Total shoulder arthroplasty - are the risk factors for long term opioid use modifiable?

 Predictors of Long-term Opioid Use After Elective Primary Total Shoulder Arthroplasty 

Using a large administrative claims database these authors identified 5676 adults who underwent elective primary TSA between 2010 and 2015 and had 1 year or more of continuous insurance enrollment, including prescription drug coverage, postoperatively. 

Long-term postoperative opioid use was defined as filling prescriptions totaling a 120-day or greater supply during the 3- to 12-month postoperative period. 

16% of patients had long-term postoperative opioid use.

The strongest predictors in a multivariate analysis were 

1. preoperative opioid use (odds ratio [OR], 4.7; 95% CI, 4.0-5.5), 

2. history of drug abuse (OR, 2.5; 95% CI, 1.3-4.9), 

3. depression (OR, 1.9; 95% CI, 1.6-2.3), 

4. anxiety (OR, 1.4; 95% CI, 1.2-1.7), 

5. surgery performed in the Western United States (OR, 1.8; 95% CI, 1.3-2.4), 

and 

6. reverse TSA (OR, 1.5; 95% CI, 1.2-1.8). 

Comment: Of these six factors, numbers 1,2,5 and 6 would not seem to be modifiable. Furthermore, it is not obvious that preoperative attempts to modify depression or anxiety are effective in lowering the risk of prolonged opiod use.  

The main takeaway is that for patients at high risk for long term opiod use, surgeons need to put in place a robust plan for postoperative pain management before surgery is scheduled. In most cases this means obtaining a preoperative agreement with a pain management specialist or primary care physician to manage pain medications after surgery.

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