Seven spine surgeons discuss the opioid crisis and offer strategies to help combat it.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
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Question: What are some strategies spine surgeons can employ to fight the opioid crisis?
Ace Tabaraee, MD. Spine and Trauma Surgeon at Stanislaus Orthopaedics and Doctors Medical Center (Modesto, Calif.): The opioid crisis is widespread and multifactorial. In order to address it, I believe spine surgeons have to use multiple tactics. First of all, allowing earlier access to spine subspecialty care may provide better patient education regarding the pathogenesis and treatment options of patient-specific spine-related issues.
Second, multidisciplinary cooperation between orthopedist, neurosurgeon, physiatrist, anesthesiologist and/or psychologist could address the multifactorial nature of multiple pain syndromes in a more efficient manner. Third, applying multimodal pain protocols that do not involve opioids during the preoperative, intraoperative and postoperative period could help reduce the side effects and potential addiction profile of opioids.
Fourth, if one is to have surgery, minimally invasive techniques could allow for less tissue destruction and less need for opioids. Finally, and maybe most importantly, addressing a person's psychosocial stressors and coping mechanisms can reduce their pain response noxious stimuli and better meet expectations of care.
Michael Gordon, MD. Spine Surgeon at Hoag Orthopedic Institute (Irvine, Calif.): The opioid crisis is upon us, with frenzied messages in media about unnecessary deaths and physician overprescription. We are increasingly under the microscope with government and insurance plans monitoring our prescribing habits and tracking our actions. There are multiple forces in the marketplace that are the source of this crisis and blame lies with each of them. I've casually split them into a few major stakeholders. These include patients with both legitimate and illegitimate opiate needs; the pharmaceutical industry with its economic incentives; government healthcare entities with varied regulatory burdens; insurance companies; and the illicit providers of illegal opiates. All of these entities push or pull at physicians. The pendulum swings from one extreme to the other. The whiplash we experience ranges from 'pain is the [fifth] vital sign and should be at zero after surgery' and 'chronic pain is an illness which should not be ignored and should be treated aggressively,' to 'doctors are needlessly overprescribing opiates and are the source of the epidemic we see today.' With bad outcomes and regardless of causation, physicians seem to share the brunt of the blame.
We interact with these stakeholders in a constant and varied balancing act, responding as we can to all of the economic, societal, legal and medical forces. Yet, all of these stakeholders share a common face — our patient, the patient-in-pain. Despite the varied causes, there are some very important actions we can take, and our spine surgery group has implemented a strategy.
As with other multifactorial illnesses, an algorithmic approach to pain management is very useful and we have implemented the following strategies with as many spine patients as possible. Whether the cause of pain is acute and post-inflammatory or post-traumatic of post-surgical, the patient is evaluated and treated. Similarly with chronic pain, a workup is done, and both legitimate and illegitimate pain medication requests are evaluated and treated. We minimize all preoperative opioids, and preferably treat acute pain with synergistic agents including NSAIDs, gabapentins, tramadol and steroids if indicated. Perioperative pain management includes heavy use of presurgical lidocaine/marcaine injections, multimodal anesthesia and minimal use of opioids.
In the hospital we only occasionally use [patient-controlled analgesia] preps and rely more on oral medications. Preoperatively, we set a timeframe for postoperative opiate use — usually no more than one month of narcotic prescription. We have almost entirely given up use of long-acting medications, such as fentanyl patches or oxycontin/mscontin mixtures. We lean more heavily on mixed agonist/antagonist agents and SSRIs. We screen heavily for multiple physician prescribing through the CURES database. Occasionally a drug screening urine test is required. Diversion of medications is minimized by small prescription sizes and no refills as well as exclusive use of e-prescribing. Rapid referral to pain management [centers] is done if pain lasts longer than expected. This is a difficult chore from time to time, and sometimes tough love is required.
Richard Kube, MD. Founder and CEO of Prairie Spine & Pain Institute (Peoria, Ill.): I believe that we as surgeons would do well to practice disease management rather than simply spine surgery. As specialists, we are in a unique position to assume control of the treatment process and hence the pharmaceutical treatment. If we manage the whole patient and not just the surgical component — that includes chronic follow-up for those with untreatable/nonsurgical conditions — we can curtail the usage of controlled substances. Additionally, for those patients who want to delay invasive treatment, we are poised to step in and offer an appropriate curative option when needed in lieu of simply adding more pills.
Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): It is important for spine surgeons to have a systematic approach to prescribing opioids. In my office, all patients are asked to sign a narcotic contract before being seen. This acknowledges that opioids are prescribed only for acute pain — such as that due to a fracture, acute disc herniation or postoperatively. Those patients with chronic pain and opioid dependence are referred to pain management for any and all pain medications.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Having met with legislators a few weeks ago on behalf of North American Spine Society, I can tell you this is incredibly top-of-mind for Congress. We encouraged looking at the pharmaceutical companies, their marketing practices and their distributors. We reiterated the necessity of allowing doctors to prescribe pain medications for acute postoperative pain and for trauma victims.
Also making spinal cord stimulators a part of a surgeon's practice is a helpful alternative to responsive patients or for those with failed-back syndrome. We also stressed to the lawmakers that to cut reimbursements for medication alternatives like SCS and intrathecal pumps would be a bad idea and likely worsen the crisis. The group of physicians were concerned that Congress' current effort would miss the mark.
S. Samuel Bederman, MD, PhD. Spine Surgeon at St. Joseph Hospital (Orange, Calif.): Pain management is a very challenging issue facing patients as well as surgeons. While we aim to help improve the lives of our patients and the pain they experience, we have to be concerned about the long-term problems associated with opioids. I rely on opioids to help manage postoperative pain, typically for a period of up to three months.
However, I rarely prescribe opioids for nonsurgical chronic conditions. There may be a role for short-term use of opioids for severe acute exacerbations of pain, but this depends on the patient and their condition. In general, I try to utilize non-opioid medications, such as anti-inflammatories, muscle relaxants and nerve medications instead of opioids, particularly for chronic conditions, in addition to other nonmedical treatments such as physical therapy, chiropractic, acupuncture and massage.
For patients with spinal problems that are amenable to surgery who continue to have severe pain following conservative treatment, I may recommend surgery rather than starting them down the road of opioids.
Neel Anand, MD. Professor of Orthopedic Surgery and Director of Spine Trauma at Cedars-Sinai Spine Center (Los Angeles): Opioid usage is on a steady rise in the United States over the last few decades, particularly in people who are affected by spinal conditions that result in severe or chronic back pain. Researchers have estimated that up to half of the people who undergo spine surgery are taking opioid medications at the time of surgery, with 20 percent of them possibly addicted to these medications. This is an essential topic for the medical community to pay significant attention to so that we can help reduce patients' dependence on and misuse of powerful opioid narcotics that aren't intended for long-term usage.
We spine surgeons have a responsibility to treat our patients as whole people, not just a spinal disorder. Because the research also indicates that other factors may contribute to continued opioid usage after surgery, it is crucial that [we] doctors do our part to recognize and address those factors as well — including psychosocial issues, anxiety and depression. In some cases, this could mean psychological counseling and an intentional period of weaning from opioid medications before surgery. Of course, this isn't to say we want to leave patients in pain. But the exploration of non-opioid methods for pain relief is gaining significant traction today and is worth consideration. These alternatives can include physical therapy, massage, non-opioid medications and mindfulness meditation, to name a few. And of course, every member of a patient's care team must commit to closely monitoring any opioid medications being used after surgery as well.
As a spine surgeon, I've seen and heard the railing against spine surgery as a 'treatment for back pain.' However, as a medical community and society, what if we began to view prescription opioid medications as a dangerous treatment for back pain? While I have written extensively on the concept that spine surgery should neither be the first line of defense in addressing a spinal condition (unless a traumatic, catastrophic injury has been sustained) nor [should it be considered] a 'magic bullet' cure that will fix everyone's spinal concerns, for the right candidates it can entirely be quality-of-life-saving. A lifetime of opioid addiction is certainly not a better alternative. We doctors owe our patients a far better prognosis than that.