Perioperative Pain Management In Spine Surgery Patients: Part I

Spine surgery patients experience high levels of pain and report poor pain management in
patient satisfaction surveys. Data examined from Allina HCAHPS (Hospital Consumer Assessment
of Healthcare Providers and Systems) pain management questions indicate that spine surgery
patients report poor pain management. In July, August, and September 2010 patients on the
Abbott Northwestern (ANW) spine surgery unit reported 62% on the composite pain score
compared to 69% to 71% for ANW overall. During these same three months, the proportion of
patients on this unit reporting their pain was always well controlled ranged from 49% to 57%
compared to 59% to 64% for the hospital overall. Since ANW serves a high number of spine
surgery patients, this poor pain management reporting is a concern for patient care and
possibly for future Medicare/Medicaid funding formulas.

Opioid-tolerant patients pose a particular challenge to pain management. The intervention to
be tested specifically targets patients who are determined to be opioid-tolerant patients.
Opioid-tolerant patients are generally patients who have severe chronic pain, and, thus, are
taking pain medication regularly. Tolerance occurs when chronic exposure to a drug
diminishes its analgesic effect or creates the need for a higher dose to maintain this
effect. Given the severe chronic pain conditions of many patients who are presenting for
spine surgery, there is a high level of opioid tolerance among these patients.

While there is no agreed upon definition in the literature about a fixed opioid amount that
constitutes "opioid tolerance," Abbott Northwestern Hospital has a working definition of
opioid tolerant patients as those who are receiving ≥ 20 mg of oxycodone (or equivalent)/day
for > 7 days. This definition is slightly more aggressive than the Institute of Safe
Medication Practices definition which set the standard at "at least 30 mg oxycodone/day for
greater than a week."

While higher postoperative pain status has been documented in opioid-tolerant patients, very
little has been done to examine customizing perioperative opioid dosing to improve pain
management in this population. The proposed intervention is designed specifically to test if
post-operative pain management can be improved in opioid-tolerant patients using
perioperative goal-directed parenteral opioid dosing based on 150% of the patient's baseline
oral morphine equivalent (OME). It is important to note this method of perioperative
goal-directed parenteral opioid dosing has been used at ANW on spine surgery patients, based
on clinical decision of the anesthesiologist. However, this strategy has not been tested
compared to standard care.

For this study our research questions are:

1. Does the intervention improve immediate (4 hours) post-operative pain over the
comparison group?

2. Does the intervention improve management during the 24 hours (or at discharge) after
the recovery period over the comparison group?

3. Is the clinical intervention associated with selected improved post-operative status
measures compared to the control group?

4. Is the clinical intervention associated with long-term differences in reported pain
scores or medication levels as measured by a phone call at 4 weeks after surgery?

Inclusion Criteria:

1. Patients must be 18 years or older.

2. Patients must be undergoing spine surgery at ANW.

3. Patients must be assessed to be opioid tolerant based on the established criteria.

4. Patients must be willing and able to provide written informed consent.

Exclusion Criteria:

1. Patients unwilling to comply with research procedures.

2. Patients having surgery for correction of scoliosis.