Arthroscopic Shoulder Surgery Outcomes With Preoperative Opioid Use

Patients with a history of preoperative opioid use can achieve improvements in outcomes after arthroscopic shoulder surgery; however, preoperative opioid use negatively affects satisfaction levels and may be a predictor of pain and continued opioid use, according to study results published in Arthroscopy: The Journal of Arthroscopic and Related Surgery.

Researchers aimed to determine the effect of preoperative opioid use on post-operative opioid use, patient-recorded outcomes, and revision rates in patients receiving arthroscopic shoulder surgery. The researchers conducted a retrospective cohort study of patient reported outcome measures (PROM) and compiled patient information via an electronic data collections service for all patients undergoing shoulder arthroscopy at preoperative and 1 year postoperative follow-up. The surgeries were performed across 4 fellowship-trained sports medicine orthopedic surgeons between January 26, 2014 and May 1, 2019.

Patients who underwent arthroscopic rotator cuff repair, SLAP repair, capsulorrhaphy, biceps tenodesis, subacromial decompression, and extensive debridement and limited debridement were included in the study and completed shoulder-specific functional PROMS, health-related quality of life PROMS, and a mental health PROMS. Patients also answered questions regarding narcotic pain medication usage at each time point. Patients were excluded from the study if they did not provide data at baseline and follow-up were worker’s compensation patients, used opioid medications for a previous surgical procedure, or were prescribed an atypical opioid like tramadol.

The study stratified patients into 2 cohorts: an opioid-naive (N-OU) group that had no opioid prescriptions filled within 12 months of surgery, and an opioid use group (OU) that had filled prescriptions within 12 months to 30 days before the date of surgery. A total of 1702 patients were available for screening, but only 1242 were eligible for analysis.

Of the eligible patients, the mean age was 56.82 years; 59.3% of patients were men. No significant differences in age, alcohol abuse, and smoking abuse were found between the OU and N-OU groups, and the most common opioid analgesics consumed by the OU group were hydrocodone (86.6%) and codeine (4.5%). During the perioperative period, the mean daily oral morphine equivalent, which was calculated based on patient’s self-reported daily pill intake and dosage of their most recent opioid prescription preceding questionnaire completion, was 32.1.

Patients in the OU group had significantly lower scores in all PROMs (all P <.001) except for the Visual Analog Scale questionnaire on pain levels. Both groups showed statistically significant improvements in all PROMs following shoulder surgery at the P (P <.05); however, the OU group had significantly worse absolute outcome scores on all PROM measures compared to the N-OU group (all P <.001). Patients in both the OU and N-OU groups showed similar magnitude improvements for all PROMs (P >.05) except for the Single Assessment Numeric Evaluation (30.3±30.2 vs. 37.2±32.3; P =.02), the Constant Murley Subjective Assessment (8.61±7.66 vs 11.0±7.52), and the Visual Analog Scale pain questionnaire (-29.4 vs -24.3), in which the N-OU cohort showed greater improvement.

Preoperative score on the VAS pain questionnaire was the strongest predictor of persistent pain at 1 year (odds ratio [OR], 1.77; 95% CI, 1.29-1.56; P <.001) followed by preoperative opioid use (OR, 1.73; 95% CI, 1.17-2.56; P =.006). The results of the matched cohort analysis showed that patients in the OU group were significantly more likely to experience and report persistent pain (OR, 2.64; 95% CI, 1.62-4.29; P <.001) and postoperative opioid use (OR, 27.74; 95% CI, 11.05-69.68; P <.001), and less likely to report patient acceptable symptomatic state, (PASS; OR, 0.54; 95% CI, 0.34-0.88; P <.001)

“Regardless of the indication for narcotic usage prior to and after surgery, these patients seem to be at higher risk for postoperative complications and poorer functional outcomes,” the study authors concluded. “Further research is needed to determine if discontinuing or limiting the use of narcotics perioperative, in opioid users, will lead to improved outcomes and a decrease in their postoperative complication rates.”

Reference

Lu Y, Beletsky A, Cohn M, et al. Perioperative opioid use predicts postoperative opioid use and inferior outcomes after should arthroscopy [published online June 4, 2020]. Arthroscopy. doi:10.1016/j.arthro.2020.05.044