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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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 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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Should patients taking narcotics get a total shoulder?

Preoperative Narcotic Use and Inferior Outcomes After Anatomic Total Shoulder Arthroplasty: A Clinical and Radiographic Analysis

These authors sought to determine whether the chronic use of preoperative narcotics adversely affected the two-year clinical and/or radiographic outcomes in seventy-three patients (79 shoulders) with primary total shoulder arthroplasty for osteoarthritis. 26 patients (28 shoulders) were taking chronic narcotic pain medication for at least 3 months before surgery while 47 patients (51 shoulders) who were not taking narcotics preoperatively.

Significant differences were noted between the narcotic and nonnarcotic groups regarding American Shoulder and Elbow Surgeons scores and visual analog scale scores, as well as forward elevation, external rotation, and all strength measurements. The nonnarcotic group had markedly higher American Shoulder and Elbow Surgeons scores, better overall range of motion and strength, and markedly lower visual analog scale scores than the narcotic group. 

Radiographic analysis found no difference between the narcotic and nonnarcotic groups with regard to the number of humeral, glenoid, or combined radiolucencies. There were no instances of mechanical failure in either group. There were four (14%) complications in the narcotic group and one (2%) in the nonnarcotic group. These included one instance each of inferior positioning of the humeral head, arthrofibrosis (defined as active and passive FE less than 90 with a firm end point), rotator cuff decompensation (defined as loss of active FE), and subscapularis failure (defined as anterior glenohumeral subluxation on radiographs with accompanying loss of active FE) in the narcotic group. In the nonnarcotic group, one patient developed arthrofibrosis. There were no revision surgeries in either group.

Comment:  Table 2 documents that patients on narcotics had functionally worse shoulders than the patients not on narcotics. This makes one wonder if these patients had worse arthritis. It would be of interest to know how the radiographs of the two groups compared before surgery with respect to joint space narrowing, glenoid version and Walch type. 

We wonder what was the range of narcotic consumption in the narcotic group. It would seem important to quantitate the effect of narcotics over the range from one Tylenol #3 in 3 months to heavy doses of MScontin every 4 hours. It would be of interest to see a plot of narcotic consumption/day versus the improvement in ASES score.

Finally, we have the issue of what is best for patients with glenohumeral arthritis who, for whatever reason (back pain, shoulder pain, phantom pain after amputation) is taking narcotics. Is it in their best interest to delay surgery until they are "de-toxed"? Or to deny them surgery altogether? Or to go ahead warning them of increased risk of an adverse outcome?

In our practice we defer elective surgery for patients on Suboxone, MSContin, OxyContin, or large daily doses of other narcotics, explaining that the risk/benefit ratio is unfavorable for them.
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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

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

How long are narcotics needed after shoulder joint replacement?

Risk factors for postoperative opioid use after elective shoulder arthroplasty

These authors sought to determine baseline opioid use in patients undergoing shoulder arthroplasty and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use in 3996 patients from a shoulder arthroplasty registry.  They identified the number of dispensed opioid medication prescriptions in each quarter of the first postoperative year.

The factors associated with increased opioid use were age <60 years, the amount of preoperative opioid use, anxiety, opioid dependence, substance abuse, and general chronic pain.

During the 1-year preoperative period, 75% of the patients used opioids (range, 1-79 prescriptions). Postoperatively, 92.6% used opioids in the early recovery period, and 38% to 42% used opioids in the later rehabilitation period, 39% at 1 year postoperatively

Depression was the most common opioid use-related comorbidity.

Comment: Like the authors, we are very concerned about the widespread use of narcotics. Preoperatively, we try to set the expectation that patients would be off narcotics within two weeks of surgery. For patients taking narcotics and seeking, we ask that they make substantial progress in reducing their dependency before scheduling surgery, explaining that the less narcotic medication they're taking before surgery, the less problem we'll have in managing their pain after surgery. We are reluctant to perform elective surgery on patients taking substantial doses of narcotics or long-term narcotics, such as Oxycontin, or MScontin.

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Pain: Avoiding MRI's and Narcotics

There is concern that too many MRI's are being ordered to evaluate pain and too many narcotics are being used to 'treat' pain. These concerns are nicely illustrated in a recent New York Times article:

Lower Back-Ache? Be Active and Wait it Out, New Guidelines Say.

While back pain is not shoulder pain, back and shoulder pain are common reasons for patients to come to see a doctor. The guidelines for managing back pain are becoming increasingly safe, conservative, and cost-effective; see this link.


"The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief."

"In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.

“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”

Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin.

Scans, like an M.R.I., for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain."

Comment: While the shoulder is not the back and every patient is an individual, we agree that two of the biggest problems encountered in caring for individuals with shoulder problems are (1) an MRI ordered by a doctor without a specific question in mind that reveals 'findings' that are not related to the patient's symptoms and (2) patients who have been given narcotic pain medications by a doctor to which they have become habituated and from which they are obtaining less and less relief.

For patients without an obvious injury, we often begin by obtaining simple x-rays (as shown in this link) and starting gentle exercises (as shown in this link).

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Caution! Preoperative narcotic use is associated with early arthroplasty revision

Preoperative Opioid Use Is Associated with Early Revision After Total Knee ArthroplastyA Study of Male Patients Treated in the Veterans Affairs System

These authors tested the hypothesis that use of opioids is associated with one year adverse outcomes after total knee arthroplasty(TKA). 

The length of time for which an opioid had been prescribed by the VA and the morphine equivalent dose were calculated for each patient. Patients for whom opioids had been prescribed for >3 months in the year prior to the TKA were assigned to the long-term opioid group. 

Of 32,636 patients 12,772 (39.1%) were in the long-term opioid group and 734 (2.2%) had a revision within a year after the TKA. 

Chronic kidney disease, diabetes, and long-term opioid use were associated with revision within 1 year—with odds ratios (95% confidence intervals [CIs]) of 1.76 (1.37 to 2.22), 1.11 (0.93 to 1.31), and 1.40 (1.19 to 1.64), respectively

The authors concluded that long-term opioid use prior to TKA was associated with an increased risk of knee revision during the first year after TKA among predominantly male patients treated in the VA system.

Comment: This study of a large series of total knee patients is likely to have relevance to all patients having arthroplasty, including those having shoulder joint replacement. It prompts us to consider two questions: (1) what does prescribed narcotic use say about the patient? and (2) what prompts patients to have a revision? The use of narcotics may indicate a low pain tolerance.  The indications for revision include continued pain after surgery. It seems likely that the patient with preoperative pain 'requiring' narcotics may be more likely to have persisting pain after surgery and that pain may increase the risk of revision.

While this study compare patients taking and not taking prescribed narcotics, their data show that 'taking narcotics' is not dichotomous, but a wide range of dose, frequency and duration. The chart below shows the number of morphine equivalent doses per month on the horizontal axis and the length of time the narcotics were prescribed on the vertical axis. Patients taking more narcotics also were on narcotics for longer periods of time. It would be of interest to know the relationship of revision rate to the amount of narcotics prescribed. The patients at the lower left of this chart might be expected to be at lower revision risk than those at the upper right. 

So how do we use these data in our practice? First, we need to inform patients that preoperative narcotic use is likely to be associated with continued pain after surgery. Second, we need to consider delaying elective surgery on patients with minimal radiographic findings who are taking narcotics. Third, when an arthroplasty fails to provide the desired pain relief, we need to be cautious about offering revision surgery to patients with pain alone (i.e. without obvious mechanical failure or infection). Fourth, the non-operative management of a painful joint should not include the prescription of narcotic medication.

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Why are we prescribing so much narcotic medication after surgery?

A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines

These authors reviewed patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period with respect to patient demographic characteristics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Their concern was that inadvertent overprescribing can lead to excess availability of opioids in the community for potential diversion.

They identified 1,416 patients with a mean age of 56 years (range, 18 to 93 years). Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a utilization rate of 34%. 

Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2 days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days) (p < 0.001). 

Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical procedures (22.0 pills) (p < 0.01). 

Procedure type, anatomic location, anesthesia type, age, and type of insurance were also all significantly associated with reported opioid consumption (p < 0.001).

They concluded that patients are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity surgical procedures. 

They recommend that surgeons consider some general guidelines for prescribing opioids postoperatively after outpatient upper extremity  

10 opioids for hand and wrist soft tissue surgical procedures, 

20 opioids for hand and wrist fracture or joint surgical procedures,

15 opioids for elbow and forearm soft-tissue surgical procedures, 

20 opioids for elbow and forearm fracture or joint surgical procedures, and

30 opioids for upper arm and shoulder surgical procedures.

Comment: We agree that there is a tendency to over use and over prescribe narcotics after surgery. This trend can be seen starting in the recovery room, where the patient is often asked to rate their pain on a 1-10 scale and then be administered narcotics even though they are tolerating the pain. Of course postoperative narcotics can lead to respiratory depression, urinary retention, confusion, unsteadiness, and the expectation that recovery from surgery will be 'painless'. This trend continues after discharge. We have found it preferable inform patients before surgery that we'll be prescribing minimal narcotics and only administer more if the patient finds that pain is substantial and interfering with their recovery. 

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Which patients continue to use narcotics after joint replacement?

Trends and predictors of opioid use after total knee and total hip arthroplasty.

These authors asked 574 patients to complete validated, self-report measures of pain, functioning, and mood before and longitudinally for 6 months after total knee (TKA) and total hip (THA) arthroplasty.

Only 8.2% of TKS and 4.3% of THA patients not taking narcotics immediately prior to surgery (opioid-naive) were still using opioids at 6 months. 

In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. 

Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Below is a conversion chart for the different narcotics from this source.

Day of surgery predictors for 6-month opioid use by opioid-naive patients included greater overall body pain (P = 0.002), greater affected joint pain (knee/hip) (P = 0.034), and greater catastrophizing (P = 0.010). 

For both opioid-naive and opioid users on the day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (adjusted odds ratio; however, change in affected joint pain (knee/hip) was not predictive of opioid use.

Among patients who were opioid naive the day of surgery, opioid use at 3 months was associated with a 56 (TKA) and 12 (THA) times greater risk of persistent opioids use at 6 months. These data support developing better monitoring of opioid use before 3 months to consider points of possible intervention.

The authors concluded that many patients taking opioids before surgery continue to use opioids after arthroplasty and some opioid-naive patients remained on opioids; however, persistent opioid use was not associated with change in joint pain.

They hypothesize that the reasons patients continue to use opioids may be due to (1) pain in other areas, (2) self-medicating for affective distress, and (3) therapeutic opioid dependence.

Comment: Management if narcotic medication after joint replacement can be one of the most difficult aspects of the post-athroplasty period, often challenging the harmony of the surgeon-patient relationship. It is helpful to counsel patients using narcotics before surgery that their recovery may be complicated as a result - special arrangements for postoperative pain management should be in place before surgery. Patients still using narcotics at 3 months have a greatly increased likelihood of using them at 6 months.

And then there is this from the CDC (link).

Seth Leopold, editor of CORR, offers this comment "Why not work with these patients in advance of elective surgery to help wean them off these drugs? It is nearly always possible, particularly if one helps patients who need it get help for depression, which often overlaps. But it takes effort and patience, and one cannot be in too much of a hurry to operate. It's worth the wait!"

Point well taken!

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Narcotics and shoulder arthroplasty outcomes - some answers and some questions

Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty.

These authors report on 224 TSAs performed for primary glenohumeral joint osteoarthritis with 2- to 5-year follow-up. Sixty patients with a history of preoperative opioid use for shoulder pain were compared with a control group of 164 patients. Preoperative opioid use was determined prospectively by asking, "Do you take narcotic pain medication (codeine or stronger) for your shoulder?"

Preoperative opioid use was significantly associated with female sex, chronic back pain, depression, increased pain, lower activity, lower strength, and less range of motion.

The magnitude of change between the groups from preoperatively to the most recent follow-up was similar for all measures and range of motion measurements.

There was a statistical difference between the 2 groups in terms of the number of satisfied patients (opioid group, 48 of 60 [80%] vs. nonopioid group, 149 of 164 [91%]; P . .03).

Comments:  As pointed out in prior posts, preoperative opioid use has been associated with worse clinical outcomes after total knee arthroplasty, spine surgery, and more recently reverse TSA.

Several questions arise:

(1) This study used a 'yes' or 'no' question to determine opioid use, does the amount of narcotic matter?

(2) How should these data be used in counseling patients and in surgical decision making?

(3) Is preoperative narcotic detoxification improve outcomes?

(4) How does preoperative narcotic medication affect postoperative pain management?

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Patients taking narcotics before surgery often have poorer results from surgery

Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery.

These authors evaluated 583 patients having lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion. The preoperative opioid consumption was correlated with the patient-reported outcome measures at three and twelve months postoperatively.

56% (326 patients) reported some degree of opioid use before surgery. Preoperative opioid use was a significant predictor of decreased scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. 

Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors.

Comment: Patients that take narcotics before surgery have a substantially increased risk of a poor outcome as well as increased preoperative risks. We have previously posted a similar finding for patients having total knee arthroplasty. Another post reviews the relationship among preoperative pain, depress and the severity of arthritis. It is important to evaluate and consider the preoperative use of narcotics and the presence of depression in the decision of if and when to carry out elective surgery, even if the patient has 'a structural lesion'.

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Narcotics may interfere with bone healing

Postoperative Opioid Administration Inhibits Bone Healing in an Animal Model

The authors observe that opiod medications are the mainstay of orthopaedic pain control. They used a rat fracture model to evaluate the effects of opioid administration on bone union in an operatively stabilized fracture. After a 0.4-mm femoral osteotomy gap was created, rats were randomized to control versus morphine-treated study groups.


There was a statistically significant (p = 0.048) reduction in callus strength in morphine-treated animals 8 weeks postoperatively compared with controls. Radiographic and histological analysis showed delayed callus maturation and lack of remodeling in the morphine group compared with control animals at 8 weeks.

The authors concluded that administration of an opioid pain medication leads to weaker callus and impedes callus maturation compared with controls.



Comment: In fracture cases as well as in shoulder arthroplasty, bone healing and remodeling are important. The authors have given us yet another reason to consider minimizing our use of narcotics.


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