Minimizing Opioids After Teens’ Spine Surgeries Appears Practical

SAN FRANCISCO — Adolescents undergoing surgery for idiopathic scoliosis appeared to fare just fine with opioid-sparing analgesic regimens in the days following their procedures, researchers said here.

In one study focusing on a multimodal protocol that combined up to five non-opioid medications along with non-pharmacologic therapies, half of patients needed no add-on opioids during inpatient recovery to maintain tolerable pain levels, and fewer than one-third were prescribed opioids at discharge.

Another study found that a regimen based on liposomal bupivacaine (Exparel) appeared to speed patients’ recovery relative to a conventional as-needed analgesic regimen, with fewer opioids required.

Both were reported at the American Academy of Orthopaedic Surgeons’ (AAOS) annual meeting.

Keeping opioid use to a minimum after surgeries of all kinds has become a key goal, with countless studies linking higher post-operative doses and lengthy prescriptions at discharge with increased rates of long-term dependence. It’s a particularly sensitive issue with adolescent patients, who may find the temptation irresistible to try opioids for recreation, and who may face peer pressure for diversion.

Michael Schallmo, MD, of Atrium Health Carolinas Medical Center in Charlotte, North Carolina, talked at AAOS about his department’s experience after one surgeon decided to switch all his adolescent scoliosis patients starting in June 2019 from conventional opioid-based pain relief to a multimodal approach. The latter included ketorolac by infusion for the first postsurgical day or two, followed by oral ibuprofen, gabapentin, acetaminophen, and diazepam, plus a variety of other pain-mitigating interventions such as cryotherapy and aromatherapy. Prior to the switch, post-op pain relief was centered on morphine and hydrocodone/oxycodone, plus non-opioid and non-pharmacological treatments.

From June 2018 to June 2019, 56 patients were treated with the conventional opioid-based regimen; in the year following the switch, 37 patients received the opioid-sparing protocol. Surgeries in this group were more extensive than previously, with a median of 11 levels fused, compared with 9.5 before the switch (P=0.036); median length of stay was unchanged at 2 days.

One major limitation of Schallmo’s study was that patient-reported outcomes were not included. However, the opioid-sparing regimen did allow patients to receive rescue opioids to keep pain levels tolerable, and 51% of patients in this group did so. But the total doses were much smaller: median 1.2 morphine milligram equivalents, compared with 65 with conventional management. About 70% of the opioid-sparing group were discharged without an opioid prescription.

Schallmo noted that the switch was not accomplished easily. “It took a lot of effort” from the surgeon, he said, to persuade nurses, residents, and other support staff that taking opioids out of the standard protocol could work. The surgeon “had to push for this internally” for many months.

In the second study, reported by Alec Giakas, MD, of Nemours Children’s Health in Wilmington, Delaware, a similar multimodal regimen was examined — this one using liposomal bupivacaine (LB) delivered during surgery as an erector spinae block. This too was a single-center, single-surgeon project, in which patients received LB at the surgeon’s discretion. A total of 119 consecutive adolescent patients treated during a 1-year period were examined for the study, of whom 53 got the LB nerve block.

The basal regimen in all cases included methadone during surgery and, post-operatively, combinations of ketorolac, acetaminophen, gabapentin, clonidine, and diazepam. Patients could receive morphine and oxycodone as needed for inpatient pain control, and diazepam doses could be adjusted upward.

Giakas’s group did collect patients’ self-assessments for pain, and these did not differ between the two groups. Other measures favored the LB-containing regimen:

• Mean length of stay: 2.42 vs 2.74 days (P=0.005)
• Discharge on post-op day 2: 55% vs 27% (P=0.002)
• Mean distance walked on post-op day 2: 889 vs 553 feet (P=0.002)
• Mean total opioid dose: 44.5 vs 70.2 morphine milligram equivalent (P<0.001)

This latter difference was largely driven by reduced oxycodone doses during inpatient recovery, Giakas noted. Other than the introduction of LB, he said, no changes in policy around pain management were implemented during the period covered by the study.

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