Is Opioid-Free Spine Surgery the Way of the Future?

Is opioid-free spine surgery viable? These experts say yes. Read about their work and why they believe opioid-free spine surgery to be the future.

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America is in the midst of an opioid crisis. On average, 130 Americans die each day from an opioid overdose, making it a leading cause of injury-related death in the United States. The situation is so dire that nearly 2 million people live with prescription opioid use disorder in the USA, the bulk of whom were prescribed opioids after injury or a surgical procedure.

Opioid free spine surgeryCan you recover from spine surgery without opioids? More and more experts are saying "yes."

With opioid addiction across the country at crisis proportions, two studies suggest that alternatives to pain management may reduce or eliminate opioids in post-spine surgery care.

Neurosurgeon Zarina Ali, MD, implemented a comprehensive program for spine and peripheral nerve surgery patients that has led to a significant reduction in the use of opioids. Although the Enhanced Recovery After Surgery (ERAS) program— spanning the periods before, during, and after surgery —is not a strictly opioid-free program, it has led to fewer patients becoming dependent on or addicted to opioid pain pills.

The ERAS multi-modal system is used on spine surgery patients at Pennsylvania Hospital where the study took place. It includes patient education, comprehensive recovery plans, nutrition information, and early movement post-surgery.

Dr. Ali’s research study enrolled 1,141 patients in the ERAS program and measured their opioid use with 149 controls who received the standard of care. One month post-op, 38.6% of the ERAS cohort needed prescription pain medications, compared to 70.5% of the control group. Six months after surgery, only 23.6% of the ERAS group needed pain medications, compared to 51.9% of the control group.

Pain Medication After Surgery: Do You Really Need Opioids?

The results of Dr. Ali’s study are encouraging in the context of the current nationwide opioid epidemic. “Opioids have historically been the mainstay of pain control for spine surgery patients,” says Richard Berkman, MD, neurosurgery specialist at Vanderbilt University Medical Center. “However, opioids don’t help as much as previously thought.”

Dr. Berkman developed a comprehensive program for opioid-free pain control after elective spine surgery. 244 patients were enrolled in the study, one-third of whom had lumbar fusions. Rather than prescribing opioids to these patients, Dr. Berkman used a multimodal pain management protocol, including ice packs, acetaminophen, ibuprofen and other non-opioid pain medications.

The study included two phases: an initial period of opioid-minimization followed by a second period in which eliminating opioids entirely was the goal. In the initial period, 47 percent of patients took no opioids in the first month after discharge. During the elimination period, 88 percent of patients took no opioids whatsoever.

Of the lumbar fusion patients who were opioid-free before surgery, 93% did not take a single opioid in the postoperative period. Surprisingly, these patients reported experiencing satisfactory pain relief.

“Opioid-free elective spine surgery, including lumbar fusions, is feasible and effective,” says Berkman. “It should be offered to patients who have not used opioids or who can be weaned off before their operation.”

Alternatives to Opioids After Spine Surgery

While it may seem like opioids are the “gold standard” in pain management, research shows this isn’t necessarily true. Patients who have used opioids long-term (3+ months) often develop hypersensitivity to pain and experience it more intensely than those who have not used opioids.

“Patients who are given opioids within 72 hours post-surgery still rate their pain higher than those who have not taken any,” says Dr. Berkman. “In fact, many patients reported getting better pain relief with Tylenol and NSAIDs than opioids.”

Knowing this, healthcare providers are opting for alternative measures for pain relief both during and after surgery. “Some patients may receive nerve-blocking anesthesia during surgery and a combination of non-opioid medications such as acetaminophen, ibuprofen, and steroids to manage pain during their recovery,” says Dr. Ali.

Alternate modes of pain management — such as ice packs and TENS machines — are also used post-surgery along with some complementary approaches, such as acupuncture and medical hypnosis, as a means of supplementing conventional medicine. This combined approach to pain management helps surgeons tailor pain control methods to each individual patient’s needs.

Patients as Partners in Pain Management

A key part of these multimodal approaches is focusing on anticipating the need for treatment before the patient actually experiences pain. Prior to spine surgery, both ERAS and Dr. Berkman’s programs involve patients in their care both before and after surgery to optimize a safe recovery. Patients are educated, expectations are managed, and most feel empowered to get through their recovery opioid-free.

“Education and expectation management are major components of the ERAS program,” explains Dr. Ali. “The patient is our partner from the get-go. We work collaboratively with our patients and all of the individuals involved with their care to make a comprehensive pain management plan, including nurses, rehabilitation therapists and anesthesiologists.”

The Future of Opioid-Free Spine Surgery

Can every spine surgery patient — no matter the procedure — be a candidate for opioid-free spine surgery? The experts believe so.

With spine surgery, patients often experience significant pain prior to surgery and have used opioids long-term for back pain relief.  For those patients, weaning off opioids before surgery is imperative to increase their tolerance for pain and eliminate their dependability on the drugs.

“Any patient who is undergoing spine surgery is a candidate,” says Dr. Berkman. If more surgeons adopt these opioid-free surgery options, “It will make a huge dent in the opioid crisis in this country.”

“Asking ourselves, ‘How can we do better than what we are right now?’ is what ERAS is all about,” says Dr. Ali. “With the widespread adoption of this thoughtful, intentional approach with multi-modal pain management, we can get patients through surgery without subjecting them to the risk of becoming chronic opioid users. I do believe this is the way of the future.”

Interested in having opioid-free spine surgery? Find a spine specialist who can perform it.

Updated on: 08/25/20
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Zarina S. Ali, MD, MS
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