Abstract
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.
Purpose
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.
Methods
(Generalized) linear mixed models evaluated multilevel factors associated with discharge
MED, opioid refill, and POU.
Results
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.
Conclusion
Significant variation in discharge prescribing practices require systems-level, evidence-based
intervention.
Key Words
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Article info
Publication history
Accepted:
May 8,
2023
Received in revised form:
April 4,
2023
Received:
December 6,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
Published by Elsevier Inc.
