In the June 2014 issue of the Journal of Bone and Joint Surgery (American edition), Dennis Lee, MD and colleagues submitted a Paper titled “Preoperative Opiod Use as a Predictor or Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery”. The paper discussed an investigation performed at the Vanderbilt Medical Center in Nashville Tennesee.
583 patients, who had spinal surgery were included in the study. You can read the details of the study, but preoperative parameters measured for the patients included use and amount of narcotics, smoking history, BMI, Oswestry or Neck Disability Index scores, and Zung Depression Scale scores.
The results indicate the use and the amount of preoperative opiod use (narcotics) correlated with worse outcome scores, disability, and depression after Spine Surgery.
As a spinal surgeon, this study is a great confirmation of what I have already seen in my practice. Unfortunately pain is a very difficult thing to measure, and some patients do have better tolerance than others. Also, pain severity can have an emotional component. To give you an example, when people are happy, they just are not as painful. When people are emotionally stressed, the pain worsens.
Unfortunately, there is an unhappy triad of pain, depression and disability. Use of narcotics often make this triad worse. The paper did make commentary on the exponential increase of narcotics sales from 1999 to 2010 (four fold, according to the paper). While the goal of the prescribers may be to help alleviate pain, the unintended consequences are multiple.
I have always advocated weaning dependent patients off narcotics, or at least reducing their narcotics before a surgery. I noticed patients who have been on chronic narcotics (over 6 months) do have the most difficulty post-op, and have the poorer outcomes. Some will say that is because those patients have the most pain, and the more serious problem. I would argue that those patients may feel more pain. That does not mean those patients have a more serious problem. I have noticed most of the poor surgical outcomes are from patients who could not taper their pain medications. Many claim no improvement after surgery.
It makes you wonder if surgery should be offered at all for those patients, as the risk for spinal surgery may not be worth a predictably bad outcome. More things to ponder. After 21 years of practice, I am still learning from these experiences. I am almost tempted to stop offering surgery if patients cannot taper. But, then again, I do not want to eliminate all hope for these folks. While there are general principles that should be followed, we still need to treat everyone one and every situation individually.