Introduction The prescription opioid epidemic and widespread use of narcotic medications have introduced new challenges when treating patients undergoing spine surgery. Given the ubiquity of preoperative opioid consumption amongst patients undergoing spine surgery, further research is needed to characterize perioperative risks. Our goal is to compare outcomes following primary lumbar decompression, instrumentation, and fusion based on preoperative opioid prescriptions. Methods Patients older than 18 years of age who underwent a primary one- to two-level lumbar decompression, instrumentation, and fusion were included in the study. Patients with known malignancy, surgery involving three or more lumbar levels, current or previous use of neuromodulation, revision surgery, anterior or far lateral interbody fusions, acute fractures, or other concurrent procedures were excluded. Patients were divided into chronic opioid therapy (COT; over six months), acute opioid therapy (AOT; up to six months), and opiate-naïve groups. Opioid prescriptions, demographics, smoking status, readmission rates within one year, and reoperation rates within two years were recorded based on electronic medical record documentation. Results Out of 416 patients identified, 114 patients met the inclusion criteria. Thirty-eight patients (33.3%) were on COT, 38 patients (33.3%) were on AOT, and 38 patients (33.3%) were opioid naïve preoperatively. Readmission rates within one year for COT, AOT, and opioid naïve patients were 34.2%, 26.3%, and 10.5%, respectively (p=0.047). Reoperation rates within two years for COT, AOT, and opioid naïve patients were 34.2%, 15.8%, and 13.2%, respectively (p=0.049). We also found current or former smokers were more likely to be on AOT or COT than never smokers (78.4% vs. 57.1%; p=0.017). Conclusion Long-term opiate use is associated with an increased risk for readmission within one year and revision within two years. Physicians should discuss the increased risks of readmission and revision surgery associated with lumbar decompression and fusion seen in patients on preoperative opioid therapy.