Classifying High-Risk Patients for Persistent Opioid Use After Major Spine Surgery: A Machine-Learning Approach

Five classification models were evaluated to predict persistent opioid use: logistic regression, random forest, neural network, balanced random forest, and balanced bagging. Synthetic Minority Oversampling Technique was used to improve class balance. The primary outcome was persistent opioid use, defined as patient reporting to use opioids after 3 months postoperatively. The data were split into a training and test set. Performance metrics were evaluated on the test set and included the F1 score and the area under the receiver operating characteristics curve (AUC). Feature importance was ranked based on SHapley Additive exPlanations (SHAP). RESULTS: After exclusion (patients with missing follow-up data), 2611 patients were included in the analysis, of which 1209 (46.3%) continued to use opioids 3 months after surgery. The balanced random forest classifiers had the highest AUC (0.877, 95% confidence interval [CI], 0.834–0.894) compared to neural networks (0.729, 95% CI, 0.672–0.787), logistic regression (0.709, 95% CI, 0.652–0.767), balanced bagging classifier (0.859, 95% CI, 0.814–0.905), and random forest classifier (0.855, 95% CI, 0.813–0.897). The balanced random forest classifier had the highest F1 (0.758, 95% CI, 0.677–0.839). Furthermore, the specificity, sensitivity, precision, and accuracy were 0.883, 0.700, 0.836, and 0.780, respectively. The features based on SHAP analysis with the highest impact on model performance were age, preoperative opioid use, preoperative pain scores, and body mass index. CONCLUSIONS: The balanced random forest classifier was found to be the most effective model for identifying persistent opioid use after spine surgery....