Pre-Operative Depression Linked to Increased Opioid Use Following Lumbar Fusion

Should lumbar spinal fusion be delayed until depression is treated, and how does depression affect post-operative pain control? With lead author Chloe O’Connell, BS, and commentary by Saad B. Chaudhary, MD, MBA.

Patients with depression who undergo lumbar fusion are at significantly greater risk for increased and chronic use of opioids post-operatively, according to a retrospective analysis published in the January issue of Neurosurgical Focus. Pre-operative depression also was linked to a significantly increased risk of complications, 30-day readmissions, and costs at 1 and 2 years post-operatively.
Surgical patient getting an exam.Patients with a pre-operative diagnosis of depression had a significantly higher mean cumulative dose of opioids.Researchers used a national longitudinal administrative database (MarketScan®) to analyze outcomes from 60,597 patients who underwent lumbar fusion between 2007 and 2014. Of this group, 4,985 had a pre-operative diagnosis of depression, and 21,905 were diagnosed with spondylolisthesis at the time of surgery. The patients had a variety of private insurance providers and Medicare.

As shown in the Table, patients with a pre-operative diagnosis of depression had a significantly higher mean cumulative dose of opioids (ß=0.25; P<0.01), were significantly less likely to stop taking opioids by 6 to 12 months (odds ratio [OR], 0.96), and were significantly more likely to have chronic post-operative opioid use (OR 1.28) after controlling for other covariates, including pre-operative opioid use and comorbidities.
Effects of Pre-Operative Depression on Opioid Use After Lumbar Fusion.Effects of Pre-Operative Depression on Opioid Use After Lumbar Fusion.Pre-operative depression also was significantly associated with secondary outcomes, including increased risk of complications (OR, 1.14), revision fusions (OR, 1.15), and 30-day readmissions (OR, 1.19). In contrast, pre-operative depression did not alter the likelihood of discharge home after surgery.

In terms of cost, pre-operative depression was linked to increased total costs at 1 year ($3,024) and 2 years ($5,598) after controlling for covariates (P<0.001 for both comparisons).

Should Lumbar Fusion Be Delayed Until Depression is Treated?
When asked if surgery should be delayed until depression is properly treated, lead author Chloe O’Connell, BS, said that the “timing of surgery should be decided on a case-by-case basis, as it varies by patient depending on their comorbidities, indication for surgery, and other patient-specific factors.”

“Our goal in publishing this study was to shed light on the connection between pain, depression, and opioid use,” said Ms. O’Connell, who is an MD/MS candidate at Stanford University School of Medicine. “While this study does not address the impact of depression treatment, we hypothesize that adequate treatment of depression may help mitigate this increased risk for opioid use in depressed patients.”

“By adding to the growing body of evidence supporting the link between depression, pain, and opioid use, we aim to pave the way for future investigations into modifiable risk factors that may counteract the increased risk for opioid use in patients with depression,” Ms. O’Connell told SpineUniverse. “We hope that future studies will address the impact of depression treatment, both pharmacological and non-pharmacological, on post-operative opioid use and experienced pain.”

How Does Depression Affect Post-Operative Pain Control?
“Given the well-established link between depression, chronic pain, and opioid use, it may be useful for surgeons to consider the patient’s psychological comorbidities and how they impact post-operative pain and opioid use,” Ms. O’Connell explained. “If surgeons and other physicians who manage pain are aware of untreated depression in a patient who is struggling with chronic pain and opioid use, referral to a psychiatrist for treatment of depression may benefit the patient not only from a psychiatric standpoint, but also with respect to their pain control. Fortunately, many care providers are aware of this link, and it is becoming more common for pain specialists and surgeons managing post-operative pain to consider psychiatric comorbidities and act accordingly.”

Commentary

Saad B. Chaudhary, MD, MBA
Minimally Invasive & Complex Spine Surgery
The Mount Sinai Hospital
Associate Director, Spine Surgery Fellowship
Assistant Professor
Icahn School of Medicine at Mount Sinai
Department of Orthopaedic Surgery

Connell et al have outlined a few significant trends with regards to lumbar spine surgery and opioid use that most spine specialists are already familiar with; however, many of us may not utilize this information to alter treatment planning for our patients. Given the findings of this article, it behooves us to more actively screen and evaluate our patients’ psychiatric histories and more specifically, their history of depression prior to proceeding with elective spine surgery.

The key takeaway points from this study include the following:

  • Pre-operative opioid use is the biggest predictor of post-operative opioid use. Therefore, it is critical to work with the patient’s primary care team and pain management team to pre-operatively wean off or at least reduce narcotic use when possible. The “high” pre-operative narcotic use segment of this population had the highest likelihood of continued narcotic use post-operatively.
  • Patients with depression clearly have higher narcotic requirements in the post-operative period and are at an elevated risk for chronic opioid use and lower likelihood of opioid cessation. Consequently, having a multi-disciplinary team approach to facilitate pre-operative screening and treatment of depression can result in an improved post-operative outcome with regards to opioid use, and perhaps in limiting other post-operative complications.
  • Another interesting trend based on this article is that patients with depression are more likely to undergo multi-level lumbar fusion surgeries compared to the control group. This can contribute to more pain, and a harder time weaning off narcotics. It may be prudent to consider hybrid constructs using a combination of laminectomies and fewer fusion segments for some of these patients, when clinically appropriate.

These findings also speak to the importance of patient counseling, which is critical for all spine surgeries. With regards to this specific patient population, patients can be made aware of the association between depression and chronic opioid use and the possibility of increased complications, and guided to seek out improved treatment for their depression and other psychiatric conditions.

In addition, while this study was designed to evaluate opioid use in patients with depression undergoing lumbar fusion surgeries, the surgical community must implement alternative pain medications whenever appropriate for all of our spinal fusion patients. I routinely utilize a multi-modal pain management approach for our spine surgery patients. This approach includes use of anti-inflammatory medications, acetaminophen, and anti-neurotropic medications such as gabapentin pre-operatively to address the various pain receptors. This multi-modal therapy is typically continued in the post-operative period to minimize narcotic use. Furthermore, using local anesthetic prior to incision and at closing along with possible use of injectable or oral steroids can facilitate pain control and minimize reliance on opioid medications.

Disclosures
Dr. O’Connell and Dr. Chaudhary have no relevant disclosures.

 

Updated on: 03/02/18
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