Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids

BACKGROUND: The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (Laos) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and Laos from our postoperative pain control regimen. OBJECTIVE: To evaluate the impact of removing benzodiazepines and Laos on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. METHODS: A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the + benzodiazepine cohort included scheduled diazepam with or without Laos. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the -benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. RESULTS: Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (-18.7%, 95% CI [-1.22%, -36.10%]), used less trigger medications (-1.55, 95% CI [-0.43, -2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the -benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P =. 021) and 6 mo postoperatively (0% vs 13.2%, P =. 039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P =. 048). CONCLUSION: Replacement of benzodiazepines and Laos in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.