Clinical Study|Articles in Press

Post-Lumbar Surgery Prescription Variation and Opioid-Related Outcomes in a Large US Healthcare System: An Observational Study


      Background Context

      Spinal decompression and fusion procedures are one of the most common procedures performed in the United States (US) and remain associated with high postsurgical opioid burden. Despite guidelines emphasizing non-opioid pharmacotherapy strategies for postsurgical pain management, prescribing practices are likely variable and guideline-incongruent.


      The purpose of this study was to characterize patient-, care-, and system-level factors associated with opioid, non-opioid pain medication, and benzodiazepine prescribing variation in the US Military Health System (MHS).

      Study Design/Setting

      Retrospective study analyzing medical records from the US MHS Data Repository.

      Patient Sample

      Adult patients (N = 6,625) undergoing lumbar decompression and spinal fusion procedures from 2016 to 2021 in the MHS enrolled in TRICARE at least a year prior to their procedure and had at least one encounter beyond the 90-day post-procedure period, without recent trauma, malignancy, cauda equina syndrome, and co-occurring procedures.

      Outcome Measures

      Patient-, care-, and system-level factors influencing outcomes of discharge morphine equivalent dose (MED), 30-day opioid refill, and persistent opioid use (POU). POU was defined as dispensing of opioid prescriptions monthly for the first three months after surgery and then at least once between 90-180 days after surgery.


      (Generalized) linear mixed models evaluated multilevel factors associated with discharge MED, opioid refill, and POU.


      The median discharge MED was 375 mg [IQR 225, 580] and days’ supply was 7 days [IQR 4, 10]; 36% received an opioid refill and 5%, overall, met criteria for POU. Discharge MED was associated with fusion procedures (+151-198 mg), multilevel procedures (+26 mg), policy release (-184 mg), opioid naïvty (-31 mg), race (Black -21 mg, another race and ethnicity -47 mg), benzodiazepine receipt (+100 mg), opioid-only medications (+86 mg), gabapentinoid receipt (-20 mg), and non-opioid pain medications receipt (-60 mg). Longer symptom duration, fusion procedures, beneficiary category, mental healthcare, nicotine dependence, benzodiazepine receipt, and opioid naivety were associated with both opioid refill and POU. Multilevel procedures, elevated comorbidity score, policy period, antidepressant receipt, and gabapentinoid receipt, and presurgical physical therapy were also associated with opioid refill. POU increased with increasing discharge MED.


      Significant variation in discharge prescribing practices require systems-level, evidence-based intervention.

      Key Words

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        • Zajacova A
        • Grol-Prokopczyk H
        • Zimmer Z.
        Pain Trends Among American Adults, 2002-2018: Patterns, Disparities, and Correlates.
        Demography. 2021; 58: 711-738
        • McDermott KW
        • Freeman WJ
        • Elixhauser A
        Overview of Operating Room Procedures During Inpatient Stays in U.S. Hospitals, 2014: Statistical Brief #233.
        Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US). 2006;
        • Deyo RA
        • Hallvik SE
        • Hildebran C
        • et al.
        Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery).
        Pain. 2018; 159: 1147-1154
        • Vraa ML
        • Myers CA
        • Young JL
        • Rhon DI.
        More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review.
        The Clinical Journal of Pain. 2022; 38: 222-230
        • Kreiner DS
        • Matz P
        • Bono CM
        • et al.
        Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain.
        Spine J. 2020; 20: 998-1024
        • Brophy RH
        • Fillingham YA.
        AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition.
        J Am Acad Orthop Surg. 2022; 30: e721-e7e9
        • Hsu JR
        • Mir H
        • Wally MK
        • Seymour RB
        Orthopaedic Trauma Association Musculoskeletal Pain Task F. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury.
        Journal of orthopaedic trauma. 2019; 33 (-e82): e158
        • Côté C
        • Bérubé M
        • Moore L
        • et al.
        Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review.
        BMC Musculoskeletal Disorders. 2022; 23: 238
        • Debono B
        • Wainwright TW
        • Wang MY
        • et al.
        Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
        The Spine Journal. 2021; 21: 729-752
        • Chou R
        • Gordon DB
        • de Leon-Casasola OA
        • et al.
        Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.
        The journal of pain: official journal of the American Pain Society. 2016; 17: 131-157
      1. Committee on Trauma of the American College of Surgeons. ACS Trauma Quality Programs: Best practices guidelines for acute pain management in trauma patients. 2020.

        • Schieber LZ
        • Guy Jr, GP
        • Seth P
        • et al.
        Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017.
        JAMA Network Open. 2019; 2 (-e)e190665
        • Patzkowski MS
        • Costantino RC
        • Kane TM
        • Nghiem VT
        • Kroma RB
        • Highland KB.
        Military Health System Opioid, Tramadol, and Gabapentinoid Prescription Volumes Before and After a Defense Health Agency Policy Release.
        Clin Drug Investig. 2022; 42: 439-446
        • Reid DBC
        • Shapiro B
        • Shah KN
        • et al.
        Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?.
        Clinical orthopaedics and related research. 2020; 478: 205-215
        • Shenoy R
        • Wagner Z
        • Kirkegaard A
        • et al.
        Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program.
        JAMA Health Forum. 2021; 2e212924
        • Raneses E
        • Secrist ES
        • Freedman KB
        • Sohn DH
        • Fleeter TB
        • Aland CM.
        Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey.
        JAAOS - Journal of the American Academy of Orthopaedic Surgeons. 2019; 27
        • Goel A
        • Feinberg A
        • McGuiness B
        • et al.
        Postoperative opioid-prescribing patterns among surgeons and residents at university-affiliated hospitals: a survey study.
        Can J Surg. 2020; 63 (-e8): E1
        • McCutcheon BA
        • Ciacci JD
        • Marcus LP
        • et al.
        Thirty-Day Perioperative Outcomes in Spinal Fusion by Specialty Within the NSQIP Database.
        Spine (Phila Pa 1976). 2015; 40: 1122-1131
        • Pletcher MJ
        • Kertesz SG
        • Kohn MA
        • Gonzales R.
        Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.
        Jama. 2008; 299: 70-78
        • Osmundson SS
        • Min JY
        • Grijalva CG.
        Opioid prescribing after childbirth: overprescribing and chronic use.
        Curr Opin Obstet Gynecol. 2019; 31: 83-89
        • Singhal A
        • Tien Y-Y
        • Hsia RY.
        Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse.
        PLOS ONE. 2016; 11e0159224
        • Townsend TN
        • Bohnert ASB
        • Lagisetty P
        • Haffajee RL.
        Did prescribing laws disproportionately affect opioid dispensing to Black patients?.
        Health Serv Res. 2022; 57: 482-496
        • Quan H
        • Li B
        • Couris CM
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        American journal of epidemiology. 2011; 173 (-82): 676
      2. Defense Health Agency. Procedural Instruction 6025.07: Naloxone in the MTFs. 2018.

      3. Defense Health Agency. Procedural Instruction 6025.04: Pain Management and Opioid Safety in the Military Health System (MHS). 2018.

      4. Opioid Prescribing Engagement Network. Opioid Prescribing Recommendations. 2022 [October 10, 2022]; Available from:

        • Subirana I
        • Sanz H
        • Vila J.
        Building Bivariate Tables: The compareGroups Package for R.
        Journal of Statistical Software; Vol. 2014; 1 (2014)
        • Lawal OD
        • Gold J
        • Murthy A
        • et al.
        Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis.
        JAMA Netw Open. 2020; 3e207367
        • Calcaterra SL
        • Yamashita TE
        • Min SJ
        • Keniston A
        • Frank JW
        • Binswanger IA.
        Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use.
        Journal of general internal medicine. 2016; 31: 478-485
        • Mathur VA
        • Trost Z
        • Ezenwa MO
        • Sturgeon JA
        • Hood AM.
        Mechanisms of injustice: what we (do not) know about racialized disparities in pain.
        Pain. 2022; 163: 999-1005
        • Herb JN
        • Williams BM
        • Chen KA
        • et al.
        The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review.
        Surgery. 2021; 170: 180-185
        • Hester G
        • Nickel AJ
        • Griffin KH.
        Accountability Through Measurement: Using a Dashboard to Address Pediatric Health Disparities.
        Pediatrics. 2020; 146
        • Kearney AM
        • Kalainov DM
        • Zumpf KB
        • Mehta M
        • Bai J
        • Petito LC.
        Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System.
        J Hand Surg Am. 2022; 47: 1035-1044
        • Howard R
        • Waljee J
        • Brummett C
        • Englesbe M
        • Lee J
        Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines.
        JAMA Surg. 2018; 153: 285-287
        • Yoo JS
        • Ahn J
        • Buvanendran A
        • Singh K.
        Multimodal analgesia in pain management after spine surgery.
        J Spine Surg. 2019; 5 (Suppl-s9): S154
        • Montgomery EY
        • Pernik MN
        • Johnson ZD
        • et al.
        Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery.
        Global Spine Journal. 2021; 21925682211035723
        • Tori ME
        • Larochelle MR
        • Naimi TS.
        Alcohol or Benzodiazepine Co-involvement With Opioid Overdose Deaths in the United States, 1999-2017.
        JAMA Network Open. 2020; 3 (-e)e202361
        • Jeffery MM
        • Hooten WM
        • Jena AB
        • Ross JS
        • Shah ND
        • Karaca-Mandic P.
        Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016.
        JAMA Network Open. 2019; 2 (-e)e198325
        • Waelkens P
        • Alsabbagh E
        • Sauter A
        • Joshi GP
        • Beloeil H.
        Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations.
        European Journal of Anaesthesiology | EJA. 2021; 38
        • Bhatia A
        • Buvanendran A.
        Anesthesia and postoperative pain control-multimodal anesthesia protocol.
        J Spine Surg. 2019; 5 (Suppl-s5): S160
        • Kurd MF
        • Kreitz T
        • Schroeder G
        • Vaccaro AR.
        The Role of Multimodal Analgesia in Spine Surgery.
        J Am Acad Orthop Surg. 2017; 25: 260-268
        • Hébert JJ
        • Abraham E
        • Wedderkopp N
        • et al.
        Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.
        Spine (Phila Pa 1976). 2020; 45 (-e30): E1421
        • Carrignan JA
        • Simmet RT
        • Coddington M
        • et al.
        Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery?.
        Archives of Physical Medicine and Rehabilitation. 2020; 101: 1389-1395
        • Schwartz CE
        • Stark RB
        • Balasuberamaniam P
        • Shrikumar M
        • Wasim A
        • Finkelstein JA.
        Moving toward better health: exercise practice is associated with improved outcomes after spine surgery in people with degenerative lumbar conditions.
        Can J Surg. 2021; 64 (e27): E419-
        • Scott-Richardson M
        • Johnson G
        • Burnett S
        • Giordano NA
        • Highland KB
        Policy Facilitators Versus Structural Barriers: Integrative Therapy Telehealth Changes in the United States During the COVID-19 Pandemic.
        Telemed J E Health. 2021;
        • Smith Jr, TW
        • Wang X
        • Singer MA
        • Godellas CV
        • Vaince FT
        Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties.
        Am J Surg. 2020; 219: 530-534
        • Grobaty L
        • Lajam C
        • Hutzler L.
        Impact of Value-Based Reimbursement on Health-Care Disparities for Total Joint Arthroplasty Candidates.
        JBJS Rev. 2020; 8e2000073
        • Novikov D
        • Cizmic Z
        • Feng JE
        • Iorio R
        • Meftah M.
        The historical development of value-based care: how we got here.
        JBJS. 2018; 100: e144
        • Brummett CM
        • Waljee JF
        • Goesling J
        • et al.
        New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults.
        JAMA Surg. 2017; 152e170504
        • Kim SC
        • Choudhry N
        • Franklin JM
        • et al.
        Patterns and predictors of persistent opioid use following hip or knee arthroplasty.
        Osteoarthritis and cartilage. 2017; 25: 1399-1406