Regional Variation in Opioid Use After Lumbar Spine Surgery Owoicho Adogwa 1 , Mark A. Davison 1 , Victoria D. Vuong 1 , Shyam A. Desai 1 , Daniel T. Lilly 1 , Jessica Moreno 2 , Joseph Cheng 3 , Carlos Bagley 2 - OBJECTIVE: The aim of this study was to investigate regional variations in use of opioids after lumbar decom- pression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. - METHODS: An insurance database, including private/ commercially insured and Medicare Advantage benefi- ciaries, was queried for patients undergoing 1-level, 2-level, or 3-level index lumbar decompression and fusion proced- ures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6 months before index sur- gery to 2 years after surgery was assessed. - RESULTS: Of the 13,257 patients included in the study, 63.1% were from the South, 24.3% from the Midwest, 10.5% from the West, and 2.1% from the Northeast. Of patients, 57.8% had a history of opioid use before index surgery, of whom 64.4% were from the South and 23.0% from the Midwest. Over the 6-month preoperative period, 51.6 opioid pills were billed by opioid users monthly (Midwest, 52.7 pills/patient/month; Northeast, 64.9 pills/patient/month; South, 50.6 pills/patient/month; West, 52.2 pills/patient/ month). During the 2-year period after surgery, an average of 33.6 opioid pills were billed by opioid users monthly (Midwest, 32.9 pills/patient/month; Northeast, 35.4 pills/ patient/month; South, 33.9 pills/patient/month; West, 32.9 pills/patient/month). In a multivariate logistic regression analysis, receiving treatment in the South (odds ratio, 1.18; 95% confidence interval, 1.07e1.29) or West (odds ratio, 1.26; 95% confidence interval, 1.10e1.45) was indepen- dently associated with prolonged (>1 year) opioid use after index surgery. - CONCLUSIONS: Our study suggests that regional varia- tions may exist in the use of opioids after lumbar decom- pression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. INTRODUCTION T he volume of lumbar decompression and fusion proced- ures has increased tremendously over the years as the population continues to age and with it, there is a greater prevalence of symptomatic lumbar stenosis and spondylolisthesis. In a 10-year span (1998e2008), the number of spinal fusions increased by 137%, which is higher than other notable inpatient procedures such as laminectomy (11.3% increase), knee arthro- plasty (126.8% increase), and hip replacement (49.1% increase). 1 Opioids are an integral mainstay for the treatment of acute postoperative pain; however, prolonged use of opioids after surgery can lead to opioid abuse or misuse. A recent retrospective study reported that >10% of their 568,465 opioid- naive patients receiving postoperative narcotics were identified as abusing or misusing their opioid prescriptions. 2 Although the amount of opioids prescribed in the United States peaked in 2010 (782 morphine milligram equivalents per capita) and has been slowly declining since, the number of deaths from opioid overdose has steadily increased by 3% annually since 2009. 3 Furthermore, the U.S. Centers for Disease Control estimated that Key words - Lumbar decompression - Lumbar spondylolisthesis - Lumbar stenosis - Lumbar surgery - Opioid use - Regional variation - Symptomatic lower back pain Abbreviations and Acronyms CI: Confidence interval HORTHO: Humana Ortho ICD: International Classification of Diseases OR: Odds ratio From the 1 Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois; 2 Department of Neurosurgery, University of Texas South Western Medical Center, Dallas, Texas; and 3 Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA To whom correspondence should be addressed: Owoicho Adogwa, M.D. M.P.H. [E-mail: owoicho.adogwa@gmail.com] Citation: World Neurosurg. (2019) 121:e691-e699. https://doi.org/10.1016/j.wneu.2018.09.192 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY 121: e691-e699, JANUARY 2019 www.journals.elsevier.com/world-neurosurgery e691 Original Article