Opioid Use vs Spine Surgery; Vitamin D and Muscle Strength; New App Tracks/Changes Behavior e.g., Smoking

Daily Opioid Users Fare Worse Post-Spine Surgery

A new study from Johns Hopkins has found that adults who had surgery for spinal deformities and had used opioids daily experienced worse outcomes than those who did not use opioids preoperatively. Some of the problems were longer intensive care unit stays and more severe postop disability. This is the first study to examine the effects of opioids on adult spinal deformities (ASD).

The study, “Association of Patient-reported Narcotic Use with Short- and Long-term Outcomes After Adult Spinal Deformity Surgery: Multicenter Study of 425 Patients With 2-year Follow-up,” appears in the March 13, 2018 edition of Spine.

Micheal Raad, M.D., an orthopedic surgery research fellow at the Johns Hopkins University School of Medicine and co-author on the paper, told OTW, “Dr. Khaled Kebaish, the senior author on this paper and my mentor, has centered his practice on complex adult spinal deformity patients.”

“He has frequently questioned the variation in outcome following surgery on different patients’ population; especially among those patients with heavy opioid use, as they appeared to do worse after surgery.”

“In light of the opioid epidemic, we thought this is a very important issue to highlight these patients.”

“Obtaining the data was a challenge. Luckily though, Dr. Kebaish is a member of the International Spine Study Group, a study group that has been collecting very comprehensive and high-quality data in the adult spinal deformity patient population.”

“Although that was a good starting point, information about opioid use was not collected, or so we thought. The study group gives patient surveys with more than 120 questions as part of their efforts to understand how the disease affects patient’s Health Related Quality of Life. Eventually, we realized that the key to opioid information actually lies on one of those questions which asks patients about their opioid use in detail.”

The authors wrote, “Of 575 patients who met the inclusion criteria, 425 (74%) had complete 2-year follow-up data. Forty-four percent reported daily preoperative narcotic use. Compared with non-daily users, daily narcotic users were older, had more comorbidities, more severe back pain, higher ODI [Oswestry disability Index] scores, longer operative times, and worse preoperative malalignment and were more likely to undergo 3-column osteotomy. Daily narcotic use independently predicted prolonged LOS [length of stay], longer ICU stay, and daily narcotic use 2 years postoperatively, as well as worse 2-year ODI score.”

Dr. Raad commented to OTW, “While the impact of opioid use on hospital length of stay and ICU length of stay was interesting, we thought that the long-term effects were astounding.”

“Patients who were using opioids heavily in the preoperative period were more likely to have higher levels of disability and were 6.9 times more likely to be using opioids heavily at two years after surgery. This is a very important consideration, particularly in a time and age where researchers and physicians are directing large amounts of resources to curb long-term opioid use in patients.”

“Pain is a complex issue. I can tell you from personal experience, my father was a terminally ill cancer patient. And I know that asking patients to stop taking medications for pain is not feasible. However, what we hoped to achieve by this work is twofold. One is highlighting the association between heavy narcotic use and poor outcomes in this patient population and second providing a foundation for future research in this matter.”

“For now, the most practical recommendations are to include opioid use as part of patient risk/outcome stratification and consider limiting or controlling opioid use in the preoperative period.”

Khaled Kebaish, M.D., professor of orthopedic surgery at the Johns Hopkins University School of Medicine, told OTW, “Patients who come into clinics reporting heavy narcotic use preoperatively, should be identified as higher risk patients who are likely to have higher long-term opioid use and disability when compared to non-heavy opioid users.”

Funding for this study was provided by DePuy Synthes Spine, K2M, Inc., NuVasive, Inc., Biomet and Orthofix International, N.V.

More Vitamin D = Better Muscle Strength, Athletic Performance

There is a new study from Stanford examining Vitamin D and its effect on sports performance. The research, “Effects of Vitamin D on Skeletal Muscle and Athletic Performance,” is published in the April 15, 2018 edition of the Journal of the American Academy of Orthopaedic Surgeons.

“Vitamin D deficiency commonly affects many people around the world,” said lead study author and orthopedic surgeon Geoffrey D. Abrams, M.D., in the April 16, 2018 news release. Dr. Abrams, who is with Stanford University, added, “With higher serum levels of vitamin D playing a role in muscle strength, injury prevention, and sports performance, it’s essential for individuals to take necessary steps to ensure they’re getting an adequate amount of vitamin D intake, whether through direct sunlight or other sources including fish, eggs, fortified dairy products, and dietary supplements. Studies also have shown that daily vitamin D supplements are proven to be more effective than weekly or monthly doses.”

“While vitamin D supplementation improves function and decreases fracture risk in people who are vitamin D deficient, it’s important for individuals to be aware of the safe dosage amount, which varies with age and the status of an individual’s current vitamin D level. We are not advocating for athletes to take additional vitamin D without first speaking with a doctor.”

Dr. Abrams told OTW, “This was a review study, but one of the only reviews done to date to focus on the role of vitamin D and its effect on sports performance. We are sports medicine physicians looking to give our athletes reduced injury risk as well as every possible competitive advantage. Vitamin D has the potential to accomplish both these goals.”

“Particular subsets of athletes (women’s basketball players) were particularly likely to have insufficient vitamin D levels. In addition, there is some suggestion that vitamin D therapy can improve muscle strength as well as some other metrics of physical performance.”

“Treatment should be individualized based on the recommendations of your physician, but there is evidence that some athletes may benefit from vitamin D supplementation. If supplementation is given, daily dosing seems to be most efficacious.”

New Computer App Tracks/Changes Behavior – Like Smoking

Now, clinicians can match their message to the patient’s readiness for behavioral change with a computer app—Stage-on-Demand (SOD)—that, according to Rhode Island-based Pro-Change, “…allows healthcare providers to assess stage of change for a variety of health risks or health behaviors and provide patients with brief, real-time, tailored, evidence-based behavior change tips based on the patient’s readiness to change.”

“One great example for orthopedics: Quitting smoking prior to elective hip or knee replacement reduces the risk of surgical complications (e.g.,https://www.sciencedaily.com/releases/2017/02/170216103943.htm). 80% of smokers want to quit, but only 20% are ready to do so. The rest are not yet ready or are getting ready to do so in the next six months.”

“Therefore, guidance matched to the smoker’s readiness to quit is critical. This tool enables the clinician to provide a message matched to the patient’s readiness to quit smoking and to prescribe a more in-depth online behavior change program to assist the patient in their journey to quitting smoking.”

“When a clinician, care coordinator, or health coach pulls up a patient’s dashboard using Pro-Change, they see a list of lifestyle behaviors on the interactive display. Clicking on a behavior will bring up Pro-Change’s validated stage assessment for that behavior which allows the clinician to quickly and accurately assess stage of change.”

“Once the patient responds, his or her stage of change is plotted on the behavior change profile by the program, and a brief intervention tip specifically designed to engage the patient in the behavior change process is delivered to the patient by way of the program interface.”

“The decision rules that determine which intervention tips are provided are based on rigorous data analytics and robust behavior change theory, which ensures that health professionals are always delivering the right behavior change feedback at the right moment.”

“Additionally, the dashboard allows clinicians to prescribe Pro-Change’s LifeStyle Management Programs for the patient to work on between visits.”

Sara S. Johnson, Ph.D., co-president and CEO of Pro-Change Behavior Systems, Inc., told OTW, “The impetus for the development of the Stage-on-Demand was the recognition that, to realize our goal of improving population health, we need to enable clinicians to deliver brief, evidence-based behavior change messages to patients at each visit.”

“It has been reported that 86% of healthcare spending is driven by patients with chronic diseases. Thus, there is an urgent need to incorporate lifestyle medicine into treatment planning and to create sustainable systems that ensure best practices are used to implement lifestyle medicine with fidelity. Stage-on-Demand is one such system that can be incorporated into an electronic health record.”

“It differs from other similar programs in that it leverages 30+ years of best practices in behavior change science. Patients differ in their readiness to change lifestyle behaviors like quitting smoking or exercising regularly. This interface enables clinicians to quickly but reliably assess a patient’s readiness to change those behaviors and to provide very brief immediate tailored feedback on the single most important behavior change strategy the patient can use to make progress on that behavior. In short, the tool allows the clinician to be an expert in behavior change without extensive training.”