Reverse total shoulder - what if the patient is taking narcotics prior to surgery?

Preoperative opioid usage predicts markedly inferior outcomes two years after reverse total shoulder arthroplasty

These authors analyzed 265 reverse total shoulder replacements (RTSAs) to determine the influence of preoperative opioid use on clinical and radiographic outcomes at a minimum of 2 years follow-up.

71 patients were classified as preoperative opioid users because they had taken narcotic pain medication for a minimum of 3 months prior to surgery (the Centers for Disease Control definition).

193 patients were classified as opioid-naive at the time of surgery. 

Opioid users were significantly younger, more likely to be female, more likely to be African-American and had significantly higher preoperative rates of mood disorders, chronic pain disorders, and disability status.

Postoperatively, opioid users had inferior VAS (2.59 vs 1.25), ASES scores (63.2 vs 75.2), active forward elevation, and internal and external rotational shoulder strength than opioid-naïve patients. 

Both groups improved from baseline preoperatively to most recent follow-up in terms of functional outcomes and pain.

Opioid users had higher rates of complications (28.2%  vs 17.1%) glenoid or humeral periprosthetic radiolucency (8.5% vs 2.1%), and subsequent revision arthroplasty (12.7% vs 4.7%).

Comment: This is an interesting study in that it found over one in four patients having RTSA to be using narcotics prior to surgery and that it suggests that opioid use may be a marker for psychosocial disorders that can increase the risk of poorer outcomes. 

The unanswered questions are 

(1) can these psychosocial disorders and opiod use be effectively modified prior to surgery so that outcomes are improved?

(2) how should the presence of opioid use change our indications for RTSA for patients who otherwise would be candidates for this procedure?

(3) if the decision is made to proceed with RTSA, how can the postoperative care for the opioid using patient be optimized?

(4) does dose and type of narcotic matter? Compare the patient who takes one oxycodone at night for sleep to the patient who is taking substantial doses of oxycontin, suboxone or MScontin?

We are grateful to the senior author of this paper for his thoughtful responses to these questions: 

1. can these psychosocial disorders and opiod use be effectively modified prior to surgery so that outcomes are improved?

We don’t really think so.  Opioid use in our practice is typically “baked into the cake” due to a number of prior factors that are very difficult to undo prior to surgery.  We use this information as a pre-operative education piece to let patients know they can make improvements after surgery, but not to the level that their peers may achieve (or that the patient may wish).

 

2. how should the presence of opioid use change our indications for RTSA for patients who otherwise would be candidates for this procedure?

It’s a data point that we consider but does not by itself change indications.  Again, we use this for patient education pre-operatively.

 

3. if the decision is made to proceed with RTSA, how can the postoperative care for the opioid using patient be optimized?

In our state regulations only allow opioid medications to be given by one provider.  So if a patient presents already taking opioids, we typically defer post-operative opioid management to that provider if possible.  In some instances, that provider may wish for us to manage the opioids for up to 3 months post-operatively and we are amenable to that.  Either way, we employ multimodal pain management (intraoperative periarticular injections, gabapentin, scheduled Tylenol, and muscle relaxers). If we are managing the opioids, we maintain the patient on their pre-operative dose and supplement with oxycodone 5-10mg per dose for breakthrough pain.  As our data suggests however, these patients have a more difficult post-operative course and have more difficulty with pain control.

 

4. does dose and type of narcotic matter? Compare the patient who takes one oxycodone at night for sleep to the patient who is taking substantial doses of oxycontin, suboxone or MScontin?

We have a previous study on opioid use prior to anatomic TSA which did find a dose-response relationship between opioid use and outcomes.  While difficult to directly extrapolate to reverse arthroplasty, we suspect this relationship likely still holds.  However, the data also suggests a discrete (yes-no) phenomenon where any amount of pre-operative opioid use is detrimental.

In our practice we assess each patient individually in partnership with a primary care physician who agrees to assist in addressing (1) the psychosocial issues and (2) assisting the patient in withdrawing from narcotics before surgery. If the patient cannot withdraw from narcotics before surgery, the primary care physician must agree to manage these medications after surgery. We emphasize that patients taking substantial narcotics prior to surgery cannot expect the same degree of pain relief as the person who is opioid naive.

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Total shoulders and opioid consumption

Study of variations in inpatient opioid consumption after total shoulder arthroplasty: influence of patient- and surgeon-related factors

These authors sought to determine factors influencing inpatient opioid utilization after 622 elective total shoulder arthroplasties (TSA) by 20 different surgeons

The average opioid dose per encounter was 47.4 ± 65.7 morphine milligram equivalents (MMEs) per day.

Pre-existing psychiatric disorders, preoperative opioid use, highest quartile of median household income, current-smoker status, and age < 60 years were associated with increased inpatient opioid consumption after TSA. Expectedly, the 7 patients not having regional anesthesia had higher inpatient opioid consumption.

Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences.

Comment: This study is useful in identifying patients who not only may require more inpatient narcotics, but who may also have greater problems with pain management after hospital discharge. We are less likely to offer elective surgery to patients who are at heightened risk for needing prolonged postoperative narcotics. If surgery is considered for these individuals, a robust in hospital and post discharge pain management plan needs to be in place.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

The narcotic epidemic - how can surgeons and patients address it?

Leading the Way to Solutions to the Opioid Epidemic

These authors point out that in the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion. In addition to reviewing the literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), they authors present some solutions to address the current opioid crisis.

One of the most disturbing parts of this article is 'how we got here'. Below is a summary:
"While opioids have long been used to treat acute pain following traumatic injury and during the postoperative period, the expansion of the use of these opioid analgesics to noncancer pain outside of the acute or immediate postoperative setting started to become more commonplace in the 1990s based on the conclusions published by Portenoy and Foley .. claiming the safety and efficacy of opioids for chronic noncancer pain, despite small patient numbers culled from 2 different studies with moderate results and several complications. At that time, extended-release oxycodone (OxyContin) entered the marketplace with claims of increased effi cacy and safety. Subsequently, the manufacturer admitted to false marketing on the safety of OxyContin , and studies have not demonstrated the increased efficacy of extended release over immediate release. Pain advocacy groups and pain specialists, many of whom have substantial financial relationships with pharmaceutical companies, successfully lobbied... to put pain at the center of all patient assessments. Physicians faced increased pressure to prescribe more opioids . This opened the door for aggressive marketing by pharmaceutical companies to expand the use of opioids to noncancer pain; the marketing included educational materials supplied by The Joint Commission, which were sponsored by Purdue Pharma....most studies were sponsored by the pharmaceutical manufacturers... a "1% risk of addiction” is commonly cited...subsequent studies have demonstrated that the risk of addiction to prescription opioids is 3% to 45% when they are used on a long-term basis. Furthermore, if patients take prescription opioids beyond 12 weeks, 50% will still be taking them at 5 years"

Here are some 'flags' they identified for possible opioid abuse.

 Here are some risk factors they associated with opioid abuse.

 Here are some non-opioid approaches to pain management around the time of surgery

And here are some suggestions for surgeon-patient discussions of pain management.

Comment: This is a most informative article. It points to ways that both surgeons and patients can be part of the solution, not part of the problem.

A thoughtful editorial on this issue has been written by Seth Leopold (see this link). He points out that "the United States represents only 4.6% of the world’s population, but Americans consume 80% of the global opioid supply and 99% of the hydrocodone. In 2015, more than 52,000 people in the United States died from drug overdoses, and some 15,000 of those overdoses involved a prescribed opioid. The CDC reports that prescription-opioid abuse, dependence, and overdose costs the US economy an estimated USD 78.5 billion each year."

Today I was consulted by a 32 year old patient who had chronic pain after orthopedic surgery performed 17 years ago. The patient has had a total of 7 surgeries and is now on Oxycontin and Oxycodone in large doses.

Our practice is to (1) inform patients before surgery that recovery from surgery is likely to be painful, but that is expected and not a sign than things are wrong, (2) let them know that our primary medications for pain control are Tylenol and anti-inflammatory medications - narcotics will be limited to the first two weeks after surgery, (3) avoid using nerve blocks to temporarily 'mask' pain and (4) be very cautious about performing elective surgery on patients taking long-acting and / or high dose narcotics, because pain is likely to persist even after a 'perfect' procedure.

Interested readers may like to read this enchanting book by our late friend and colleague, Paul Brand

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder exercises,  shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials' See from which cities our patients come.