This article is more than 5 years old. Information may no longer be current.

Do not be an enabler to chronic opioid use in spine surgery

ByJohn C. Liu, MD

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

Spine surgeons see chronic pain and opioid use on a regular basis. The number of patients who present already taking opioid pain medications for a variety of spine-related problems has increased rapidly in recent years. In my own practice, at least 50% of new consultations are patients who have been taking opioid pain medications for at least 3 months.

John C. Liu

I recently saw a patient with failed neck surgery and continued neck, shoulder and chronic arm pain. Innocently enough, she started taking Tylenol with codeine for nagging neck and shoulder pain. Ten years later, she was now taking multiple high-dose opioid pain medications and patches, yet still had severe pain. When I asked her if the medications reduced the pain, her response was “no, but it took the edge off.” After I gave her my opinion about her spine and chronic opioid use and offered her a referral to a good opioid detox physician, she said that if she had known now about negative effects of the pills, then she would have never started taking them.

Increased use of pain medications

This issue’s Cover Story details how the use of pain medications has increased significantly during the past 20 years. Sadly, however, the benefits of pain medications do not always outweigh the problems. Chronic high-dose opioid abuse can contribute to difficulty in postoperative pain control and significantly higher hospital stay.

The problem of chronic opioid use may have been sparked by the 1986 Portenoy study which found that pain was undertreated and for patients with chronic pain, taking opioids would not lead to any long-term effects. By the 1990s, physicians throughout the United States began to increase the number of opioid prescriptions they wrote. Many negative effects have occurred since, including an increase in unintended overdoses, addiction issues, illicit drug trafficking and even physicians prosecuted for over-prescribing narcotics which have led to overdose deaths. This trend also has generated a group of patients who chronically use opioids without an end in sight.

Have a road map

Spine surgeons need to do more than just write a prescription with multiple refills and see a patient 6 months later. They have a responsibility to their patients to not become their enablers. This is similar to teachers who move an unqualified student along, possibly resulting in an illiterate adult. Having a road map to treat patients in chronic pain is crucial to reduce the increase of opioid abuse.

We need to closely monitor the use and writing of prescriptions for powerful pain medications. Opioid use is not effective on nerve pain and its best use is for noceptor-generated pain and post-surgical incisional pain. Neurogenic, neuropathic, mechanically or non-structurally related chronic spine pain have not been shown to be effectively controlled with chronic opioid-based treatment strategies. Spine surgeons, and in fact all physicians, need to become better educated on the medications for which we write prescriptions and their uses, adverse events and addictive potential.

Spine surgeons must educate patients about medications before we write a prescription. Recognize and speak with patients who seek your opinion for spine problems that their choice of opioid is detrimental to overall care and likely will lead to other chronic opioid-induced problems, such as tolerances, hypersensitivity to pain, addiction and even depression.

If a patient has been chronically taking pain medication prior to surgery, then spine surgeons need to consider a medication adjustment and detox program to greatly help a patient’s postoperative course. We need to educate and be able to refer patients to qualified physicians for proper drug detox. Just as every spine surgeon has a list of referring cardiologists or primary physicians, we should also have a list of qualified referring pain physicians and psychologists who can help with detox and the associated depression.

If a spine surgeon needs to start a patient on opioids, then he or she should talk about patient expectations, set a limit on duration and how to taper off the medications. Patients need other strategies for pain control and they need to know when they can no longer get a prescription for the medication.

Patients should be screened for depression. The Zung patient questionnaire can be used to get a sense of a patient’s psychological well-being. The association between depression, chronic pain and dependency is strong. If we do not follow up with how patients are doing, then they could be suffering from the treatment. Patients found to have depression should be referred to a qualified psychologist for treatment.

Always communicate with patients’ primary care physicians or pain physicians. They need to know the medications that have been added to the mix and for how long the medications are planned to be used. This is another way to ensure all physicians communicate on the patient’s behalf. New York has instituted a program which should be considered nationally. This program monitors how often a patient refills a prescription and the patient gets prescriptions from other physicians as well. It is another line of safeguards to help prevent over-prescription and abuse.