0.430.0482.7 ± 0.472.5 ± 0.500.43

Values are reported as the number (%) of patients or as the mean ± SD.

Low dose was defined as < 90 MMED, and high dose was defined as ≥ 90 MMED.

Short-term duration of preoperative opioid use was defined as < 6 months, and long-term duration of use was defined as ≥ 6 months.

Postoperative Outcomes

Our postoperative outcomes of interest were as follows: opioid use (of any dose) at the 2-year follow-up visit, high opioid dose (≥ 90 MMED) at the 2-year follow-up visit, and rates of opioid use at each postoperative time point.

Statistical Analysis

Baseline comparisons were performed with Student t-tests for continuous variables and chi-square tests for categorical variables. Multivariate logistic regression analysis controlling for age, race, ASA class, BMI, smoking status, history of diabetes, history of anxiety or depression, and the number of spinal levels fused was used to evaluate associations between preoperative opioid use, dose, and duration of use and the outcomes of interest. Rates of opioid use at each follow-up visit were compared using 2-proportion Z-tests. Of 348 opioid use observations between 6 weeks and 12 months postoperatively, 26 (7.5%) were missing and excluded from analysis. All patients included in this study had opioid use data at the preoperative evaluation and 2-year follow-up time points, and 64 of 87 patients had opioid use data at all postoperative time points. A p value < 0.05 was considered significant. Statistical analyses were performed using R software (version 3.6.3; R Foundation for Statistical Computing).

Results

Long-Term Postoperative Opioid Use

At 2 years after undergoing ASD surgery, a larger proportion of patients in the preoperative OU group (54%; 32/59) reported continued opioid use than in the ON group (7.1%; 2/28) (p < 0.001). After adjustment for potential confounders, patients in the OU group had 14-fold greater odds of reporting postoperative opioid use at the 2-year follow-up visit compared with those in the ON group (95% CI 2.5–82) (Table 3). Patients were more likely to indicate continued opioid use at 2 years after surgery if they reported taking high doses of opioids preoperatively (adjusted odds ratio [aOR] 7.3, 95% CI 1.1–48) or if they reported long-term preoperative opioid use (aOR 17, 95% CI 2.2–123) (Table 3). Age, race, ASA class, BMI, smoking status, history of diabetes, history of anxiety or depression, and the number of levels fused were not associated with significantly greater odds of long-term postoperative opioid use.

TABLE 3.

Adjusted odds of opioid use 2 years after undergoing ASD surgery

ParameterβaOR (95% CI)p Value
All patients (n = 87)
 Preop opioid use2.714 (2.5–82)0.003
 Age0.0041.0 (0.95–1.1)0.87
 Caucasian1.02.8 (0.24–33)0.41
 Current/former smoker–1.10.33 (0.10–1.1)0.08
 BMI0.071.1 (0.97–1.2)0.18
 Anxiety/depression1.33.8 (0.97–21)0.12
 Diabetes–0.280.76 (0.14–4.1)0.75
 ASA class0.431.5 (0.50–4.7)0.45
 No. of spinal levels fused0.0051.0 (0.87–1.2)0.95
Patients reporting preop opioid use (n = 59)
 High dose*2.07.3 (1.1–48)0.04
 Long-term use2.817 (2.2–123)0.006
 Age0.031.0 (0.96–1.1)0.36
 Caucasian–0.730.48 (0.02–13)0.67
 Current/former smoker–1.60.21 (0.03–1.3)0.10
 BMI0.081.1 (0.94–1.3)0.28
 Anxiety/depression0.782.1 (0.17–27)0.55
 Diabetes0.651.9 (0.18–19)0.60
 ASA class1.02.8 (0.43–18)0.28
 No. of spinal levels fused0.121.1 (0.93–1.4)0.20

High dose was defined as ≥ 90 MMED.

Long-term preoperative opioid use was defined as ≥ 6 months.

Fifteen patients reported taking a high opioid dose (≥ 90 MEDD) at the 2-year follow-up, all of whom had reported taking opioids preoperatively. A high opioid dose at the 2-year follow-up visit was associated with high opioid doses preoperatively (aOR 247, 95% CI 5.8–10,546; p = 0.004) but not long-term preoperative opioid use (aOR 4.0, 95% CI 0.18–91; p = 0.39).

Opioid Cessation

Opioid use decreased from 6 weeks to 2 years after ASD surgery in both the OU (94% to 54%) and ON (62% to 7.1%) groups (Fig. 1). Compared with the ON group, patients in the OU group had significantly higher rates of opioid use at each postoperative time point from 6 weeks to 2 years (p < 0.001) (Fig. 1). Of 51 patients reporting opioid use at 6 months, 25 (49%) reported opioid cessation by the time of the 2-year follow-up visit, whereas of 40 patients reporting opioid use at 1 year, only 12 (30%) reported cessation by 2 years. After adjusting for potential confounders and preoperative use, we found that opioid use at 1 year was independently associated with opioid use at 2 years (aOR 33, 95% CI 6.8–261), whereas opioid use at 6 months was not associated with use at 2 years (aOR 4.3, 95% CI 0.95–24).

FIG. 1.
FIG. 1.

Postoperative opioid cessation timelines of 59 patients who reported opioid use and 28 who reported no opioid use before undergoing ASD surgery from 2013 to 2017. Bars indicate the 95% CIs.

The proportion of patients reporting opioid cessation by the time of the 6-week follow-up visit was significantly greater in the ON group (10/26) compared with the OU group (3/53) (p < 0.001). However, for patients in both groups who reported opioid use at 6 weeks, the timelines of postoperative use were similar for the remainder of the study period (Fig. 1). Patients in the OU group also reported taking a higher median dose at 1 year (16 MMED) and 2 years (5 MMED) than those in the ON group (0 MMED at 1 and 2 years).

Discussion

We found that 68% of our 87 patients undergoing surgery for ASD reported preoperative opioid use, and 39% reported using opioids at 2 years after surgery. Patients who used opioids preoperatively had higher rates of long-term and high-dose postoperative opioid use, as did patients who reported taking high doses of opioids preoperatively. Opioid use for 6 months or more preoperatively was also associated with long-term opioid use but not with high-dose opioid use at 2 years. Patients who used opioids preoperatively had consistently higher rates of postoperative use from 6 weeks to 2 years after surgery compared with patients who reported no preoperative use.

The proportion of patients who reported preoperative opioid use in our study (68%) was higher than previously reported rates of use before spine surgery, which range from 34% to 57%.3,4,11,17,19 This difference may reflect greater opioid use by patients with ASD compared with the general spine surgery population. In addition, patients with less debilitating disease that does not require strong analgesic medication may have been less likely to follow up for at least 2 years and, therefore, would not have met our inclusion criteria. Overall, the prevalence of opioid use in our study declined significantly after surgery, with only 49% of patients reporting continued opioid use at 1 year and 39% at 2 years. These rates, as well as patient variables, are consistent with other studies of long-term opioid use after spine surgery.4,12,16,31

Patients in the OU group had a significantly higher mean BMI value than patients in the ON group. Also, patients taking high preoperative opioid doses had a significantly higher average ASA class than patients taking lower doses. This may reflect a greater likelihood to prescribe high doses of opioids for those with more severe disease or more comorbid conditions.

Our finding that high-dose preoperative opioid use was associated with opioid use at 2-year follow-up suggests a dose-response relationship between preoperative dose and long-term postoperative use. In addition, long-term preoperative use was also associated with higher odds of opioid use at 2 years compared with short-term preoperative use, corroborating a previous investigation that reported similar results in a general lumbar spine surgery population.31

Patients in the ON group reported consistently lower rates of postoperative opioid use, with a greater proportion reporting no opioid use by the 6-week follow-up visit compared with OU patients. This finding suggests that, although patients who took opioid medications preoperatively were more likely to continue taking opioids 2 years after surgery, much of this effect may be attributable to a substantial proportion of ON patients who cease opioid use within 6 weeks after surgery (Fig. 1). However, opioid use before the 1-year follow-up visit was not associated with use at 2 years independently of preoperative use. Therefore, although differences in opioid cessation between the OU and ON groups began as early as 6 weeks postoperatively, postoperative opioid use at up to 6 months was not a reliable predictor of long-term opioid use after ASD surgery.

Our study has several limitations. First, our opioid use and dose data were obtained retrospectively from patient electronic medical records, including medication reviews and surgeon notes; therefore, these data may not accurately measure patients’ true daily opioid consumption.32 State opioid utilization records were unavailable to allow retrospective verification of documented opioid use. However, our data are more quantitative than the measures used in previous studies (e.g., daily/weekly/never) and allow comparison among subgroups of patients reporting daily opioid use. Although subject to the limitations of retrospective data collection, self-reports of medication use may be more reflective of actual use than database reports of ordered or filled prescriptions. Second, although our data abstraction included opioid dose, we did not have reliable data on whether analgesics were prescribed for other indications, and it is possible that we overestimated pre- and postoperative use and underestimated postoperative rates of cessation. Third, we excluded patients who lacked documentation of opioid use at the 2-year follow-up. Patients who have less severe disease or better outcomes may be less likely to complete 2 years of follow-up. However, our postoperative opioid use data for both OU and ON groups are comparable to previously reported values.16 We included patients who were missing documentation of opioid use between the 6-week and 1-year follow-up visits because the rate of missing data was small (7.5% between these time points), and it did not affect our primary endpoint of opioid use at the 2-year follow-up examination. Fourth, our sample size was small, particularly when assessing risk factors for postoperative high-dose opioid use. However, our quantitative dose and duration data allowed us to analyze associations of these factors with outcomes after ASD surgery, which has not been done before, to our knowledge.

Conclusions

Our study suggests that a higher dose and longer duration of preoperative opioid use are associated with higher rates of long-term postoperative opioid use in patients with ASD, and high-dose preoperative opioid use is associated with a continued high opioid dose at 2 years after surgery. Patients who reported preoperative opioid use were more likely to report postoperative use from 6 weeks through 2 years after surgery than those who reported no preoperative opioid use. This was largely because a greater proportion of patients in the ON group reported opioid cessation within 6 weeks after surgery compared with patients in the OU group. Although a substantial proportion of patients taking opioids at the 6-month follow-up visit discontinued use by 2 years, opioid use at 1 year was associated with continued use at 2 years. Further research is needed to determine whether these correlations indicate a benefit to reducing opioid use before ASD surgery.

Disclosures

Dr. Kebaish reports consultant fees and other support from DePuy Synthes and K2M, as well as support from Orthofix and SpineCraft. Dr. Riley discloses being a shareholder, on the advisory board panel, and a stockholder of and receiving other support from Avitus. Dr. Neuman reports support of non–study-related clinical or research effort he oversees from DePuy Synthes and that he is on the speaker’s bureau for Medtronic.

Author Contributions

Conception and design: Neuman, Ren. Acquisition of data: Ren, Bryant, Kebaish, Riley, Cohen. Analysis and interpretation of data: Neuman, Ren, Skolasky, Harris. Drafting the article: Neuman, Ren. Critically revising the article: Neuman, Ren. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Neuman. Statistical analysis: Neuman, Ren, Skolasky. Administrative/technical/material support: Neuman, Skolasky. Study supervision: Neuman.

Supplemental Information

Previous Presentations

The main results of this study (associations of preoperative opioid use, dose, and duration with long-term postoperative opioid use; and timeline of postoperative opioid use from 0 to 2 years) were presented at the 34th Annual Meeting of the North American Spine Society in Chicago, Illinois, September 25–28, 2019.

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    Ames CP, Scheer JK, Lafage V, et al. Adult spinal deformity: Epidemiology, health impact, evaluation, and management. Spine Deform. 2016;4(4):310322.

    • Search Google Scholar
    • Export Citation
  • 21

    Diebo BG, Shah NV, Boachie-Adjei O, et al. Adult spinal deformity. Lancet. 2019;394(10193):160172.

  • 22

    Kebaish KM, Neubauer PR, Voros GD, et al. Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender. Spine (Phila Pa 1976). 2011;36(9):731736.

    • Search Google Scholar
    • Export Citation
  • 23

    Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):10821085.

    • Search Google Scholar
    • Export Citation
  • 24

    Pellisé F, Vila-Casademunt A, Ferrer M, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):311.

    • Search Google Scholar
    • Export Citation
  • 25

    Smith JS, Shaffrey CI, Glassman SD, et al. Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine (Phila Pa 1976). 2011;36(10):817824.

    • Search Google Scholar
    • Export Citation
  • 26

    Kluba T, Dikmenli G, Dietz K, et al. Comparison of surgical and conservative treatment for degenerative lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):15.

    • Search Google Scholar
    • Export Citation
  • 27

    Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012;37(1):6776.

    • Search Google Scholar
    • Export Citation
  • 28

    Sing D, Khanna R, Burch S, Berven SH. Increasing rates of surgical management of adult spinal deformity in patients over sixty. Spine J. 2015;15:S204.

    • Search Google Scholar
    • Export Citation
  • 29

    Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J. 2009;9(1):1321.

  • 30

    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):149.

    • Search Google Scholar
    • Export Citation
  • 31

    Schoenfeld AJ, Belmont PJ Jr, Blucher JA, et al. Sustained preoperative opioid use is a predictor of continued use following spine surgery. J Bone Joint Surg Am. 2018;100(11):914921.

    • Search Google Scholar
    • Export Citation
  • 32

    Ahn J, Bohl DD, Tabaraee E, et al. Preoperative narcotic utilization: accuracy of patient self-reporting and its association with postoperative narcotic consumption. J Neurosurg Spine. 2016;24(1):206214.

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    • Export Citation

Contributor Notes

Correspondence Brian J. Neuman: The Johns Hopkins University, Baltimore, MD. bneuman7@jhmi.edu.

INCLUDE WHEN CITING Published online June 5, 2020; DOI: 10.3171/2020.3.SPINE20111.

Disclosures Dr. Kebaish reports consultant fees and other support from DePuy Synthes and K2M, as well as support from Orthofix and SpineCraft. Dr. Riley discloses being a shareholder, on the advisory board panel, and a stockholder of and receiving other support from Avitus. Dr. Neuman reports support of non–study-related clinical or research effort he oversees from DePuy Synthes and that he is on the speaker’s bureau for Medtronic.

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    Postoperative opioid cessation timelines of 59 patients who reported opioid use and 28 who reported no opioid use before undergoing ASD surgery from 2013 to 2017. Bars indicate the 95% CIs.

  • 1

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  • 2

    Jain N, Brock JL, Phillips FM, et al. Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion. Spine J. 2018;18(11):19891998.

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  • 3

    Lawrence JT, London N, Bohlman HH, Chin KR. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine (Phila Pa 1976). 2008;33(19):20742078.

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  • 4

    Mesfin A, Lenke LG, Bridwell KH, et al. Does preoperative narcotic use adversely affect outcomes and complications after spinal deformity surgery? A comparison of nonnarcotic- with narcotic-using groups. Spine J. 2014;14(12):28192825.

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  • 5

    Tank A, Hobbs J, Ramos E, Rubin DS. Opioid dependence and prolonged length of stay in lumbar fusion: a retrospective study utilizing the National Inpatient Sample 2003–2014. Spine (Phila Pa 1976). 2018;43(24):17391745.

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  • 6

    Villavicencio AT, Nelson EL, Kantha V, Burneikiene S. Prediction based on preoperative opioid use of clinical outcomes after transforaminal lumbar interbody fusions. J Neurosurg Spine. 2017;26(2):144149.

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  • 7

    Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976). 2006;31(18):E648E663.

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  • 8

    Anderson PA, Subach BR, Riew KD. Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis. Spine (Phila Pa 1976). 2009;34(2):161166.

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  • 9

    Lee D, Armaghani S, Archer KR, et al. Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am. 2014;96(11):e89.

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  • 10

    Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res. 2015;473(7):24022412.

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  • 11

    Nathan JK, Waljee JF, Park P, Oppenlander ME. Persistent opioid prescribing in adult patients with spinal deformity undergoing operative or nonoperative treatment. J Am Coll Surg. 2018;227(4)(suppl 1):S188.

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  • 12

    Raad M, Jain A, Neuman BJ, et al. Association of patient-reported narcotic use with short- and long-term outcomes after adult spinal deformity surgery: Multicenter study of 425 patients with 2-year follow-up. Spine (Phila Pa 1976). 2018;43(19):13401346.

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    • Export Citation
  • 13

    Sharma M, Ugiliweneza B, Sirdeshpande P, et al. Opioid dependence and health care utilization after decompression and fusion in patients with adult degenerative scoliosis. Spine (Phila Pa 1976). 2019;44(4):280290.

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  • 14

    McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond). 2017;6:19.

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  • 15

    Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty. 2016;31(9)(suppl):282287.

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    • Export Citation
  • 16

    Armaghani SJ, Lee DS, Bible JE, et al. Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Spine (Phila Pa 1976). 2014;39(25):E1524E1530.

    • Search Google Scholar
    • Export Citation
  • 17

    Armaghani SJ, Lee DS, Bible JE, et al. Increased preoperative narcotic use and its association with postoperative complications and length of hospital stay in patients undergoing spine surgery. Clin Spine Surg. 2016;29(2):E93E98.

    • Search Google Scholar
    • Export Citation
  • 18

    Kalakoti P, Hendrickson NR, Bedard NA, Pugely AJ. Opioid utilization following lumbar arthrodesis: Trends and factors associated with long-term use. Spine (Phila Pa 1976). 2018;43(17):12081216.

    • Search Google Scholar
    • Export Citation
  • 19

    Pugely AJ, Bedard NA, Kalakoti P, et al. Opioid use following cervical spine surgery: trends and factors associated with long-term use. Spine J. 2018;18(11):19741981.

    • Search Google Scholar
    • Export Citation
  • 20

    Ames CP, Scheer JK, Lafage V, et al. Adult spinal deformity: Epidemiology, health impact, evaluation, and management. Spine Deform. 2016;4(4):310322.

    • Search Google Scholar
    • Export Citation
  • 21

    Diebo BG, Shah NV, Boachie-Adjei O, et al. Adult spinal deformity. Lancet. 2019;394(10193):160172.

  • 22

    Kebaish KM, Neubauer PR, Voros GD, et al. Scoliosis in adults aged forty years and older: prevalence and relationship to age, race, and gender. Spine (Phila Pa 1976). 2011;36(9):731736.

    • Search Google Scholar
    • Export Citation
  • 23

    Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):10821085.

    • Search Google Scholar
    • Export Citation
  • 24

    Pellisé F, Vila-Casademunt A, Ferrer M, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):311.

    • Search Google Scholar
    • Export Citation
  • 25

    Smith JS, Shaffrey CI, Glassman SD, et al. Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine (Phila Pa 1976). 2011;36(10):817824.

    • Search Google Scholar
    • Export Citation
  • 26

    Kluba T, Dikmenli G, Dietz K, et al. Comparison of surgical and conservative treatment for degenerative lumbar scoliosis. Arch Orthop Trauma Surg. 2009;129(1):15.

    • Search Google Scholar
    • Export Citation
  • 27

    Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012;37(1):6776.

    • Search Google Scholar
    • Export Citation
  • 28

    Sing D, Khanna R, Burch S, Berven SH. Increasing rates of surgical management of adult spinal deformity in patients over sixty. Spine J. 2015;15:S204.

    • Search Google Scholar
    • Export Citation
  • 29

    Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J. 2009;9(1):1321.

  • 30

    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):149.

    • Search Google Scholar
    • Export Citation
  • 31

    Schoenfeld AJ, Belmont PJ Jr, Blucher JA, et al. Sustained preoperative opioid use is a predictor of continued use following spine surgery. J Bone Joint Surg Am. 2018;100(11):914921.

    • Search Google Scholar
    • Export Citation
  • 32

    Ahn J, Bohl DD, Tabaraee E, et al. Preoperative narcotic utilization: accuracy of patient self-reporting and its association with postoperative narcotic consumption. J Neurosurg Spine. 2016;24(1):206214.

    • Search Google Scholar
    • Export Citation

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