SPINE Volume 38, Number 25, pp 2196-2200 ©2013, Lippincott Williams & Wilkins
Spine CLINICAL CASE SERIES
Preoperative Narcotic Use and Its Relation to Depression and Anxiety in Patients Undergoing Spine Surgery Sheyan J. Armaghani, MD,* Dennis S. Lee, MD,* Jesse E. Bible, MD,* Kristin R. Archer, PhD, DPT,* David N. Shau, BS,* Harrison Kay, BS,* Chi Zhang, BA,* Matthew ). McGirt, MD,t and Clinton J. Devin, MD"
Study Design. Prospective review of registry data at a single institution from October 2010 to June 2012. Objective. To assess whether the amount of preoperative narcotic use is associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. Summary of Background Data. Previous work suggests that narcotic use and psychiatric comorbidities are significantly related. Among other psychological considerations, depression and anxiety may be associated with the amount ot preoperative narcotic use in patients undergoing spine surgery. Methods. Five hundred eighty-three patients undergoing lumbar (60%), thoracolumbar (11 %), or cervical spine (29%) were included. Self-reported preoperative narcotic consumption was obtained at the initial preoperative visit and converted to daily morphine equivalent amounts. Preoperative Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores were also obtained at the initial preoperative visit and recorded as measures of depression and anxiety, respectively. Resistant and robust bootstrapped multivariable linear regression analysis was performed to determine the association between ZDS and MSPQ scores and preoperative narcotics, controlling for clinically important covariates. Mann-Whitney U tests examined preoperative narcotic use in patients who were categorized as depressed (ZDS s 33) or anxious (MSPQ > 12). Results. Multivariable analysis controlling for age, sex, smoking status, preoperative employment status, and prior spinal surgery demonstrated that preoperative ZDS (P = 0.006), prior spine surgery (P = 0.007), and preoperative pain (0.014) were independent risk
From the 'Department of Orthopaedics, Vanderbilt Orthopaedic Institute, Vanderbilt University School of Medicine and tDepartment of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, TN. Acknowledgement date: May 28, 2013. Revision date: August 12, 2013. Acceptance: August 29, 2013. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, grants. Address correspondence and reprint requests to Clinton J. Devin, MD, Vanderbilt Orthopaedic Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, 1215 21st Ave S, Ste 4200, Nashville, TN 37232-8774; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000011 2196
www.spinejournal.com
factors for preoperative narcotic use. Preoperative MSPQ (P = 0.083) was nearly a statistically significant risk factor. Patients who were categorized as depressed or anxious on the basis of ZDS and MSPQ scores also showed higher preoperative narcotic use than those who were not ( P < 0.0001). Conclusion. Depression and anxiety as assessed by ZDS and MSPQ scores were significantly associated with increased preoperative narcotic use, underscoring the importance of thorough psychological and substance use evaluation in patients being evaluated for spine surgery. Key words: narcotic use, chronic pain, depression, anxiety, spinal surgery, preoperative, opioid, back pain.
Level of Evidence: 2 Spine 2013;38:2196-2200
N
arcotics remain a common agent used for the management of pain in patients undergoing ortbopedic surgery. Opioid use during the past 20 years bas increased exponentially with national campaigns for the under-treatment of pain.'-^ In 2004, the United States consumed 99% of the global supply of the opioid hydrocodone.' Opioid dependence is an issue in patients undergoing spinal surgery, and it has been described that the prevalence of opioid dependence in patients undergoing spine surgery may be as high as 20%.'* However, chronic pain is a complex issue that can involve psychosocial factors that can worsen disability^"^ as well as outcome after surgery.^"'^ Depression and anxiety are 2 of the most common psychiatric illness in the United States and are not uncommon in patients undergoing spine surgery with 25% and 10%, respectively on medication for those conditions.'' The literature does describe an association between chronic opioid use and concurrent psychiatric illness; however, the relationship between the 2 has not been evaluated in patients with spine problems undergoing surgery. Our primary aim was to assess whether increasing amounts of preoperative narcotic use was associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. We hypothesize that there is a positive association between preoperative narcotic use and concurrent depression and anxiety in patients undergoing elective spine surgery. An December 2013
Spine
Cl iNiCAi
association between opioid use and psychiatric conditions can assist surgeons in preoperatively addressing these psychiatric comorbidities to optimize perioperative pain control and long-term narcotic independence.
MATERIALS AND METHODS A prospective spine registry database was used to evaluate a consecutive cohort of patients with at least 1-year follow-up from October 2010 to June 2012 at a single institution. All patients undergoing elective spine surgery at our institution are enrolled into a prospective Web-based registry. Enrollment into this prospective registry has become standard of care at our institution and has received institutional review board exemption status. Inclusion criteria were as follows: (1) patients undergoing elective spinal surgery of the cervical, thoracic, or lumbar spine for a structural lesion, (2) age more than 18 years, (3) English speaking, and (4) willingness to participate in the study. Eive hundred eighty-three patients were available for inclusion in the study. Demographic data were captured by the registry. Preoperative narcotic use was obtained for all patients using self-reported daily opioid consumption, which was then converted into daily morphine equivalents for comparison purposes using an online calculator with standardized conversion ratios. " Patients were administered preoperatively the Zung Depression Scale (ZDS)''' to assess depression quantitatively. Patients were also administered the Modified Somatic Perception Questionnaire (MSPQ)'^" to assess anxiety. Those scoring 33 or more on the ZDS were considered depressed, and those scoring 12 or more on the MSPQ were considered anxious on the basis of previously published spine literature.'* Descriptive statistics were used to summarize all study variables (means, medians, standard deviations, frequency, and skewness). Continuous variables of ZDS and MSPQ scores and amount of preoperative narcotic use were examined for the assumptions required for parametric analyses. Regression diagnostics were also performed to assess leverage, influence, and residuals of the outcomes preoperative narcotic to identify outliers and the need for resistant regression. Bivariate linear regression analyses were then conducted to assess the association between demographic and clinical variables and preoperative narcotic use. Variables that were significant at P < 0.05 in bivariate analysis or considered relevant to the outcome from a clinical perspective were entered into a resistant and robust bootstrapped multivariable linear regression model for analysis. These a priori variables included pain, prior spinal surgery, and preoperative depression and anxiety. Pain was calculated by averaging preoperative visual analogue scale pain scores for the neck and arm for all patients with neck problems and scores for back and leg pain for patients with back problems. These data were collected routinely as part of the registry. Einally, sensitivity analyses were conducted by comparing final model results to analysis without data points with high influence. Eor comparison of morphine equivalent amounts with ZDS and MSPQ as dichotomous variables using ZDS score 33 or more as a cutoff for depression and MSPQ score 12 or more for anxiety, we used the Mann-Whitney U test. Stata statistical software (version 11.0; Stata Corp, College Station, TX) was Spine
Preoperative Narcotie Use • Armaghani et al
used to analyze the data. The level of significance was set at P < 0.05.
RESULTS A total of 583 patients from a prospectively collected spine registry at a single institution were sampled and preoperative narcotic use, ZDS, and MSPQ scores were evaluated. Patients underwent lumbar (60%), thoracolumbar (11%), or cervical spine (29%) surgery. The mean ± SD age of our cohort of patients was 57 ± 13.2 with 317 females and 266 males. Median and interquartile range (IQR) of preoperative morphine equivalent amounts was 10 (0-37.5), with 319 (55%) of our patients taking opioids prior to surgery. Mean ZDS and MSPQ score was 37.9 ± 9.8 and 7.6 ± 5 . 1 , respectively. Mean pain as assessed by the visual analogue scale was 4.22 ± 1.98. Depression, as categorized by ZDS 33 or more, was present in 392 (67%) patients and anxiety, as categorized by MSPQ 12 or more, was present in 94 (16%) patients. Current smokers (155) comprised 26% of our cohort. Complete data regarding demographics of our patient database is presented in Table 1. Independent risk factors of preoperative narcotic use in multivariable linear regression analysis (Table 2) were preoperative ZDS score (P = 0.006), preoperative pain (P = 0.014), and prior spine surgery (P = 0.007). Preoperative MSPQ score was nearly a statistically significant independent risk factor (P = 0.083). Age, sex, smoking history, and preoperative employment were not statistically significant. In patients who were depressed (ZDS score a 33), there was a statistically significant increase in preoperative narcotic use compared with those who were not depressed (P < 0.0001; Eigure 1). The median and IQR for depressed patients compared with those who were not depressed by preoperative ZDS score was 16.6 mg (0-45 mg) versus 0 mg (0-17.1 mg). As preoperative morphine equivalents increased, an increase in ZDS score was observed (Spearman Rank Correlation; P < 0.000001; Eigure 2). In patients who were anxious (MSPQ > 12), there was also a statistically significant increase in preoperative narcotic use compared with those who were not anxious (P < 0.0001; Eigure 1). The median and IQR for those who were anxious compared with those who were not anxious by preoperative MSPQ score was 30 mg (6.25-60 mg) versus 0.75 mg (0-30 mg). As preoperative morphine equivalents increased, an increase in MSPQ score was also observed (Spearman Rank Correlation; P < 0.000001; Eigure 3).
DISCUSSION This study is the first to evaluate the relationship between depression and anxiety with preoperative opioid use in patients undergoing elective spinal surgery. We found that patients with underlying depression and anxiety have increasing preoperative opioid requirement prior to undergoing spinal surgery. This may be because of patients using increasing preoperative opioids being predisposed to taking opioids because of their poor pain coping mechanisms related to their underlying psychological conditions and also self-medicating to treat these comorbid conditions. www.spinejournal.com
2197
Spine
Preoperarive Narcotic Use • Armaghani er al
CLINICAL CASE SERIES
1
TABLE!. ^ • g l i n e L}emographic and Clinical
TABLE 2. \
CTraracteristics of Study PopulatioiM Characteristic
Total
Mean age (SD)
57.0(13.2)
Sex Female
317(54)
Male
266 (46)
ß
95% CI
P
Pain
1.219
0.249-2.187
0.014*
Age
-0.059
- 0 . 1 9 1 to 0.073
0.380
Male vs. female sex
-0.327
- 3 . 7 6 9 to 3.115
0.852
2.719
- 2 . 3 7 9 to 7.818
0.296
-2.144
- 6 . 0 3 1 to 1.742
0.280
Prior spine surgery
5.348
1.444-9.251
0.007*
Preoperative ZDS score
0.417
0.121-0.713
0.006*
Preoperative MSPQ score
0.385
- 0 . 0 5 0 to 0.822
0.083
Variable
Current smoker
Race Caucasian
512 (88)
Nonwhite
71 (12)
Insurance Public
291 (50)
Private
292 (50)
Smoking history Never
273 (48)
Current
155(26)
Former
155(26)
Diabetes No
456(78)
Yes
127(22)
BMI category Normal
104(18)
Overweigbt
251 (43)
Obese
228(39)
Opioid use Current
322 (55)
Never
261 (45)
Mean pain score (SD)
4.22 (1.98)
Median MFA and (IQR)
10(0-37.5)
Mean ZDS score (SD) Mean MSPQ score (SD)
37.9(9.8) 7.6(5.1)
Primary vs. revision surgery Primary
381 (65)
Revision
202 (35)
Type of surgery Lumbar microdiscectomy Lumbar laminectomy Lumbar fusion
59(10) 86(15) 203 (36)
Deformity/cancer/infection
67(11)
Anterior cervical
101 (17)
Posterior cervical/anterior -1posterior cervical
67(11)
Values given are % (n), unless otherwise specified. SD indicates standard deviation; BMI, body mass index; ZDS, Zung Depression Scale; MSPQ, Modified Somatic Perception Questionnaire; MEA, morphine equivalent amounts; IQR, interquartile range.
2198
^•tivariable Linear Kegression ^ ^ H ^ d e l of Preoperative Narcotic U ^ ^ ^ J
www.spinejournal.com
Preoperative employment
*P < 0.05. ZDS indicates Zung Depression Scale; MSPQ, Modified Somatic Perception Questionnaire.
Chronic opioid use may be considered as a marker for other psychosocial factors that are associated with worsening perception of pain as well as poor treatment outcomes." Extensive research has been conducted to better understand the relation between depression and pain,'** and robust evidence supports the fear-avoidance model as a framework for understanding chronic pain syndromes." The model suggests that there are 2 pathways based on the way acute pain is interpreted. Pain that is perceived as nonthreatening will lead to a return to normal activity, but pain that is perceived as threatening will promote anxiety and give rise to fear of movement. This fear leads to avoidance behaviors and a "disuse" syndrome that is associated with deconditioning and depression, which subsequently perpetuates the pain process. Fears of movement and depression have been found to be significant risk factors for poor outcomes after spinal surgery.'"'-' Multimodal interventions that target preoperative narcotic use as well as depressive symptoms and negative pain beliefs have the potential to improve recovery in patients at risk for poor postoperative outcomes. The correlation between concurrent psychiatric disorders and opioid dependence may be secondary to patients using opioid to treat depression or anxiety. Martins et aP- gathered data on more than 43,000 patients and found a general vulnerability to opioid use for nonmedical reasons in those with psychopathologies. The patients with depression/anxiety may also self-medicate with opioids not only to improve pain but also to alleviate distress and psychiatric symptoms.-- This selfmedication model'^ can explain why increasing daily morphine equivalents in our study are linearly associated with increases in depression and anxiety. Those patients without concurrent psychiatric disorders have more capable coping mechanisms and do not need to self-medicate with opioids to alleviate their anxiety or depression. Because, pain is a frequent complaint in spine clinics and pain itself can hinder the diagnosis and treatment of the mood December 2013
A! CASE SFRIFS
Preoperative Narcotic Use • Armaghani et al
I Depressed Not-depressed
Anxious
Not-anxious
Figure 1. Morphine equivalents as categorized by mood disorder. Preoperative morphine equivalents were significantly higher in those who were depressed and anxious than those who were not. Mean and 95% Cl for depressed patients was 33.68 (28.84-38.52) and 12.7 (8.9-16.49) for nondepressed patients (P < 0.001). Mean and Cl for anxious patients were 49.79 (32.87-50.70) and 23.47 (19.63-27.32) for nonanxious patients (P < 0.001 ). Cl indicates confidence intervals.
disorder,-"* we advocate screening patients for these concurrent psychiatric conditions. Studies have demonstrated that cognitive and behavioral strategies, such as relaxation techniques, goal setting, problem solving, and coping strategies, are effective in decreasing pain intensity and improving negative mood in patients recovering from spinal surgery."^-^'--^ Presumably, concurrent treatment of the depression and anxiety through the modalities mentioned earlier, and medication if needed, will help optimize a patient to better control the pain perioperatively and assist in gaining narcotic independence postoperatively. This study helps in expanding our knowledge of the underlying conditions associated with chronic narcotic use in a consecutive group of patients undergoing elective spinal surgery. Previous studies were either retrospective, did not use validated measures for depression or anxiety, or did not
60
CO Q N
300
Figure 3. As preoperative morphine equivalents are increased, an associated increase in preoperative MSPQ score was observed (Spearman Rank Correlation P < 0.000001). MSPQ indicates and Modified Somatic Perception Questionnaire.
quantify the amount of narcotics used prior to surgery. There are limitations, however. First, data gathered were only from 1 institution, which can introduce geographical biases. We obtained daily preoperative opioid use from patient report, which can introduce recall and reporter bias. Also, in our statistical analysis there was a large range of values for preoperative narcotic use. However, data were analyzed using medians and IQRs as opposed to means and standard deviations, as well as through resistant and robust bootstrapped modeling to downgrade influential observations. Lastly, the ZDS and MSPQ are validated questionnaires to quantify the level of depressive or anxious symptoms in a given patient, but does not meet accepted criteria for a diagnosis of depression or an anxiety disorder. A formal evaluation by a psychiatrist could be completed in the future to diagnose and treat these patients.
CONCLUSION Future directions include randomized, prospective studies involving additions of cognitive-behavioral modalities prior to surgery in those patients who are identified as at risk due to screening examinations. We also plan to evaluate factors that are associated with achieving narcotic independence in those with concurrent mood disorders on preoperative screening and evaluate the effect on patient reported outcomes.
80
o u tn
100 200 Morphine equivalents
40
Key Points
20
• 100 200 Morphine equivalents
300
Figure 2. Change in ZDS score with increased morphine equivalents. As preoperative morphine equivalents are increased, an associated increase in preoperative ZDS score was observed (Spearman Rank Correlation P < 0.000001). ZDS indicates Zung Depression Scale. Spine
Narcotic use among patients with spine problems is extensive and has grown in popularity during tbe last 20 years. Psychiatric comorbidities are also frequently associated witb narcotic use.
D We found tbat depression and anxiety are directly related to preoperative narcotic use in patients undergoing spine surgery for a structural lesion. www.spinejournal.com
";:
2199
Spine
CLINICAL CASE SERIF^
References 1. American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Practice Guidelines for Acute Pain Management in the Perioperative Setting: a report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology 1995;82:1071-81. 2. American Pain Society Quality of Gare Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995;274:1874-80. 3. Kuehn B. Opioid prescriptions soar/AMA 2007;297:249-53. 4. Walid MS, Hyer L, Ajjan M, et al. Prevalence of opioid dependence in spine surgery patients and correlation with length of stay. / Opioid Manag 2007;3:\27-S, 30-2. 5. Garragee EJ, Alamin TF, Miller JL, et al. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spi'w/2005;5:24-35. 6. Vranceanu A-M, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. / Bone Joint Surg 2009;91:2014-8. 7. Turk DG. Psychological aspects of pain. In: Warfield G, Bajwa Z eds. Principles and Practice of Pain Medicine. 2nd ed. New York: McGraw-Hill Professional; 2004:139-47. 8. Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain 2002;99:485-91. 9. Fisher DA, Dierckman B, Watts MR, et al. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. / Arthroplasty 2007;22:39^2. 10. Lawrence JT, London N, Bohlman HH, et al. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine (Phila Pa 1976) 2008;33:2074-8. 11. Webster BS, Verma SK, Gatchel RJ. Relationship between eady opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976) 2007;32:2127-32. 12. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 2006;31:E648-63. 13. McAuley D. Narcotic analgesic converter. Available at http:// www. globalrph.com/narcotic.cgi. Accessed March 1, 2013. 14. Zung WW. A Self-Rating Depression Scale. Arch Gen Psychiatry 1965;12:63-70.
2200
www.spinejournaLcom
Preoperative Narcotic Use • Armaghani et al
15. Main GJ. The Modified Somatic Perception Questionnaire (MSPQ). / Psychosom Res 1983;27:503-14. 16. Main GJ, Wood PL, Hollis S, et al. The Distress and Risk Assessment Method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine (Phila Pa 1976) 1992; 17:42-52. 17. Miotto K, Kaufman A, Kong A, et al. Managing co-occurring substance use and pain disorders. Psychiatr Clin N Am 2012;35: 393-409. 18. Gampbell LG, Glauw DJ, Keefe FJ. Persistent pain and depression: a biopsychosocial perspective. Biol Psychiatry 2003;54:399-409. 19. Leeuw M, Goossens ME, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. / Behav Med 2007;30:77-94. 20. Seebach GL, Kirkhart M, Lating JM, et al. Examining the role of positive and negative affect in recovery from spine surgery. Pain 2012;153:518-25. 21. Archer KR, Wegener ST, Seebach G, et al. The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976) 20n;36:1554-62. 22. Martins SS, Keyes KM, Storr GL, et al. Pathways between nonmedical opioid use/dependence and psychiatric disorders: results from the National Epidemiologie Survey on Alcohol and Related Gonditions. Drug Alcohol Depend 2009;103:16-24. 23. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry 1997;4:231-44. 24. Bair MJ, Robinson RL, Eckert GJ, et al. Impact of pain on depression treatment response in primary care. Psychosom Med 2004;66:17-22. 25. Archer KR, Motzny N, Abraham G.A., et al. Gognitive-bebavioral based physical therapy (GBPT) to improve surgical spine outcomes: a case series. Phys Th'er 2013;93:l 130-9. 26. Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial. Spine (Phila Pa 1976) 2010;35: 848-57. 27. Ghristensen FB, Laurberg I, Bunger GE. Importance of the backcafe concept to rehabilitation after lumLiar spinal fusion: a randomized clinical study with a 2-year follow-up. Spine (Phila Pa 1976) 2003;28:2561-9.'
December 2013
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Spine CLINICAL CASE SERIES
Preoperative Narcotic Use and Its Relation to Depression and Anxiety in Patients Undergoing Spine Surgery Sheyan J. Armaghani, MD,* Dennis S. Lee, MD,* Jesse E. Bible, MD,* Kristin R. Archer, PhD, DPT,* David N. Shau, BS,* Harrison Kay, BS,* Chi Zhang, BA,* Matthew ). McGirt, MD,t and Clinton J. Devin, MD"
Study Design. Prospective review of registry data at a single institution from October 2010 to June 2012. Objective. To assess whether the amount of preoperative narcotic use is associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. Summary of Background Data. Previous work suggests that narcotic use and psychiatric comorbidities are significantly related. Among other psychological considerations, depression and anxiety may be associated with the amount ot preoperative narcotic use in patients undergoing spine surgery. Methods. Five hundred eighty-three patients undergoing lumbar (60%), thoracolumbar (11 %), or cervical spine (29%) were included. Self-reported preoperative narcotic consumption was obtained at the initial preoperative visit and converted to daily morphine equivalent amounts. Preoperative Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores were also obtained at the initial preoperative visit and recorded as measures of depression and anxiety, respectively. Resistant and robust bootstrapped multivariable linear regression analysis was performed to determine the association between ZDS and MSPQ scores and preoperative narcotics, controlling for clinically important covariates. Mann-Whitney U tests examined preoperative narcotic use in patients who were categorized as depressed (ZDS s 33) or anxious (MSPQ > 12). Results. Multivariable analysis controlling for age, sex, smoking status, preoperative employment status, and prior spinal surgery demonstrated that preoperative ZDS (P = 0.006), prior spine surgery (P = 0.007), and preoperative pain (0.014) were independent risk
From the 'Department of Orthopaedics, Vanderbilt Orthopaedic Institute, Vanderbilt University School of Medicine and tDepartment of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, TN. Acknowledgement date: May 28, 2013. Revision date: August 12, 2013. Acceptance: August 29, 2013. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, grants. Address correspondence and reprint requests to Clinton J. Devin, MD, Vanderbilt Orthopaedic Institute, Vanderbilt University School of Medicine, Medical Center East, South Tower, 1215 21st Ave S, Ste 4200, Nashville, TN 37232-8774; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000011 2196
www.spinejournal.com
factors for preoperative narcotic use. Preoperative MSPQ (P = 0.083) was nearly a statistically significant risk factor. Patients who were categorized as depressed or anxious on the basis of ZDS and MSPQ scores also showed higher preoperative narcotic use than those who were not ( P < 0.0001). Conclusion. Depression and anxiety as assessed by ZDS and MSPQ scores were significantly associated with increased preoperative narcotic use, underscoring the importance of thorough psychological and substance use evaluation in patients being evaluated for spine surgery. Key words: narcotic use, chronic pain, depression, anxiety, spinal surgery, preoperative, opioid, back pain.
Level of Evidence: 2 Spine 2013;38:2196-2200
N
arcotics remain a common agent used for the management of pain in patients undergoing ortbopedic surgery. Opioid use during the past 20 years bas increased exponentially with national campaigns for the under-treatment of pain.'-^ In 2004, the United States consumed 99% of the global supply of the opioid hydrocodone.' Opioid dependence is an issue in patients undergoing spinal surgery, and it has been described that the prevalence of opioid dependence in patients undergoing spine surgery may be as high as 20%.'* However, chronic pain is a complex issue that can involve psychosocial factors that can worsen disability^"^ as well as outcome after surgery.^"'^ Depression and anxiety are 2 of the most common psychiatric illness in the United States and are not uncommon in patients undergoing spine surgery with 25% and 10%, respectively on medication for those conditions.'' The literature does describe an association between chronic opioid use and concurrent psychiatric illness; however, the relationship between the 2 has not been evaluated in patients with spine problems undergoing surgery. Our primary aim was to assess whether increasing amounts of preoperative narcotic use was associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. We hypothesize that there is a positive association between preoperative narcotic use and concurrent depression and anxiety in patients undergoing elective spine surgery. An December 2013
Spine
Cl iNiCAi
association between opioid use and psychiatric conditions can assist surgeons in preoperatively addressing these psychiatric comorbidities to optimize perioperative pain control and long-term narcotic independence.
MATERIALS AND METHODS A prospective spine registry database was used to evaluate a consecutive cohort of patients with at least 1-year follow-up from October 2010 to June 2012 at a single institution. All patients undergoing elective spine surgery at our institution are enrolled into a prospective Web-based registry. Enrollment into this prospective registry has become standard of care at our institution and has received institutional review board exemption status. Inclusion criteria were as follows: (1) patients undergoing elective spinal surgery of the cervical, thoracic, or lumbar spine for a structural lesion, (2) age more than 18 years, (3) English speaking, and (4) willingness to participate in the study. Eive hundred eighty-three patients were available for inclusion in the study. Demographic data were captured by the registry. Preoperative narcotic use was obtained for all patients using self-reported daily opioid consumption, which was then converted into daily morphine equivalents for comparison purposes using an online calculator with standardized conversion ratios. " Patients were administered preoperatively the Zung Depression Scale (ZDS)''' to assess depression quantitatively. Patients were also administered the Modified Somatic Perception Questionnaire (MSPQ)'^" to assess anxiety. Those scoring 33 or more on the ZDS were considered depressed, and those scoring 12 or more on the MSPQ were considered anxious on the basis of previously published spine literature.'* Descriptive statistics were used to summarize all study variables (means, medians, standard deviations, frequency, and skewness). Continuous variables of ZDS and MSPQ scores and amount of preoperative narcotic use were examined for the assumptions required for parametric analyses. Regression diagnostics were also performed to assess leverage, influence, and residuals of the outcomes preoperative narcotic to identify outliers and the need for resistant regression. Bivariate linear regression analyses were then conducted to assess the association between demographic and clinical variables and preoperative narcotic use. Variables that were significant at P < 0.05 in bivariate analysis or considered relevant to the outcome from a clinical perspective were entered into a resistant and robust bootstrapped multivariable linear regression model for analysis. These a priori variables included pain, prior spinal surgery, and preoperative depression and anxiety. Pain was calculated by averaging preoperative visual analogue scale pain scores for the neck and arm for all patients with neck problems and scores for back and leg pain for patients with back problems. These data were collected routinely as part of the registry. Einally, sensitivity analyses were conducted by comparing final model results to analysis without data points with high influence. Eor comparison of morphine equivalent amounts with ZDS and MSPQ as dichotomous variables using ZDS score 33 or more as a cutoff for depression and MSPQ score 12 or more for anxiety, we used the Mann-Whitney U test. Stata statistical software (version 11.0; Stata Corp, College Station, TX) was Spine
Preoperative Narcotie Use • Armaghani et al
used to analyze the data. The level of significance was set at P < 0.05.
RESULTS A total of 583 patients from a prospectively collected spine registry at a single institution were sampled and preoperative narcotic use, ZDS, and MSPQ scores were evaluated. Patients underwent lumbar (60%), thoracolumbar (11%), or cervical spine (29%) surgery. The mean ± SD age of our cohort of patients was 57 ± 13.2 with 317 females and 266 males. Median and interquartile range (IQR) of preoperative morphine equivalent amounts was 10 (0-37.5), with 319 (55%) of our patients taking opioids prior to surgery. Mean ZDS and MSPQ score was 37.9 ± 9.8 and 7.6 ± 5 . 1 , respectively. Mean pain as assessed by the visual analogue scale was 4.22 ± 1.98. Depression, as categorized by ZDS 33 or more, was present in 392 (67%) patients and anxiety, as categorized by MSPQ 12 or more, was present in 94 (16%) patients. Current smokers (155) comprised 26% of our cohort. Complete data regarding demographics of our patient database is presented in Table 1. Independent risk factors of preoperative narcotic use in multivariable linear regression analysis (Table 2) were preoperative ZDS score (P = 0.006), preoperative pain (P = 0.014), and prior spine surgery (P = 0.007). Preoperative MSPQ score was nearly a statistically significant independent risk factor (P = 0.083). Age, sex, smoking history, and preoperative employment were not statistically significant. In patients who were depressed (ZDS score a 33), there was a statistically significant increase in preoperative narcotic use compared with those who were not depressed (P < 0.0001; Eigure 1). The median and IQR for depressed patients compared with those who were not depressed by preoperative ZDS score was 16.6 mg (0-45 mg) versus 0 mg (0-17.1 mg). As preoperative morphine equivalents increased, an increase in ZDS score was observed (Spearman Rank Correlation; P < 0.000001; Eigure 2). In patients who were anxious (MSPQ > 12), there was also a statistically significant increase in preoperative narcotic use compared with those who were not anxious (P < 0.0001; Eigure 1). The median and IQR for those who were anxious compared with those who were not anxious by preoperative MSPQ score was 30 mg (6.25-60 mg) versus 0.75 mg (0-30 mg). As preoperative morphine equivalents increased, an increase in MSPQ score was also observed (Spearman Rank Correlation; P < 0.000001; Eigure 3).
DISCUSSION This study is the first to evaluate the relationship between depression and anxiety with preoperative opioid use in patients undergoing elective spinal surgery. We found that patients with underlying depression and anxiety have increasing preoperative opioid requirement prior to undergoing spinal surgery. This may be because of patients using increasing preoperative opioids being predisposed to taking opioids because of their poor pain coping mechanisms related to their underlying psychological conditions and also self-medicating to treat these comorbid conditions. www.spinejournal.com
2197
Spine
Preoperarive Narcotic Use • Armaghani er al
CLINICAL CASE SERIES
1
TABLE!. ^ • g l i n e L}emographic and Clinical
TABLE 2. \
CTraracteristics of Study PopulatioiM Characteristic
Total
Mean age (SD)
57.0(13.2)
Sex Female
317(54)
Male
266 (46)
ß
95% CI
P
Pain
1.219
0.249-2.187
0.014*
Age
-0.059
- 0 . 1 9 1 to 0.073
0.380
Male vs. female sex
-0.327
- 3 . 7 6 9 to 3.115
0.852
2.719
- 2 . 3 7 9 to 7.818
0.296
-2.144
- 6 . 0 3 1 to 1.742
0.280
Prior spine surgery
5.348
1.444-9.251
0.007*
Preoperative ZDS score
0.417
0.121-0.713
0.006*
Preoperative MSPQ score
0.385
- 0 . 0 5 0 to 0.822
0.083
Variable
Current smoker
Race Caucasian
512 (88)
Nonwhite
71 (12)
Insurance Public
291 (50)
Private
292 (50)
Smoking history Never
273 (48)
Current
155(26)
Former
155(26)
Diabetes No
456(78)
Yes
127(22)
BMI category Normal
104(18)
Overweigbt
251 (43)
Obese
228(39)
Opioid use Current
322 (55)
Never
261 (45)
Mean pain score (SD)
4.22 (1.98)
Median MFA and (IQR)
10(0-37.5)
Mean ZDS score (SD) Mean MSPQ score (SD)
37.9(9.8) 7.6(5.1)
Primary vs. revision surgery Primary
381 (65)
Revision
202 (35)
Type of surgery Lumbar microdiscectomy Lumbar laminectomy Lumbar fusion
59(10) 86(15) 203 (36)
Deformity/cancer/infection
67(11)
Anterior cervical
101 (17)
Posterior cervical/anterior -1posterior cervical
67(11)
Values given are % (n), unless otherwise specified. SD indicates standard deviation; BMI, body mass index; ZDS, Zung Depression Scale; MSPQ, Modified Somatic Perception Questionnaire; MEA, morphine equivalent amounts; IQR, interquartile range.
2198
^•tivariable Linear Kegression ^ ^ H ^ d e l of Preoperative Narcotic U ^ ^ ^ J
www.spinejournal.com
Preoperative employment
*P < 0.05. ZDS indicates Zung Depression Scale; MSPQ, Modified Somatic Perception Questionnaire.
Chronic opioid use may be considered as a marker for other psychosocial factors that are associated with worsening perception of pain as well as poor treatment outcomes." Extensive research has been conducted to better understand the relation between depression and pain,'** and robust evidence supports the fear-avoidance model as a framework for understanding chronic pain syndromes." The model suggests that there are 2 pathways based on the way acute pain is interpreted. Pain that is perceived as nonthreatening will lead to a return to normal activity, but pain that is perceived as threatening will promote anxiety and give rise to fear of movement. This fear leads to avoidance behaviors and a "disuse" syndrome that is associated with deconditioning and depression, which subsequently perpetuates the pain process. Fears of movement and depression have been found to be significant risk factors for poor outcomes after spinal surgery.'"'-' Multimodal interventions that target preoperative narcotic use as well as depressive symptoms and negative pain beliefs have the potential to improve recovery in patients at risk for poor postoperative outcomes. The correlation between concurrent psychiatric disorders and opioid dependence may be secondary to patients using opioid to treat depression or anxiety. Martins et aP- gathered data on more than 43,000 patients and found a general vulnerability to opioid use for nonmedical reasons in those with psychopathologies. The patients with depression/anxiety may also self-medicate with opioids not only to improve pain but also to alleviate distress and psychiatric symptoms.-- This selfmedication model'^ can explain why increasing daily morphine equivalents in our study are linearly associated with increases in depression and anxiety. Those patients without concurrent psychiatric disorders have more capable coping mechanisms and do not need to self-medicate with opioids to alleviate their anxiety or depression. Because, pain is a frequent complaint in spine clinics and pain itself can hinder the diagnosis and treatment of the mood December 2013
A! CASE SFRIFS
Preoperative Narcotic Use • Armaghani et al
I Depressed Not-depressed
Anxious
Not-anxious
Figure 1. Morphine equivalents as categorized by mood disorder. Preoperative morphine equivalents were significantly higher in those who were depressed and anxious than those who were not. Mean and 95% Cl for depressed patients was 33.68 (28.84-38.52) and 12.7 (8.9-16.49) for nondepressed patients (P < 0.001). Mean and Cl for anxious patients were 49.79 (32.87-50.70) and 23.47 (19.63-27.32) for nonanxious patients (P < 0.001 ). Cl indicates confidence intervals.
disorder,-"* we advocate screening patients for these concurrent psychiatric conditions. Studies have demonstrated that cognitive and behavioral strategies, such as relaxation techniques, goal setting, problem solving, and coping strategies, are effective in decreasing pain intensity and improving negative mood in patients recovering from spinal surgery."^-^'--^ Presumably, concurrent treatment of the depression and anxiety through the modalities mentioned earlier, and medication if needed, will help optimize a patient to better control the pain perioperatively and assist in gaining narcotic independence postoperatively. This study helps in expanding our knowledge of the underlying conditions associated with chronic narcotic use in a consecutive group of patients undergoing elective spinal surgery. Previous studies were either retrospective, did not use validated measures for depression or anxiety, or did not
60
CO Q N
300
Figure 3. As preoperative morphine equivalents are increased, an associated increase in preoperative MSPQ score was observed (Spearman Rank Correlation P < 0.000001). MSPQ indicates and Modified Somatic Perception Questionnaire.
quantify the amount of narcotics used prior to surgery. There are limitations, however. First, data gathered were only from 1 institution, which can introduce geographical biases. We obtained daily preoperative opioid use from patient report, which can introduce recall and reporter bias. Also, in our statistical analysis there was a large range of values for preoperative narcotic use. However, data were analyzed using medians and IQRs as opposed to means and standard deviations, as well as through resistant and robust bootstrapped modeling to downgrade influential observations. Lastly, the ZDS and MSPQ are validated questionnaires to quantify the level of depressive or anxious symptoms in a given patient, but does not meet accepted criteria for a diagnosis of depression or an anxiety disorder. A formal evaluation by a psychiatrist could be completed in the future to diagnose and treat these patients.
CONCLUSION Future directions include randomized, prospective studies involving additions of cognitive-behavioral modalities prior to surgery in those patients who are identified as at risk due to screening examinations. We also plan to evaluate factors that are associated with achieving narcotic independence in those with concurrent mood disorders on preoperative screening and evaluate the effect on patient reported outcomes.
80
o u tn
100 200 Morphine equivalents
40
Key Points
20
• 100 200 Morphine equivalents
300
Figure 2. Change in ZDS score with increased morphine equivalents. As preoperative morphine equivalents are increased, an associated increase in preoperative ZDS score was observed (Spearman Rank Correlation P < 0.000001). ZDS indicates Zung Depression Scale. Spine
Narcotic use among patients with spine problems is extensive and has grown in popularity during tbe last 20 years. Psychiatric comorbidities are also frequently associated witb narcotic use.
D We found tbat depression and anxiety are directly related to preoperative narcotic use in patients undergoing spine surgery for a structural lesion. www.spinejournal.com
";:
2199
Spine
CLINICAL CASE SERIF^
References 1. American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Practice Guidelines for Acute Pain Management in the Perioperative Setting: a report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology 1995;82:1071-81. 2. American Pain Society Quality of Gare Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995;274:1874-80. 3. Kuehn B. Opioid prescriptions soar/AMA 2007;297:249-53. 4. Walid MS, Hyer L, Ajjan M, et al. Prevalence of opioid dependence in spine surgery patients and correlation with length of stay. / Opioid Manag 2007;3:\27-S, 30-2. 5. Garragee EJ, Alamin TF, Miller JL, et al. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spi'w/2005;5:24-35. 6. Vranceanu A-M, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. / Bone Joint Surg 2009;91:2014-8. 7. Turk DG. Psychological aspects of pain. In: Warfield G, Bajwa Z eds. Principles and Practice of Pain Medicine. 2nd ed. New York: McGraw-Hill Professional; 2004:139-47. 8. Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain 2002;99:485-91. 9. Fisher DA, Dierckman B, Watts MR, et al. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. / Arthroplasty 2007;22:39^2. 10. Lawrence JT, London N, Bohlman HH, et al. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine (Phila Pa 1976) 2008;33:2074-8. 11. Webster BS, Verma SK, Gatchel RJ. Relationship between eady opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976) 2007;32:2127-32. 12. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 2006;31:E648-63. 13. McAuley D. Narcotic analgesic converter. Available at http:// www. globalrph.com/narcotic.cgi. Accessed March 1, 2013. 14. Zung WW. A Self-Rating Depression Scale. Arch Gen Psychiatry 1965;12:63-70.
2200
www.spinejournaLcom
Preoperative Narcotic Use • Armaghani et al
15. Main GJ. The Modified Somatic Perception Questionnaire (MSPQ). / Psychosom Res 1983;27:503-14. 16. Main GJ, Wood PL, Hollis S, et al. The Distress and Risk Assessment Method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine (Phila Pa 1976) 1992; 17:42-52. 17. Miotto K, Kaufman A, Kong A, et al. Managing co-occurring substance use and pain disorders. Psychiatr Clin N Am 2012;35: 393-409. 18. Gampbell LG, Glauw DJ, Keefe FJ. Persistent pain and depression: a biopsychosocial perspective. Biol Psychiatry 2003;54:399-409. 19. Leeuw M, Goossens ME, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. / Behav Med 2007;30:77-94. 20. Seebach GL, Kirkhart M, Lating JM, et al. Examining the role of positive and negative affect in recovery from spine surgery. Pain 2012;153:518-25. 21. Archer KR, Wegener ST, Seebach G, et al. The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976) 20n;36:1554-62. 22. Martins SS, Keyes KM, Storr GL, et al. Pathways between nonmedical opioid use/dependence and psychiatric disorders: results from the National Epidemiologie Survey on Alcohol and Related Gonditions. Drug Alcohol Depend 2009;103:16-24. 23. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry 1997;4:231-44. 24. Bair MJ, Robinson RL, Eckert GJ, et al. Impact of pain on depression treatment response in primary care. Psychosom Med 2004;66:17-22. 25. Archer KR, Motzny N, Abraham G.A., et al. Gognitive-bebavioral based physical therapy (GBPT) to improve surgical spine outcomes: a case series. Phys Th'er 2013;93:l 130-9. 26. Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial. Spine (Phila Pa 1976) 2010;35: 848-57. 27. Ghristensen FB, Laurberg I, Bunger GE. Importance of the backcafe concept to rehabilitation after lumLiar spinal fusion: a randomized clinical study with a 2-year follow-up. Spine (Phila Pa 1976) 2003;28:2561-9.'
December 2013
Copyright of Spine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
