The Role of Spine Surgeons in Reducing Opioid Overdoses

North American Spine Society 34th Annual Meeting Highlight

Peer Reviewed

As the number of opioid-related overdose deaths continue to rise, spine surgeons play a key role in helping reduce these rates, said Katherine D. Travnicek, MD, at the North American Spine Society (NASS) 34th Annual Meeting in Chicago, IL. Spine surgeons can limit the dose and duration of opioid prescriptions after spine surgery and help better identify patients at risk for opioid use disorders and fatal or non-fatal overdose using standardized tools.

opioid-related overdose deaths continue to riseSpine surgeons can make a positive impact on opioid-related overdose deaths by changing, among other things, how much opioid is prescribed. Photo Source:

The landscape of the opioid crisis has changed over time, said Dr. Travnicek, who is a physiatrist and pain management physician at the Pain Institute of Nevada in Las Vegas.

“Initially, patients were overdosing on prescription opiates, and then overdoses were more likely due to heroin, and now our problem is illicit fentanyl,” Dr. Travnicek said.1 “US deaths from synthetic opiates have risen more than 10-fold in 5 years … from 3,000 in 2013 to more than 30,000 in 2018, and illicit fentanyl now is involved in twice as many deaths as heroin,” Dr. Travnicek said.1

“Each of these overdose deaths provides an opportunity for prevention, and we can make a positive impact by changing how much opioid we prescribe to reduce overdose and overdose deaths while providing better care for our patients,” Dr. Travnicek told NASS attendees. “We can reduce the opioid burden before the surgery and in the peri-operative periods, which results in a marked reduction in the need for opioids in the postoperative period.”

Chronic low back pain is the primary diagnosis for an opioid prescription, and up to 60% of patients are exposed to or currently taking opioids prior to spine surgery.2 While preoperative opioid use is a predictor of continued use following spine surgery,3 “a significant portion of patients who become addicted to opioids start with a prescription after surgery, whether it be minor or major. We can make a change at this point.4

The lecture series focused on other options as well. We should consider the broader array of evidence-based, drug-free options available for treating pain. In select patients with moderate spinal stenosis, the use of interspinous spacers can significantly decrease opioid use as has been demonstrated by robust 5-year postoperative research data.5 Also, advances in spinal cord stimulation, such as combination therapy can target multiple pain areas simultaneously and has shown strong results. Radiofrequency ablation for axial pain has been available since the early 1990s and remains an option that is often overlooked.”

Who is At Risk for Opioid Use Disorder?

To assess which patients are at the highest risk for opioid use disorders before surgery, Dr. Travnicek presented data on the Opioid Risk Tool (ORT), which was revised in 2019 based on newer validity studies. However, it is important to know that risk tools rely on patient reporting.6

“The most consistent finding across validity studies was that if a patient had a personal history of substance use abuse or misuse, they are at a higher risk for addiction,” Dr. Travnicek said.6 In addition, “The revised Opioid Risk Tool removed history of preadolescent sexual abuse in women and left in a family history of substance abuse, personal history of substance abuse, age 16 to 45 years, and psychological disease (ie, attention deficit disorder, obsessive compulsive disorder, bipolar, schizophrenia, and depression) as risk factors,” she said.

While the revised Opioid Risk Tool can be useful in determining the risk for an opioid use disorder, it is not useful in predicting the risk of overdose death or respiratory depression, Dr. Travnicek noted.

Who Is at Risk for Opioid Overdose?

In a retrospective chart review by Zedler et al, the risk of respiratory depression and overdose deaths in medical users of prescription opioids was strongly correlated to 1) opiate dependence, and 2) hospitalization during the 6 months prior to the overdose event.7 The study also showed that patients who experienced serious toxicity or an overdose event were typically sicker, as they were more likely to be hospitalized or have medical comorbidities including pancreatitis and moderate or severe liver disease, Dr. Travnicek told NASS attendees.7

The study also found that patients with the highest risk of respiratory depression/overdose deaths were those prescribed greater ≥100 mg of morphine equivalent daily dose, which was linked to a 4-fold higher risk of overdose death or serious opioid-related toxicity.7 Doses of ≥20 mg to <50 mg were linked to a 1.5-fold increased risk, and doses of 50 to <100 mg were linked to a 2.2-fold increased risk. Long-acting agents also were associated with an increased risk. Interestingly, tramadol was linked to a decreased risk for respiratory depression/overdose deaths, Dr. Travnicek explained.

These findings were also corroborated in an analysis of data from 18 million commercially-insured patients in which investigators concluded that “The risk factor profiles for serious opioid-induced respiratory depression among US medical users of prescription opiates with private and public health insurance were largely concordant despite substantial differences in the populations, demographics, clinical conditions, clinical practices, and healthcare delivery systems.”8

The same patient population of 18 million patients was used in a validation study of the RIOSORD (Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression).9 Dr. Travnicek noted that patients typically require help completing this index and recommended that spine surgeons coordinate care with the patient’s primary physician and pain management physician in order to get an appropriate score. The higher the score on this index, the greater the probability the patient will have an opioid overdose event, Dr. Travnicek explained.

Effect of Legislation on Opioid Prescribing Following Spine Surgery

In a retrospective review of patients who underwent selected lumbar spine surgeries (lumbar discectomy, lumbar decompression without fusion, and posterior lumbar), a greater than 50% decline in the number of pills and morphine milligram equivalents doses (P<0.001 for each comparison) was found after passage of mandatory statewide narcotic-limiting legislation in Rhode Island.10 No significant change in emergency department visits or unplanned hospital readmissions occurred after opioid prescription limits were enacted.

“We can do better,” Dr. Travnicek said. “We can prescribe less medicine for less amount of time, and patients may actually do better. However, we need more data, as this is the first study published on this topic.”

“We have to change our opiate prescribing habits, but we also need to assess risk,” Dr. Travnicek concluded. “We need to find out which of our patients are at risk for substance use disorders or opioid use disorder using the Revised ORT for that. The RIOSORD questionnaire can be used to assess patients’ risk of opioid-induced respiratory depression or overdose.”

“Besides reducing the dose and duration of prescriptions after surgery, we always recommend providing naloxone to patients,” Dr. Travnicek said. “I usually give a prescription to my patients.” Many states have naloxone over-the-counter but patients may not be able to afford it or may not purchase it due to stigma.

Dr. Travnicek added not to forget an interdisciplinary pain management approach that should incorporate psychiatrists, pain management specialists, primary care physicians, addiction specialists, and other medical providers.

Dr. Travnicek has no disclosures.

Updated on: 12/20/19
Continue Reading
Enhanced Recovery After Surgery (ERAS) Protocol Reduces Opioid Use After Spinal Surgery
Katherine Travnicek, MD
Physiatrist, Pain Medicine
Pain Institute of Nevada
Las Vegas, NV

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