Combating the narcotic epidemic in spine surgery patients: A new post-surgical solution

Spine

The medical management of muscular skeletal disorders and injuries remains the most prevalent and costly service of the U.S. healthcare system.

Outpatient prescription narcotics, while highly effective at acute pain relief for musculoskeletal disorders, have become increasingly recognized for their morbid complications and addictive traits. The high prevalence of opioid related adverse events and costly consequences to our society has prompted many to critically look at our practice of outpatient opioid prescription. As a result, multiple stakeholders in US healthcare are adopting nonnarcotic pain management solutions, education, and awareness programs.

In the hospital setting, however, intravenous and oral narcotics remain the mainstay of acute pain management. When administered under nurse supervision or through patient controlled anesthetic (PCA) devices, the historical assumption has been that narcotics offer the best balance between safety and effectiveness for acute pain control. Based on several recent and reproducible study results, this notion is being challenged.

Recently, investigators sampling administrative Medicare records from 2010-2012 found that opioid related adverse events (ORAE) occur in up to one out of every eight patients undergoing spine surgery [1], whether it be cervical [2] or low-back surgery [3]. Even when intravenous narcotics are administered through PCA devices, specifically aimed at maximizing safety of inpatient narcotic use, they appear to introduce greater safety concerns than previously recognized. In a recent analysis of 1998-2012 national Medicare records, our research team recently observed that PCA use for pain control after low back surgery was associated with an increase in ORAEs independent of extent of surgery or patients' co-morbidities. Despite patient controlled PCA-narcotic delivery in an observed hospital environment, almost one in ten patients experienced an opioid related adverse event. [4]

Over 50% of hospital admissions include the administration of narcotics [5]. An estimated one-third of all hospital adverse events are related to adverse drug events, affect approximately two million hospital stays annually, and prolong hospital length of stay by an average of 2 to 5 days. [6] With close to a million preventable complications per year arising from in-patient narcotic prescription, one has to consider whether it is time for a large and rapid paradigm shift for hospital-based pain control; Particularly within a U.S. healthcare system that is currently operating with unsustainable cost increases. As recent studies are suggesting, inpatient narcotics are not only associated with preventable deaths and adverse events, they also increase length of stay, reduce mobilization, increase cost of the episode of care, and lead to greater resource utilization in the immediate post discharge period. Furthermore, narcotic use has recently been recognized to reduce the short and long-term benefit of musculoskeletal treatments such as spine surgery.[7-8]

In a healthcare reform era aimed at improving the value (quality/cost) of services by increasing quality and reducing cost of that care, inpatient narcotic use contradicts the value-based reform movement as it reduces safety and healthcare quality while increasing utilization and cost of care. Multi–modal, non-opioid pain management paradigms should be supported and implemented in the hospital setting to increase the value and efficiency of not only musculoskeletal care, but all hospital based care. As we begin to more critically look at U.S. healthcare opportunities for quality improvement and its value-based evolution, our hospital based narcotic practices represents low hanging fruit. No one stands to benefit more than our patients.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

References:

1. Polly D, Ong K, Lovald S, Lau E, Kurd M, Radcliff K. Opioid related adverse events with spine surgery: Is the risk real? Presented at the Annual Meeting of AANS/CNS Joint Spine Section, Phoenix, Arizona. March 4-7, 2015
2. Kurd M, Ong K, Lovald S, Lau E, Radcliff K. Opioid related adverse events following cervical spine surgery. Presented at the Annual Meeting of AANS/CNS Joint Spine Section, Phoenix, Arizona. March 4-7, 2015
3. Ibid
4. McGirt MJ, Devin C, Lau E, Lovald S, Ong K. Prevalence of PCA device use for inpatient posterior lumbar spine fusion surgery and associated opioid-related complications and costs.
5. Herzig SJ1, Rothberg MB, Cheung M, Ngo LH, Marcantonio ER. Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals J Hosp Med. 2014 Feb;9(2):73-81
6. Draft National Action Plan for Adverse Drug Event (ADE) Prevention (2013). U.S. Department of Health and Human Services.http://www.health.gov/hai/pdfs/ade-action-plan.pdf
7. Lee D, Armaghani S, Archer KR, Bible J, Shau D, Kay H, Zhang C,McGirt MJ, Devin C. Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. J Bone Joint Surg Am. 2014 Jun 4;96(11):e89
8. Armaghani SJ, Lee DS, Bible JE, Archer KR, Shau DN, Kay H, Zhang C, McGirt MJ, Devin CJ. Preoperative opioid use and its association with perioperativeopioid demand and postoperative opioid independence in patients undergoing spine surgery. Spine (Phila Pa 1976). 2014 Dec 1;39(25):E1524-30

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