Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution

INTRODUCTION

Perioperative pain management presents a substantial challenge in spine surgery, because pain can be severe and lead to increased morbidity and complications if poorly controlled. Patients may suffer from delayed mobilization, extended hospital stay, slower functional recovery, development of chronic pain syndromes, and higher readmission rates if their pain is not effectively managed.^1–7 Pugely et al⁷ assessed lumbar spine surgery patients for unplanned 30-day readmissions and found that pain-related reasons (22.4%) were behind only wound-related complications (38.6%) as the most frequent cause for readmission. Opioid analgesics have long been the first-line for postoperative pain management in major surgeries, including those involving the spine, with sales and distribution in the United States increasing nearly 4-fold between 1997 and 2010.⁸ However, opioid overuse has also been associated with significant adverse effects, including urinary retention, confusion, nausea and vomiting, constipation, respiratory depression, and even death.^9,10

As the opioid crisis has gained national attention, there has been an increasing effort to decrease opioid usage without compromising effective pain control. Prescription opioid use has been shown to increase the risk of drug overdose by a factor of 6 and opioid dependence was estimated^11,12 to be as high as 26% among patients receiving pain treatment in 2006. In 2008, opioids were implicated in 14 800 deaths in the United States, a 3-fold increase over the course of a decade.¹³ Nonopioid therapies have been increasingly used as part of individualized, multimodal analgesia (MMA) regimens in an effort to improve pain control and minimize opioid-related side effects.^10,14,15 Studies^16,17 have reported on the capability of these MMA regimens to effectively reduce postoperative pain while also decreasing total opioid use. By relying on the synergistic action of multiple nonopioid medications, MMA regimens are able to manage pain with less of the unfavorable side effects associated with increased opioid usage.

Simultaneously, patient satisfaction is a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. Patients who have less pain, better physical function, and a more positive impression of their hospital care after surgery have higher satisfaction scores.^18–20 Given this connection and the increased rates of opioid use in recent years, some authors²¹ have cautioned clinicians about attempts to optimize patient satisfaction scores by prescribing more opioids. However, recent studies have also shown promise in the ability of MMA regimens to reduce opioid use without compromising satisfaction scores. Jirarattanaphochai et al²² found in 2008 that the addition of parecoxib versus a saline placebo after lumbar discectomy, decompression, or fusion procedures led to a 39% reduction in morphine use, along with reduced pain at rest and greater satisfaction. The purpose of this study was, therefore, to examine rates of pain medication prescription, both opioid and nonopioid, and concurrent patient satisfaction in spine surgery patients at our institution, where active efforts have been made to reduce opioid usage.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Effective postoperative pain management ultimately amounts to the reduction of pain and improvement of functional outcomes while minimizing adverse events associated with analgesic use. Whereas opioid medications are still the standard therapy used in treating postoperative pain, growing concern about opioid overdoses in the United States has spurred institutional attempts to reduce their use and misuse in the inpatient setting.^23,24 This is especially relevant in spine surgery, because these procedures are associated with high levels of postoperative pain, and existing research^25–27 has shown an increased risk of inappropriate opioid prescriptions and chronic opioid use in orthopedic surgery patients. As a way to combat this, multimodal approaches to pain management relying on synergistic effects between multiple nonopioid medications have increased in popularity. At the same time, patient satisfaction is an important metric to consider when evaluating the efficacy of pain management in patient care. Thus, the purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients at our institution, where an active effort has been made to reduce opioid usage.

In the entire patient population analyzed in our study, mean opioid use in total MMEs per patient hospitalization through the entire year was 574.46. Although the mean total MME per hospitalization decreased each quarter from 615.06 in Q1 to 504.05 in Q4, there was no statistical significance. However, the mean MME per day per patient did significantly decrease between quarters, with the highest mean of 91.84 in Q2 and lowest 77.50 in Q4. Though the total amount of opioid usage per hospitalization did not decrease significantly over the course of the year, the daily amount used per patient was successfully reduced. Despite the reduction of mean MME per day, length of stay did not significantly change across quarters. This is perhaps explained by a nonsignificant trend toward decreasing total MME by quarter (615.06 in Q1 and 504.05 in Q4) that emerged upon assessing changes in usage on a day-to-day level. This suggests that the physicians at our institute overall were successful in reducing opioid usage as the year progressed.

Subanalyzing patients by physician, we found that 3 physicians had decreasing mean MME per day values for their patients. Two of these physicians also had decreased total MME. None of the other physicians had statistically significant decreases in total MME or MME per day throughout the year, though most did demonstrate lower mean values in Q4 compared with Q1. This is likely attributable to smaller sample sizes per quarter and highlights the benefit of examining an aggregate of cases. When we assessed opioid usage by procedure type, MME per day decreased (from 74.78 to 52.37) and total MME trended toward a significant decrease (from 465.73 to 341.63) for discectomy cases. After controlling for age and revision, we found that total MME decreased for discectomies and also trended toward a decrease for fusions.

Along with decreased opioid use, there was a concurrent increase in prescriptions for other, nonopioid pain medications during the year. Among all patients, prescription rates for acetaminophen, NSAIDs, and steroids all increased throughout the year. NSAID prescription rates also increased in laminectomy patients. These changes highlight an increasing use of nonopioid medications to manage postoperative pain at our institution. At the same time, benzodiazepine and GABA analog prescriptions decreased among all patients over the course of the year. Benzodiazepine prescriptions also decreased in fusion patients specifically. Side effects of benzodiazepines and GABA analogs can be synergistic with the inhibitory effects from opioids due to action on the same receptors, so a concomitant decrease in their usage in pain regimens is a promising development.²⁸ In particular, the combination of opioid medications with benzodiazepines increases the risk of respiratory depression and death, and a 2016 study by Dasgupta et al found a nearly 10-fold increase in risk of death from overdose in outpatients concurrently using high-dose opioids and benzodiazepines.^29,30 Therefore, decreases in benzodiazepine and GABA analog prescriptions for postoperative patients already on opioids should also improve safety.

In spite of changes in medication use, there were no cumulative differences in patient satisfaction throughout the year. Mean hospital ratings from the Press Ganey Satisfaction Survey did not change significantly across quarters (8.66 for Q1, 8.60 for Q2, 8.36 for Q3, and 8.40 for Q4). There were also no differences between quarters in responses to questions regarding how often hospital staff talk about pain, how often staff talk about pain treatment, or whether the patient would recommend the hospital. This was also the case for top-box ratings for the same questions, with the majority of patients selecting the top-box response for each question in each quarter. Altogether, this establishes that, over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas patient satisfaction scores remained unchanged.

Our study has some limitations. Because this was a retrospective cohort study, it has all of the accompanying limitations of such a study, such as the potential introduction of selection bias and information bias. We also had limited sample sizes when splitting patients up by physician, which may have limited our ability to detect the significance of changes in the use of both opioid and nonopioid medications throughout the year. With Press Ganey survey data available for significantly fewer patients than medication use data, we may not be seeing fully the potential changes in patient satisfaction over the year. Recent changes in Press Ganey survey questions about pain management may have also affected our satisfaction data. Some questions in the survey were changed in 2017, during our study time frame, to reflect a greater emphasis on communication between providers and patients about pain rather than patient perception about how successful pain treatment was. The question about how often hospital staff talked about pain replaced a similar question about how often pain was “well controlled.” Similarly, the question about how often staff talked about pain treatment replaced one about whether the staff “did everything they could” to help with pain. Although these replacement questions were thematically related, their different focus may have led patients to answer differently than in the original questions.

Future studies could benefit from implementing a lower opioid-use protocol when examining opioid prescriptions and patient satisfaction scores. As more institutions attempt to reduce their opioid usage, findings in these projects could also be weighed against the possibility of underprescribing for pain. In addition, certain procedure types had more significant differences in drug use at our institution, and further exploration into what accounts for these differences may be beneficial. For example, postoperative opioid usage tended to be higher overall in fusion cases but reductions in use were more significant in discectomy cases. This may be related to the invasiveness of these procedures. Because the more invasive fusions likely necessitated more opioid usage for pain control, they may have been less liable to significant opioid reductions. Meanwhile, the less invasive discectomies may have proven to require minimal opioid usage in the first place, without further reductions negatively affecting pain. This also highlights that further adjustments in pain regimens could still be made, depending on procedure type. Overall, the findings of our study indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without impacting overall satisfaction rates.

CONCLUSIONS

Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without impacting overall satisfaction rates.