Hello everyone in the AANS Annual Conference 2020 virtual world. My name is Lindsay Ross and I am a spine fellow at Cedars-Sinai Medical Center and I will be talking to you today about our preliminary results from our retrospective analysis of our high opioid use patients who underwent participation in a pre-operative pain program prior to their spine surgery. I have no disclosures for you today. A little background, so preoperative opioid use is a predictor of adverse post-op patient reported outcomes in patients undergoing spine surgery. We also know that patients who use opioids preoperatively have a higher risk of 90-day complications. We know that they continue to use opioids post-operatively and we know that they use more health care resources. Some literature has shown a threshold for patients where about we can achieve a minimally clinically important difference. However, this is still under debate as some studies have shown that any preoperative opioid use will cause issues post-operatively and cause complications. The literature does show that there are strategies when strategies are used to decrease opioid use prior to surgery that you can improve outcomes but this has been primarily in the joint arthroplasty literature. So we looked at our patients first and we saw that the higher the preoperative MED, indeed the higher the length of stay. We also saw that patients in the red and yellow zone, that is patients that have preoperative MEDs greater than 80 for yellow and greater than 120 for red, had higher readmission rates. So the preoperative pain program was conceived in 2014. Today all patients who enter the spine center are screened for opioid use and then they were referred to the pain program if their MED is greater than 80. We have an opioid reduction protocol that primarily consists of a decrease of at least 10% MED per week and the program consists of an interdisciplinary team that includes a pain specialist, addiction psychiatrist, and therapist when appropriate. Together the group determines a MED and that MED is achieved, once that MED is achieved the patients are able to go about with their spine surgery. We look at multiple outcomes but some important ones that we are evaluating include the length of stay, the post-operative complications, re-operations, re-admissions, and functional outcomes that are determined via the PROMIS score system. The patients are followed post-operatively and their pain medications are managed and their functional outcomes are continued to be reported. So the patients are typically in the preoperative pain program for about one to three weeks so far. There is a large range in participation and that depends on multiple factors, primarily what their needs are and how important it is for them to get their surgery at a specific date. There is a clear dose-response relationship so the longer that you're in the preoperative pain program the more you're able to reduce your MED. So this was a retrospective evaluation. We're still continuing much of our statistical analysis but so far we have 329 high opioid use patients who underwent spine surgery from 2015 to 2019 where we were able to capture some follow-up data. There are 199 patients that were enrolled in the PPP and 230 who were not enrolled in the PPP. So far there's not much difference statistically between their ages, their comorbidities, their surgery types, or their BMI and so the groups are quite comparable. Additionally, the MED distribution between most both groups are equal. I would like to note one interesting aspect that we found and that is for patients who were enrolled in the preoperative pain program but then later dropped out we found that those 10% of those patients had MEDs in a very very very high group which was greater than 800. Looking at the PROMIS scores we found here that the pain intensity, the depression scores, and the physical functions did not change throughout each preoperative pain visit. So as the MEDs were coming down pain didn't change much or the depression didn't change much for the physical function. One really important piece of data that we found so far is that our readmission rates for high opioid users who participated in the preoperative pain program were six times less than high opioid use patients who did not participate in the program. Although not statistically significant, we did find that patients who participated in the preoperative pain program had a slightly lower reoperation rate at six months. With regards to length of stay, we did find that that patients who participated in the pain program actually had a longer length of stay, closer to average of seven days versus five days. We're not quite sure why this may be but some possible reasons could be differences in psychological comorbidities or could be an innate problem with the pain program. So we're able to draw a couple conclusions from our study thus far and one is that preoperative opioid weaning is entirely feasible for patients undergoing spine surgery and that a multidisciplinary team is essential and mental health services are frequently used and very, very helpful. We also know that patient participation depends significantly on the surgeon's support and that support should be consistent throughout the entirety of the process. Patients don't typically cancel surgery or seek care elsewhere just because we ask them to participate in the program. We know that post-operative opioid reduction should be monitored really to optimize those patient reported outcome scores and that the effect size can actually be quite large which is evidenced by our readmission rate. So what are the future directions? We've discussed this already before we even obtained our final statistical results and we talked a little bit about who are we asking to be in the preoperative pain program and maybe we should be asking patients with MED greater than 30 not just greater than 80. What should our goals be for reduction in the pain program? Should it be greater than 50% of what they came in on or should there be an absolute target of MED less than 30 milligrams per day? One particular issue that we would like to focus on and improve is acceptance in surgery delays both for the patients and the surgeons and I think that can only be truly achieved with data that shows that surgical outcomes and long-term functional outcomes are improved with participation in programs such as these. I would like to thank Carl Wittenabel who is the preoperative pain program director and the principal investigator for this study. I would also like to thank Dr. Patrick Johnson who is a co-investigator and my mentor. I would like to thank Keith Siegel for quite a bit of analysis on the data thus far and Jean Black for her help in design of the study as well as Dr. Terence Kim, Dr. Sang Kim, Dr. Barron, Dr. Perry and Dr. Tichman and the other faculty at Cedars-Sinai for their assistance in the study by contributing their patients to the preoperative pain program. Thank you.

pre-operative pain program

spine surgery

readmission rates

preoperative opioid weaning

patient-reported outcomes