What do powerful painkillers (opioids) really do before and after spine surgery?

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Patient Guide. Uncritically prescribed opioid-containing medications can cause tremendous problems when performing surgery. In this article, the correlations are described and strategies for avoidance are shown.

Before you start reading

Please take the time to answer the questions. The answers cannot be related to you personally. They help us get a realistic picture. Thank you very much!

The opioid crisis in the USA as an eye-opener

Uncritical prescribing of opiate medications has led to a crisis in the U.S. with thousands of drug deaths. Although more than $13 billion in compensation has already been paid, the long-term consequences and the cleanup still needed will take at least a generation. Even though opioid abuse numbers from the U.S. are higher than in other countries ¹https://pubmed.ncbi.nlm.nih.gov/31318808/ , it is worth following this drama and pointing out the dangers associated with opioid medication.

The aim of this article is therefore to create awareness among you – dear patient – of the side effects of opioids. This is done especially in relation to a possible upcoming spine surgery. Please take the time to read the following lines. Please do not lightly change an ongoing therapy, but take this article as an opportunity to talk to your doctor about it.

As a scientific spine surgeon, I have frequently come across reports in recent years of higher complication rates after spinal fusion surgery when patients had previously taken opioids. This is not necessarily immediately obvious because, after all, one would think that opioids, being very strong painkillers, should actually make the world easier for the patient. But there are also side effects.

General opioid side effects

Well known side effects are fatigue, listlessness and constipation. Sometimes this results in additional problems such as falls or bowel obstruction. The latter can be avoided by ensuring (also with medication) a pulpy stool consistency.

However, the side effects I will report in this post are not as well known.

What do opiods do in the body?

1. Opioids reduce the release of our stress hormone cortisol by inhibiting the production of the precursor hormones CRH and ACTH in the brain. In everyday life, this may not be a problem. However, in the context of a major operation, such as a spinal fusion surgery, maximum performance is expected from the organism. This organism is expected to be able to handle this form of stress from the surgery (e.g., increase blood pressure and blood sugar to free more energy reserves). If the body’s response is weaker because the cortisol level is too low, medication must be used to increase blood pressure, for example, which in turn can have a negative effect on the blood supply to the organs (e.g. brain and spinal cord) because these drugs also constrict the blood vessels. An insufficient stress response also means insufficient stimulation of the immune system. However, it is precisely the immune system that is needed postoperatively to eliminate invading bacteria (in every operation – no matter how aseptically performed – bacteria enter the organism) and to coordinate the healing phase.
2. While we’re on the subject of bacteria. Opioids have a direct effect on the cells of our immune system. Nearly all of these cells have sensitive antennae for endorphins (our body’s own opioids), which are secreted, for example, when we are seriously injured to temporarily protect us from overwhelming pain. These defense cells can therefore now be directly disrupted by opioids in the form of drugs, which in turn increases susceptibility to infection after surgery.
3. Opioids inhibit the release of sex hormones. Low levels of the sex hormones estrogen (woman > man) and testosterone (man > woman) inhibit bone metabolism and lead to bone loss (osteoporosis). This is especially tragic if the patient already has osteoporosis and therefore severe pain. Sometimes osteoporosis also causes vertebral fractures and requires surgical intervention.
   Does that apply to you? Talk to your doctor about the dilemma! Solutions should be sought here. Osteoporosis can become a problem before spine surgery or other orthopedic surgeries, as it may prevent implants from being fixed as well.
4. Opioids make people diabetic (diabetes mellitus), or more precisely, they make certain organs of the body insensitive to insulin (insulin resistance). Insulin is the hormone that, like a key, opens the door for sugar to enter our cells. This lowers the blood sugar level. Sugar is converted to fat by insulin in our adipose tissue, and elevated insulin levels then act as a fattening agent. With insulin resistance, more insulin must be produced to lower blood glucose levels. As a result, the fat cells become more and larger – the patient gets fatter and fatter. Diabetics are always at increased risk for complications from major surgery, such as spinal fusion.

So this is for the theory. So how do these side effects manifest themselves when performing surgery? Could I be affected by this as a patient?

Postoperative complications due to preoperative opioid medication.

The following statements are supported by high-quality clinical studies and linked in the physician edition of this article. The focus is on orthopedic / spine surgery. However, studies exist in cardiovascular surgery and abdominal surgery with similar results.

Complications in arthroplasty

Patients who receive an artificial shoulder, hip, or knee joint with prolonged preoperative opioid medication (>3 months) had more frequent wound infections and more frequent need for repeat surgery for complications. Hospital length of stay and subsequent medical costs were higher within one year after surgery.

Complications in spine surgery

Patients with spinal problems are more likely to have opioid contact than other patients. This underpins the particular impairment of patients and cannot be criticized as an auxiliary measure. However, a treatment plan should be put in place expeditiously with the patient’s opioid relief as one of the goals. The longer the patient has been taking opioid prior to spinal surgery (e.g., for a herniated disc or spinal instability), the less likely he or she will be able to get rid of these medications after surgery.

As has been the case in arthroplasty, wound healing problems and infections are more common among opioid-naive patients. In addition, neurological complications (paralysis) and problems with implant fixation (loosening of screws) are more common. Problems with the kidneys and thrombosis have been frequently described.

If one manages to discontinue opioid 3 months preoperatively, then the risk for such complications also decreases.

What to do?

Prescribing and discontinuing medications is done for medical reasons. Therefore, it is important that you discuss your medication with your doctor. Under no circumstances should you independently simply stop an ongoing opioid medication abruptly, as this can be accompanied by severe withdrawal symptoms.

If you’d like to take less pain medication, it involves work. On the one hand, it’s brain work because you have to think about what will relieve your pain (non-drug measures like warmth for muscels, electrotherapy,…). Your doctor needs this information to work with you to develop an opioid exit strategy.
If your doctor agrees to a dose reduction, you will also have to assign yourself to physical training in order to make your muscles perform well in the long term. Psychological und physical aspects of this opioid retraction could be easily accomplished in a rehabilitation setting. If weaning is done in preparation for orthopedic surgery, this could be done as so-called prehabilitation to improve the success of the surgery.

Please discuss the options with your physician, feel free to refer to the physician version of this article.