Burden of Pre-operative Opioid Use and Its Impact on Healthcare Utilization After Primary Single Level Lumbar Discectomy

Background context: The complication profile and higher cost of care associated with pre-operative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models.

Purpose: To study the burden of pre-operative opioid use and its effect on post-operative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy.

Study design: Retrospective cohort study PATIENT SAMPLE: 29,745 patients undergoing primary single level lumbar discectomy from the IBM® MarketScan® (2000-2018) database.

Outcome measures: 90-day and 1-year utilization of lumbar epidural steroid injections (ESIs), emergency department (ED) services, lumbar magnetic resonance imaging (MRI), hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months post-operatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups.

Methods: Patients were categorized in opioid use groups based on the duration and number of oral prescriptions prior to discectomy (opioid naïve, < 3-months opioid use, chronic pre-operative use, chronic pre-operative opioid use with 3-month gap before surgery, and other). The risk of association of pre-operative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables.

Results: A total of 29,745 patients with mean age of 45.3± 9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar ESIs, MRI, ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared to patients with < 3-months use and opioid naïve patients (p<0.001). Chronic post-operative opioid use was present in 62.6% of the pre-operative chronic opioid users as compared to 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described.

Conclusion: Chronic pre-operative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year post-operatively. Two-third of chronic pre-operative opioid users had continued long-term post-operative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term post-operative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.

Keywords: Opioids; bundled payments; discectomy; lumbar; narcotic; outcomes; risk; spine; value.