Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion

Publication date: November 2018

Source: The Spine Journal, Volume 18, Issue 11

Author(s): Nikhil Jain, John L. Brock, Frank M. Phillips, Tristan Weaver, Safdar N. Khan

Abstract

Background Context

As health-care transitions to value-based models, there has been an increased focus on patient factors that can influence peri- and postoperative adverse events, resource use, and costs. Many studies have reported risk factors for systemic complications after cervical fusion, but none have studied chronic opioid therapy (COT) as a risk factor.

Purpose

The objective of this study was to answer the following questions from a large cohort of patients who underwent primary cervical fusion for degenerative pathology: (1) What is the patient profile associated with preoperative COT? (2) Is preoperative COT a risk factor for 90-day systemic complications, emergency department (ED) visits, readmission, and 1-year adverse events? (3) What are the risk factors and 1-year adverse events related to long-term postoperative opioid use? (4) How much did payers reimburse for management of complications and adverse events?

Study Design

This is a retrospective review of Humana commercial insurance data (2007–Q3 2015).

Patient Sample

The patient sample included 29,101 patients undergoing primary cervical fusion for degenerative pathology.

Methods

Patients and procedures of interest were included using International Classification of Diseases (ICD) coding. Patients with opioid prescriptions for >6 months before surgery were considered as having preoperative COT. Patients with continued opioid use until 1-year after surgery were considered as long-term users. Descriptive analysis of patient cohorts has been done. Multiple-variable logistic regression analyses adjusting for approach, number of levels of surgery, discharge disposition, and comorbidities were done to answer first three study questions. Reimbursement data from insurers have been reported to answer our fourth study question.

Results

Of the entire cohort, 6,643 (22.8%) had preoperative COT. Preoperative COT was associated with a higher risk of 90-day wound complications (odds ratio [OR] 1.39, 95% confidence interval [CI]: 1.16–1.66), all-cause 90-day ED visits (adjusted OR 1.22, 95% CI: 1.13–1.32), and pain-related ED visits (adjusted OR 1.39, 95% CI: 1.24–1.55). Patients who had preoperative COT were more likely to receive epidural or facet joint injections within 1 year after surgery (adjusted OR 1.68, 95% CI: 1.47–1.92). These patients were also more likely to undergo a repeat cervical fusion within a year than patients who did not have preoperative COT (adjusted OR 1.21, 95% CI: 1.01–1.43). Preoperative COT had a higher likelihood of long-term use after surgery (adjusted OR 4.72, 95% CI: 4.41–5.06). Long-term opioid use after surgery was associated with a higher risk of new-onsetconstipation (adjusted OR 1.34, 95% CI: 1.22–1.48). The risk of complications and adverse events was not found to be significant in patients with <3 months of preoperative opioid use or those who stopped opioids for at least 6 weeks before surgery. The cost of additional resource use for medications, ED visits, constipation, injections, and revision fusion ranged from $623 to $27,360 per patient.

Conclusions

Preoperative opioid use among patients who underwent cervical fusion increases complication rates, postoperative opioid usage, health-care resource use, and costs. These risks may be reduced by restricting the duration of preoperative opioid use or weaning off before surgery. Better understanding and management of pain in the preoperative period with judicious use of opioids is critical to enhance outcomes after cervical fusion surgery.

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