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 is a really important and well-done research study conducted using a large population-based sample, so the results should be pretty generalizable,” says Judith Turner, a pain psychologist at the Center for Pain Relief and a professor in the School of Medicine at the University of Washington, Seattle, US, who was not involved in the study. 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.
Surgery rarely ends opioid use
Deyo says he took on the study because, at medical conferences, he has seen surgery posed as an alternative to long-term opioids as a treatment for back pain. “And yet in the [scientific] literature, there’s evidence that in fact patients often continue to take opioids even following surgery that is considered successful in technical terms. So it’s a good idea to take a look at what happens pre- and post-surgery.”
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.
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.
Considering the risks associated with long-term opioid use, Turner says, “those are sobering numbers.”
When considering patients’ opioid use, the researchers looked at the seven months before and the seven months after surgery, including the “perioperative period” of 30 days before and after surgery, when opioid use may be elevated during the lead-up to and recovery from surgery. To be considered long-term opioid users before surgery, patients had to fill at least four prescriptions in the seven months before surgery, with at least three of the fills more than a month before surgery. Similarly, long-term use after surgery was determined by at least four prescription fills after surgery, with three of them more than a month after surgery.
The researchers also wondered whether patients using opioids long-term before surgery were using a different dose after surgery. Although nine 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.
“So not only are many patients on long-term opioid therapy not stopping opioid use after fusion surgery for chronic back pain, almost half are increasing their dose,” says Turner.
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. 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.
After her most recent surgery—just a few weeks ago—she is taking a significantly lower dose of opioids than before surgery, but she has no illusions that she will be pain-free or halt opioids altogether. “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.
“The message for patients and providers is, if someone with chronic low back pain is using opioids long-term to manage their pain and is considering spinal fusion in hopes of decreasing pain substantially, it’s unlikely they’re going to discontinue using opioids for pain afterwards,” says Turner.
That finding fits with other research, says Ballantyne. “We are now seeing from the data—because so many people have been treated with opioids—that people who have been on opioids for more than 30 days have a high chance of staying on opioids for life.” (See a related report from the US Centers for Disease Control and Prevention.)
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.
Patients on long-term opioids, Ballantyne says, “have two whammies against them: their pain doesn’t disappear after surgery, and it’s hard to come off of opioids after recovery because of dependence. And a third whammy is that they need an increased dose of opioids to get through the surgery recovery—which we give them, because we’re a humane people—and then it becomes possibly even a higher dose than before surgery.”
In general, a key to avoiding long-term opioid use and its associated risks after surgery, Turner says, is to limit short-term opioid use after surgery.
“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.
“Every day you take opioids after surgery, you increase the odds of long-term use a year later,” Turner says.
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.
It’s also a very expensive procedure—in the neighborhood of $100,000—though with insurance, patients pay much less. Nevertheless, 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 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.
“This is major surgery with considerable risks,” says Turner. “Patients trying to decide whether to have spinal surgery for back pain need to consider the research evidence on the benefits of this surgery and the risks, including the risk of long-term opioid therapy after surgery.”
For patients like Andres, who have lived with intractable pain for months or years before surgery, those risks are worth running, she says. “None of these surgeries are without risk. I do not take them lightly—I don’t think anyone having a fusion goes into it lightly.”
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.
“Some doctors believe surgery is indicated to relieve back pain even in the absence of pain radiating to the leg, or of important spinal deformities. But randomized controlled trials from Europe suggest that for back pain alone, outcomes from surgery are not more effective than rigorous rehabilitation,” says Deyo.
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. Based on clinical experience and previous research, Deyo says, “surgeons and patients often expect to come out without significant pain.”
From her perspective as a patient, Andres says surgery may not erase pain or end opioid use, “but that doesn’t mean that spinal fusion is faulty or shouldn’t be done, or that pain medications don’t work.” For some patients, she believes, even after a successful surgery, pain remains and opioids are required and appropriate.
Still, the current study suggests that when it comes to opioid use after spinal fusion surgery, many patients’ expectations may not match the reality.
Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance writer in Southern California.