Avoiding Opioids During Surgery May Harm Patients

By Pat Anson, PNN Editor

Many U.S. hospitals have adopted policies that reduce or even eliminate the use of opioids during surgery, with the goal of lowering the risk of a patient later becoming addicted. That has resulted in greater use of spinal anesthesia as a substitute for general anesthesia.

During spinal anesthesia, non-opioid medications are used to numb the lower part of the body through an injection into the spinal column. During general anesthesia, a combination of opioids and other analgesics are administered intravenously or through a breathing tube to sedate patients.

But a large new study suggests that spinal anesthesia may actually increase the use of prescription opioids – at least when it comes to hip fracture surgeries.

In an analysis of 1,600 patients who had surgery to repair hip fractures, researchers at the University of Pennsylvania Perelman School of Medicine found that patients who received spinal anesthesia reported more pain in the 24 hours after surgery than those who receive general anesthesia. They were also more likely to be using prescription opioids 60 days after surgery.

“In our study, patients who got spinal anesthesia did get fewer opioids in the operating room, but they ended up having more pain, and more prescription pain medication use after surgery,” said lead author Mark Neuman, MD, an associate professor of Anesthesiology and past chair of the Penn Medicine Opioid Task Force.

“While our study can’t determine conclusively whether this was due to the spinal anesthesia itself or the fact that fewer opioids were given up front, this is a result that should make people examine some of the assumptions informing current care pathways.”

The study findings, published this week in The Annals of Internal Medicine, show patients had their worst pain the day after surgery. Spinal anesthesia patients rated their pain an average of 7.9 (on a zero to 10 pain scale), slightly higher than the average of 7.6 reported by those under general anesthesia.

Researchers say 25 percent of patients in the spinal anesthesia group were using prescription opioids 60 days after surgery, compared to 18.8 percent of patients in the general anesthesia group. There were no significant differences in prescription pain medicine use after six and 12 months, but Neuman is wary of what he saw.

“Even though the 180- and 365-day findings are not statistically significant, the 60-day finding is still concerning, since there could be medication-related harms like respiratory depression or over-sedation that could still occur over the short term,” Neuman said.

Neuman and his colleagues found no significant differences in patient satisfaction, pain levels or mental health status after 60, 180 or 365 days between the spinal anesthesia and general anesthesia groups.

More than 250,000 older Americans suffer hip fractures every year and nearly all are repaired through surgery. In the past, most would receive general anesthesia, but in recent years the use of spinal anesthesia has increased significantly, due in part to the belief by some anesthesiologists that it was safer for frail, older patients.  

Elimination of Opioids Has “Unintended Safety Risks’

There is a growing reluctance on the part of surgeons to eliminate the use of opioid anesthesia or to allow patients to opt out of opioids during surgery.

In an op/ed recently published in The Conversation, three physicians at the University of Michigan Medical School called opioid medication “an essential tool in the operating room.”  

“Opioids stand out among the typical sedatives and anesthetics used in the operating room by significantly reducing the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness,” wrote Drs. Mark Bicket, Jennifer Waljee and Paul Hilliard. 

“Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.”  

Seven states currently allow patients to sign non-opioid directives telling their physicians not to treat them with opioids. Congress is considering bills in the House and Senate that would allow patients to make similar directives nationwide. Although both bills allow providers to override a patient’s directive in special circumstances, Bicket, Waljee and Hilliard are concerned the directives will lead to unsafe care.

“We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it difficult if not impossible to avoid harming patients,” they wrote.

General Anesthesia as Safe as Spinal Injections for Hip Fracture Surgery

By Pat Anson, PNN Editor

General anesthesia is just as safe as spinal anesthesia for patients undergoing hip fracture surgery, according to a large new study that dispels a common belief that patients who receive spinal injections have better outcomes.

Researchers from the Perelman School of Medicine at the University of Pennsylvania enrolled 1,600 mostly elderly patients having hip fracture surgery at 46 U.S. and Canadian hospitals, and randomly assigned them to receive either spinal or general anesthesia.

They found that rates of survival, delirium and functional recovery post-surgery were similar for patients, regardless of the type of anesthesia they received. The findings are published in The New England Journal of Medicine.

“Our study argues that, in many cases, either form of anesthesia appears to be safe," said lead investigator Mark D. Neuman, MD, an associate professor of Anesthesiology and Critical Care at Perelman. "This is important because it suggests that choices can be guided by patient preference rather than anticipated differences in outcomes in many cases."

During general anesthesia, inhaled and intravenous medications are used to make patients unconscious, which often requires a breathing tube during surgery. For spinal anesthesia, medications are used to numb the lower part of the body through an injection into the spinal column. Patients anesthetized this way are typically able to breathe on their own during surgery and rarely require a breathing tube.

About 250,000 people have hip fracture surgery annually in the United States. In the past, most would receive general anesthesia, but in recent years the use of spinal anesthesia for hip fracture surgeries has increased significantly, due in part to the belief by some anesthesiologists that it was safer for frail, older patients.  

To get a better idea of possible outcomes associated with both forms form of anesthesia, researchers looked at post-surgical death rates, whether patients regained the ability to walk, and if they experienced any cognitive decline.

Statistically, there was hardly any difference in outcomes between the two groups. Sixty days after surgery, 18.5% of patients assigned to spinal anesthesia had either died or were unable to walk; versus 18 percent of patients who received general anesthesia. About 21 percent of patients assigned to spinal anesthesia experienced delirium, versus 20 percent of those given general anesthesia.

"What our study offers is reassurance that general anesthesia can represent a safe option for hip fracture surgery for many patients," said Neuman. "This is information that patients, families, and clinicians can use together to make the right choice for each patient's personalized care."

Neuman and his research team say previous comparisons of general and spinal anesthesia came from studies that didn’t randomly assign patients, which creates self-selection bias. Some patients may have chosen spinal anesthesia with the goal of avoiding complications, while others opted for general anesthesia to avoid a spinal injection or because they feared inadequate sedation during surgery.

The most common types of medications used during spinal injections are anesthetics, opioids or corticosteroids. A recent study of patients with hip osteoarthritis warned of serious long-term complications for those given steroid injections. Patients who received steroids were 8.5 times more likely to develop rapidly destructive hip disease, a condition that causes the loss of blood flow and death of bone tissue in the hip.

Hip Fractures Often Ignored as Sign of Osteoporosis

By Pat Anson, Editor

Most older adults who suffer hip fractures aren't told they may have osteoporosis, despite the fact that hip fractures nearly always signify the presence of the bone weakening disease and can result in serious complications, according to a small survey of patients.

More than 10 million Americans suffer from osteoporosis and 44 million have its precursor, a loss in bone density that raises the risk of fractures and disability.  Studies have found that breaking a bone in your spine or hip may be so traumatic that it doubles your chances of developing chronic widespread body pain.

"You can die after a hip fracture, and you're at great risk of prolonged complications," said Gisele Wolf-Klein, MD, director of geriatric education for Northwell Health, the largest healthcare provider in New York state.

"You can also be left as an invalid, a fear of many older adults. When we think about how preventable hip fractures are, the fact that most patients aren't told or understand they have osteoporosis - a disease that can be treated - is an enormous problem."

Wolf-Klein and her colleagues surveyed 42 hip fracture patients aged 65 and older, and found a startling level of misinformation and mismanagement surrounding osteoporosis. 

A majority (57%) of patients said their hospital physicians did not recommend osteoporosis medication after treating their hip fracture. One in four patients said they would reject taking the drugs.

Nearly two-thirds (64%) of those who said they were being treated for osteoporosis were taking calcium and vitamin D supplements, which the Northwell researchers say are "useless" at preventing osteoporotic fractures.

More effective osteoporosis medication - which maintains bone density and lower the risk of a fracture - is available in many forms, including twice-yearly infusions or weekly pills. But the researchers say they're not prescribed as often as they should be.

"There's an enormous amount of misunderstanding about osteoporosis among the public and lack of education from physicians taking care of patients,"  said Stuart Weinerman, MD, an endocrinologist at Northwell Health, "Doctors don't talk about it and the perception is that these osteoporosis drugs are dangerous or not effective. Unfortunately, these misperceptions are just incorrect. So a lot of public education needs to be done, but it should start with physicians."

Lack of effective treatment can lead to additional fractures. Over a third of the patients surveyed sustained a fall within a year, and nearly half (44%) suffered an additional fracture.

"These numbers show the need to improve our overall treatment plan for osteoporosis, which includes fall-prevention education for patients and their families," said Mia Barnett, MD, a Geriatric fellow. "We can definitely get that re-fracture number lower if patients are treated with osteoporosis medications."

A quarter-million Americans sustain a hip fracture each year, according to the National Osteoporosis Foundation, but less than a quarter are treated for osteoporosis afterwards.

A recent study found that elderly men are far less likely to be screened for osteoporosis or to take preventive measures against the bone-thinning disease than women. The risk of death after sustaining a hip fracture is twice as high in men compared to women.

A large study of over half a million adults, published in the Archives of Osteoporosis, found that men and women who had a spine fracture and women who had a hip fracture were more than twice as likely to experience long term widespread pain.