Chronic opioid use before shoulder arthroplasty prolonged opioid use postoperatively
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Patients undergoing total shoulder arthroplasty with a history of chronic opioid use preoperatively had the highest risk of prolonged postoperative opioid use, according to published results.
Using the Humana database, Brian Forsythe, MD, and colleagues categorized 12,038 patients undergoing primary total shoulder arthroplasty between 2007 and 2015 as either opioid-naïve patients who did not fill a prescription prior to surgery (29.8%) or those who filled opioid prescriptions within 3 months preoperatively (OU group; 43%). Researchers subcategorized patients in the OU group into either an acute preoperative opioid user group if they only filled an opioid prescription within 1 month prior to surgery (10.6%) or a chronic preoperative opioid user group if they filled an opioid prescription between 1 and 3 months prior to surgery (32.4%). Researchers evaluated incidence of opioid use for each cohort preoperatively and longitudinally and used multivariate analysis to identify factors associated with opioid use at 12 months postoperatively.
Despite a decline in opioid use after the first postoperative month, results showed the OU cohort had a significantly greater incidence of opioid use at 1 year compared with the opioid-naïve cohort. Postoperative opioid use for anatomic and reverse total shoulder arthroplasties had a similar decline, according to results of the subgroup analysis. In the multivariate analysis, researchers noted the strongest risk factor for opioid use at 12 months after anatomic and reverse total shoulder arthroplasties was chronic preoperative opioid use.
“Chronic opioid users, those who have filled a prescription between 1 and 3 months prior to surgery, were at greatest risk for opioid use 12 months after anatomic and reverse shoulder arthroplasty,” Forsythe told Healio Orthopedics. “The relative risk was 0.96, meaning that patients were almost 10-times more likely to be using opioids 1 year postoperatively if they filled a prescription between 1 and 3 months preoperatively. This study is a tremendous screening tool for preoperative counseling of patients in the need to discontinue narcotic use.” – by Casey Tingle
Disclosure: Forsythe reports no relevant financial disclosures.
Perspective
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Christopher R. Chuinard, MD, MPH
Because orthopedic surgeons are the third highest opioid prescribers in the United States, a considered approach to perioperative pain management is necessary to deal with the current opioid crisis. Moreover, as joint arthroplasty moves to an outpatient venue, pain management has become one of the critical factors in successful outcomes. The authors of this study utilized a large database with over 12,000 shoulder replacement patients to gather meaningful "birds-eye view" data about factors that may contribute to prolonged narcotic use after anatomic and reverse shoulder arthroplasty. Narcotic use within three months of shoulder arthroplasty, age <65, and fibromyalgia were highly correlated with narcotic use at 1-year postoperatively (10-12x's as likely if not narcotic naive). Moreover, it’s important to note that 40% of the patients were identified as having received a narcotic prescription within three months of the procedure. As other studies have linked modifiable risk factors like tobacco and opioid dependence with prolonged postoperative narcotic use, surgeons should inform and direct patients to seek ways of reducing the intake prior to any elective procedure. Furthermore, multimodal pain management and narcotic reduction strategies should become part of every orthopedic surgeon's practice.
Traverse City, Michigan
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