Ketamine Use During Spine Surgery: Implications for Opioid Reduction Policies

New Evidence: Intraoperative Ketamine and Postoperative Opioid Use

A September 2026 retrospective database analysis published on PubMed (PMID: 42777275) investigates whether administering ketamine during lumbar spine surgery influences chronic opioid use postoperatively. The study includes both patients with and without diagnosed opioid use disorder (OUD), providing a rare comparative perspective on this population. The findings are directly relevant to ongoing debates about perioperative pain management and the search for alternatives to opioids in surgical settings.

Mechanisms and Clinical Context: Why Ketamine?

Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is used intraoperatively for its analgesic and anesthetic properties. Its mechanism—modulating central sensitization and reducing opioid tolerance—makes it an attractive adjunct in surgeries with high postoperative pain, such as lumbar spine procedures. The rationale is that ketamine may blunt the development of opioid tolerance and hyperalgesia, potentially reducing the need for chronic opioid therapy after surgery. Notably, patients with a history of OUD are at higher risk for persistent opioid use, making the search for effective adjuncts critical in this subgroup.

Policy and Research Implications: Informing Pain Management Protocols

The study's retrospective design leverages a large clinical database to compare rates of chronic opioid use—typically defined as opioid prescriptions extending beyond 90 days post-surgery—between patients who received intraoperative ketamine and those who did not. The inclusion of both OUD and non-OUD cohorts allows for nuanced analysis of whether ketamine's effects differ in populations with baseline opioid tolerance or dependence. While the findings do not establish causality, they provide real-world evidence that can inform hospital protocols and payer policies regarding ketamine's role in multimodal analgesia.

• For clinicians: The results may support or challenge existing Enhanced Recovery After Surgery (ERAS) protocols that include ketamine as a standard adjunct, especially for high-risk patients.
• For policymakers: The data contribute to the evidence base needed for guidelines on perioperative opioid stewardship, particularly in jurisdictions considering limits or incentives for opioid prescribing.
• For researchers: The study highlights the need for prospective, randomized controlled trials (RCTs) to validate these findings and clarify patient selection criteria.

One non-obvious insight is that the study's large, real-world dataset captures a spectrum of comorbidities and perioperative variables often excluded from RCTs, providing a more pragmatic view of ketamine's impact in diverse surgical populations.

Risks, Limitations, and Unknowns

Retrospective analyses like this are subject to confounding, including selection bias (patients receiving ketamine may differ systematically from those who do not) and unmeasured variables (such as intraoperative dosing or postoperative pain management strategies). The study cannot account for all factors influencing chronic opioid use, such as psychosocial determinants, surgical complexity, or provider prescribing habits. Furthermore, ketamine itself carries risks—including psychotomimetic side effects and potential for misuse—requiring careful patient selection and monitoring.

Importantly, the study does not address long-term functional outcomes, quality of life, or pain scores, which are critical endpoints for both patients and policymakers. The lack of randomization means that any observed associations should be interpreted cautiously, and the findings should not be generalized to all surgical populations or to ketamine use outside the intraoperative setting.

Looking Ahead: Next Steps for Research and Policy

The publication of this analysis signals growing interest in non-opioid adjuncts for perioperative pain management, particularly in populations vulnerable to chronic opioid use. Future research should prioritize prospective RCTs stratified by OUD status, as well as studies examining functional recovery and patient-reported outcomes. Policymakers and hospital systems may consider pilot programs or registry-based studies to further evaluate ketamine's utility and safety profile in routine practice.

As the opioid crisis continues to drive innovation in pain management, nuanced, population-specific data—such as that provided by this study—will be essential for evidence-based policy and clinical decision-making. The challenge remains to balance the promise of ketamine with its risks and to ensure that interventions are tailored to the needs of diverse surgical patients.

By Dr. Jamie L. Chen, MD, MPH, Clinical Associate Professor of Anesthesiology. Reviewed by Dr. Marcus Feldman, PharmD, on 2026-09-25. Research based on the original PubMed publication and direct review of perioperative pain management guidelines.