Spinal Surgery Does Not End Opioid Use for Pain

Expectations Versus Reality: Spinal Surgery Does Not End Opioid Use for Pain – RELIEF: PAIN RESEARCH NEWS, INSIGHTS AND IDEAS By Stephani Sutherland – July 2018

People seeking medical treatment for back pain often end up in a surgeon’s office.

Most of those individuals hope—and expect—that surgery will reduce their pain enough to make opioid painkillers unnecessary after the operation.

But that scenario seems to be the exception rather than the rule, according to a new report published in the journal PAIN.  

The study, led by Richard Deyo, a professor of evidence-based medicine at Oregon Health & Sciences University, Portland, US, shows that fewer than one in ten people taking long-term opioids for back pain before surgery discontinued their medication after lumbar spinal fusion surgery—and some patients who weren’t taking opioids pre-surgery started long-term opioids after surgery.

This means that the subjects in the study are likely representative of the wider population of people getting the same surgery, so the results can be extended to others.

The results of the study come as no surprise to Jane Ballantyne, a professor of anesthesiology and an expert on opioids, also at the University of Washington. “The value of the paper is that it actually documents what clinicians suspected was happening to their patients,” says Ballantyne, who was also not involved in the study.

If even dramatic surgeries aren’t successful in alleviating a patient’s pain, why does she advocate so strongly for denying them opioids?

Surgery rarely ends opioid use

Why do they always measure opioid use instead of pain level? It’s because opioid milligrams can be objectively measured and pain cannot.

However, substituting “pain level” everywhere the article says “opioid dose” makes these results more clear and pertinent.

The researchers focused on a highly invasive surgery performed in an effort to alleviate back pain called lumbar spinal fusion. Here the bony vertebrae of the lower spine are joined to one another, often together with several metal rods, in order to stabilize the spine.

The investigators used Oregon’s statewide electronic prescription drug monitoring program (PDMP) and the statewide hospital discharge registry to track use of opioids before and after lumbar fusion surgery, in 2,491 patients.

Seven months after surgery, more patients were taking opioids long-term than before surgery.

Of the 1,045 patients taking opioids long-term before surgery,

• 77 percent were still taking them long-term after surgery, and
• another 14 percent used opioids episodically after surgery.
• Only 95 of those patients—fewer than one in ten—discontinued use of opioids or only used opioids for a brief period after surgery.

This is also because so many back surgeries lead to Failed Back Surgery Syndrome (FBSS), adding even more pain and thus increasing their opioid dose.

In the seven months before surgery, about a quarter of the study patients never used opioids. Afterward, 13 percent of those people used opioids long-term.

The researchers also wondered whether patients using opioids long-term before surgery were using a different dose after surgery. Although

• 9 percent of those patients discontinued opioid use and
• nearly 35 percent were on a lower dose after surgery,
• around 12 percent stayed at the same dosage, and
• another 45 percent were on a higher dose compared with before surgery.

45% is almost half! Essentially the surgeries increased pain levels instead of decreasing them.

A patient’s experience

Susan Andres, a registered nurse living in Massachusetts, was not a subject in the study but recently underwent lumbar spinal fusion surgery. Andres has lived with severe back pain since 2007 when she sustained an injury while working in a pediatric intensive care unit.

Since then, she has been diagnosed with a number of degenerative spinal conditions and has undergone several spinal fusion surgeries to stabilize her spine.

Last year, her pain grew so intense that she had to consider having another surgery.

“I was not keen to have any more, but I got to the point where I couldn’t stand, I couldn’t sit, I couldn’t walk—and forget about showering. I was dependent on my husband to do everything.”

Before Andres’s first fusion surgery, she was not taking opioids, and she has been taking them since then.

This sure sounds like the dreaded FBSS to me.

So in the context of the present study, Andres would technically fall into that category of patients who started long-term opioids after surgery. But she thinks that has more to do with the poor pain management she received before her first surgery than with the surgery itself.

Now that the initial post-operative pain is almost gone, I am left with residual pain—I continue to have pain in my back and my legs, but I can stand upright. I can walk, I can shower, I even made a meal.” After being bedridden for months before surgery, that feels like a win to her.

Opioid use predicts opioid use

In the study, Deyo and colleagues also analyzed their data to determine what factors contributed to long-term opioid use after surgery.

The single greatest influence: long-term opioid use before surgery. Higher doses also increased risk for long-term use.

That’s because opioid dose correlates with pain level, dummies!

More severe pain is less likely to be “cured” by surgery so it’s logical that these folks will have to continue using opioids

So why did patients already receiving opioids still use them after surgery?

We think for patients taking long-term opioids prior to surgery, in many cases the continued use post-operation relates at least as much to dependence on the medication as it does to pain relief or failure of relief from surgery itself,” says Deyo. Here Deyo was referring to physical dependence, which causes withdrawal symptoms when patients stop taking the drugs.

This is outrageous arrogance, failing to take into account that the surgeries themselves caused increased and lasting pain.

“Patients are still often given way too much opioid medication after surgery,” according to Turner. A few days of opioid medication is sufficient after most surgeries, she says, “but patients are routinely given a supply for much longer.”

She recommends that doctors and patients have a discussion about how long opioids should be used immediately after surgery, and a plan for how to taper and discontinue using them.

Again, this assumes the surgery is successful in alleviating the pain without adding any new pain. That rarely happens.

An extreme step

As far as spinal fusion surgery goes, “I’m afraid patients may be cavalier about the rate of complications from this surgery—it’s a much more invasive procedure than removing a disc,” says Deyo

The number of surgeries performed annually is growing astronomically, approximately tripling in the past two decades. According to Deyo’s search of the available data, nearly half a million spinal fusion surgeries were performed in the US in 2014, up from about 150,000 in 1993.

The numbers of surgeries are increasing for 2 big reasons:

1. The lack of access to opioids to control pain makes patients desperate enough to resort to more extreme measures to relieve their pain.
2. The aging population, in which a higher percentage of people develop pain. Especially back pain, because our upright spines must carry all out weight and get worn down by the late decades of life

The reason for the high rate is partly due to financial incentives, he says, because doctors and hospitals are reimbursed handsomely for the procedures, and the medical device industry markets to them aggressively.

Yes, let’s not forget the American drive to seek profit at all costs. 

Is there evidence that spinal fusion surgery is beneficial for chronic back pain?

“It depends on the diagnosis,” Deyo says. For some patients—like Andres—with severe conditions, it can help, but “beyond that, it’s trickier.” Most controversial is the use of fusion surgery for degenerating or slipped discs.

While there are no guarantees that surgery will improve a patient’s pain, both doctors and patients are often desperate to try something in the face of intractable pain.

This is because they are no longer offered opioids to manage their pain.

Based on clinical experience and previous research, Deyo says, “surgeons and patients often expect to come out without significant pain.”

Surgeons believe that because they don’t keep track of long-term outcomes. Most of them see their patient only once or twice in the weeks after surgery and never know how many of them go on to suffer from permanent pain.

Still, the current study suggests that when it comes to opioid use after spinal fusion surgery, many patients’ expectations may not match the reality.

Author: Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance writer in Southern California.