The Effect of Sunlight on Postoperative Analgesic Medication Use: A Prospective Study of Patients Undergoing Spinal Surgery
Jeffrey M. Walch, BSA, Bruce S. Rabin, MD, PhD, Richard Day, PhD, Jessica N. Williams, BS, Krissy Choi, BS and James D. Kang, MD
From the Departments of Pathology (J.M.W., B.S.R.), Biostatistics (R.D.), and Orthopedics (J.D.K.), University of Pittsburgh, Pittsburgh, Pennsylvania; and Carnegie Mellon University, Pittsburgh, Pennsylvania (J.N.W., K.C.).
Address correspondence and reprint requests to Jeffrey M. Walch, BSA, Clinical Immunopathology Lab-CLSI Suite 5725, UPMC-CHMT, 200 Lothrop Street, Pittsburgh PA 15213-2582. E-mail: walchjm{at}upmc.edu.
Objective: Exposure to natural sunlight has been associated with improvement in mood, reduced mortality among patients with cancer, and reduced length of hospitalization for patients who have experienced myocardial infarction. Our aim was to evaluate whether the amount of sunlight in a hospital room modifies a patient’s psychosocial health, the quantity of analgesic medication used, and the pain medication cost.
Methods: A prospective study of pain medication use was conducted in 89 patients undergoing elective cervical and lumbar spinal surgery where they were housed on either the "bright" or "dim" side of the same hospital unit. Analgesic medication was converted to standard morphine equivalents for interpatient comparison. The intensity of sunlight in each hospital room was measured daily and psychologic questionnaires were administered on the day after surgery and at discharge.
Results: Patients staying on the bright side of the hospital unit were exposed to 46% higher-intensity sunlight on average (p = .005). Patients exposed to an increased intensity of sunlight experienced less perceived stress (p = .035), marginally less pain (p = .058), took 22% less analgesic medication per hour (p = .047), and had 21% less pain medication costs (p = .047). Age quartile was the only other variable found to be a predictor of analgesic use, with a significant negative correlation (p <.001). However, patients housed on the bright side of the hospital consistently used less analgesic medications in all age quartiles.
Conclusion: The exposure postoperatively of patients who have undergone spinal surgery to increased amounts of natural sunlight during their hospital recovery period may result in decreased stress, pain, analgesic medication use, and pain medication costs.
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The United Kingdom recently established a Private Finance Initiative (PFI) to redevelop 25% of all healthcare buildings within 10 years, incurring a cost of over $2.1 billion to date (23). The British government’s National Health Service proposed an Achieving Excellence Design Evaluation Toolkit (AEDET) to assess current healthcare buildings and provide design specifications for new PFI hospitals (24). One major element of the AEDET assessment is whether the hospital design provides a therapeutic environment for patients (23,24). The beneficial outcomes presented in this study may encourage architects to consider the level of sunlight exposure for patients. An optimal therapeutic hospital design may maximize sunlight exposure for patients with high use of analgesic medication. This research may also inspire architects and researchers to conduct similar studies that examine the effect of other hospital room design elements on the healing process.
Patients on the bright side in our study reported a significantly greater decrease in perceived stress at the time of discharge; however, this was not statistically associated with lower mean levels of analgesic use. These findings suggest that different mechanisms may mediate the effects of sunlight on psychosocial factors and analgesic use. Possible mechanisms may involve hormonal alteration in response to light. One particular neurotransmitter is serotonin, the concentration of which increases after light exposure. The activity of serotonin n-acetyltransferase, which catalyzes the conversion of serotonin into melatonin, is reduced after exposure to light (14). The serotonin metabolite concentration in the cerebrospinal fluid peaks during the summer months (25). This occurs during a time of higher-intensity sunlight and a longer period of daylight compared with the winter months that have the lowest concentration of hypothalamic serotonin (26). Research has shown that high-intensity light (phototherapy) increases platelet imipramine-binding sites (27), which are an indicator of serotonin uptake.
Serotonin is secreted by nuclei that originate in the brainstem (15). It then acts as an inhibitor of pain pathways in the spinal cord and other areas of the central nervous system (15). The role of serotonin in nociceptive processes is well documented (28), along with studies that correlate low serum serotonin concentrations and a high level of tenderness for patients with temporomandibular disorders (29).
Data from over 40 controlled trials indicates that tricyclic antidepressants (TCAs) reduce a patient’s pain perception (30). TCAs block the removal of serotonin from the synaptic cleft and thus prolong and increase the time that serotonin remains active in the body (31). This is analogous to having an increase serotonin concentration in the central nervous system (CNS) during time periods of exposure to higher-intensity sunlight (25). Therefore, our hypothesis is that exposure to sunlight may reduce a patient’s perception of pain and their need for analgesic medication.
Side effects from opioid use are common among postoperative patients. One survey reported that 82% of patients taking opioid medications had at least 1 side effect from that medication (13). The incidence of common side effects such as nausea and vomiting increases with an increase in the opioid dose (32). A reduction in opioid use among postoperative patients who are exposed to increased sunlight may cause a reduction in the occurrence of specific dose-dependent side effects. The potential health benefits of patient exposure to sunlight may cause physicians to encourage their patients to leave the blinds open in their hospital room.
Analgesic medication use in this patient population was the most in the youngest age group (22–49 year-olds). This is consistent with prior research demonstrating that the duration of pain relief after a single dose of an opioid increases with age (33). Sunlight had the most significant effect on analgesic use among the youngest age group and also on the first day after surgery, when the most pain medication was used. This study demonstrated that hospital patients who use the highest amount of analgesia received the most benefit from sunlight exposure. These results may encourage hospital administrators to relocate patient populations with high-analgesic requirements to units with higher-intensity sunlight.
The influence of the hospital environment on the healing process may contribute to a significant reduction of healthcare costs. This is of great importance during the present time because inpatient healthcare expenditures in the United States rose 6.2% from January 2002 to June 2002 (34), with pharmacy departments representing the third largest component of hospital costs (35). In our study, pain medication costs for patients on the bright side were reduced by 21%. These findings suggest that the exposure of surgical patients to increased amounts of natural sunlight during their hospital recovery period not only has important medical benefits for the patient, but also has significant cost saving benefits for health systems.
The authors thank all the patients who took part in this study. The authors also acknowledge the work of Nicole Daver and Michelle Webb as senior research assistants; and the assistance of Stephen Blank and Treacy Silverstein in data analysis. The authors also thank Gregory Bascug, Reneeta Basu, Steven Buslovich, Colleen Carroll, Caroline Chen, Melissa Frisby, Salome Ho, Meng Lu, Tara Marsh, Sara Rankin, Ken Shurin, Usmeet Singh, Zach Svigals, Derek Tang, and Georgia Thomas for their help with data collection. The authors thank Colleen Dunwoody, Michelle Hughes, Dr. Amy Burkert, Dr. William Brown, and Irene Kane for their administrative assistance. Finally, this research would not have been possible without the cooperation of Mary Beth, Joanna, and all of the nurses of Montefiore 8 South, who cared for this patient population.
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wtf, is this EXTREME MEASURES?
http://en.wikipedia.org/wiki/Extreme_Measures
