Introduction:The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery. Methods: This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries. Results: There was a statistically significant decrease in hospital LOS (P = 0.028), inpatient opioid use (P = 0.001), and the average number of steps per communication encounter (P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities (P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P , 0.001) and medium-magnitude surgeries (49% reduction, P , 0.001). For smallmagnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P , 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference (P = 0.734). Outpatient opioid prescription quantities were markedly

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