Abstract
The way that we measure success in all specialties of medicine continues to evolve, and becomes more complicated. The late and sadly controversial Ignaz Semmelweiss, in his work from 170 years ago at the Vienna General Hospital in Austria, is often credited with having introduced scientific observational analytics into medicine by comparing the death rates associated with puerperal infections with and without hand disinfection of health care practitioners involved in ob/gyn deliveries. His metrics were simple—death versus survival. 1 This elemental dichotomy required further refinement for many specialties. In the beginning of 1990s, efforts at quality of care assessment expanded to other parts of medicine. 2 Orthopaedic surgery, especially, with its more diffuse patient quality-of-life–centered care focus, rapidly became a leader in developing and using patient reporting outcomes tools as shown with the visionary MODEMS system, which was unfortunately ahead of its time. 3,4 Patient-reported outcomes and epidemiologic reporting has become the standard of clinical research in spine care, as can be seen in the articles in this current edition of Global Spine Journal. As we are looking at the next frontier with computer adaptive response testing (CAT) for patient reported outcomes (PRO’s) and are grasping the implications of adopting consumer industry standards to clinical medicine with “patient satisfaction” surveys, we are apt to miss a serious emerging health metric in spine care: prescription opiate use. 5,6 For the first time since the AIDS epidemic crested in the early 1990s, the life expectancy in the United States has fallen, with the dramatic rise in the number of prescription opiate related deaths being the most likely cause. 7 As physicians involved in spine care, which is one of the leading contributors to pain management challenges, refining the tools with which we quantify reporting of opiate and analgesic use is a necessary first step. To this end, a standardized reporting of analgesic medication intake would be a very meaningful metric to introduce for clinical outcomes reporting. This metric is actually available in form of opioid equivalency scoring (ECS) tables, in which an oral 10 mg dose of morphine is assigned a relative coefficient of 1. In comparison, for instance, 3600 mg of aspirin are assigned a value of 1/360 and 0.1 mg of IM or IM/IV fentanyl is ascribed a value coefficient of 50-100. 8,9 With the increasing use of electronic medical records (EMR), it would stand to reason to develop an integrated pain medication calculator to go along with clinic visits to enable clinicians to have a better visual grasp of pain medication consumption. This is not really done right now as it requires personal effort. Having such a metric automated and reporting on it routinely with clinical studies would allow us to much more comprehensively correlate complexity of surgery, underlying patient health with PRO’s, patient satisfaction scores and opioid equivalency scoring. Hopefully we will see an increase in reporting use of pain medication for clinical outcomes reporting in spine surgery in the not too distant future as we are trying to refine our understanding of how interventions in spine care and nonoperative management are an integral part in positively changing patient’s lives. By becoming more aware of prescription opioid use, we can rise to being champions for better and more lasting meaningful quality of life for our spine patients.