Outpatient narcotic consumption following total shoulder arthroplasty

Martusiewicz, Alexander; Khan, Adam Z.; Chamberlain, Aaron M.; Keener, Jay D.; Aleem, Alexander W.

doi:10.1016/j.jses.2019.11.005

Cited by 15 publications

(9 citation statements)

References 20 publications

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“…Martusiewicz et al prospectively analyzed the opiate consumption of 50 patients after TSA and found that with the use of an interscalene block catheter for 3 days, the majority of the patient’s consumed <25 5mg oxycodone tablets. 20 The same patients additionally reported satisfaction with their postoperative pain control. Interestingly, the average initial prescription for the 17,706 patients in our study was greater than 90 5 mg oxycodone tablets.…”

Section: Discussionmentioning

confidence: 95%

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Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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Introduction Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group ( P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

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Section: Discussionmentioning

confidence: 95%

“… 21 While the majority of patients achieve sufficient pain control with their original prescription, some go on to require additional refills or progress to prolonged opioid use. 7 , 20 Identifying these patients and associated risk factors is critical as a single postsurgical refill has been shown to increase the potential of misuse by more than 40%. 5 …”

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confidence: 99%

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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“… 11 , 12 , 13 Furthermore, smaller prescriptions have been associated with lower opioid consumption without affecting patient satisfaction with pain management and decreasing addiction potential. 11 , 12 , 14 , 15 However, prescribers may prefer to use a higher percentile for patients without risk factors and give a higher number of pills to reduce the refill needs based on their practice location and regional regulations regarding opioid prescriptions.…”

Section: Discussionmentioning

confidence: 99%

Patients Use Fewer Opioids Than Prescribed After Arthroscopic Release of Elbow Contracture: An Evidence-Based Opioid Prescribing Guideline to Reduce Excess

Rojas

Rotman

Shields

et al. 2021

Arthroscopy, Sports Medicine, and Rehabilitation

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Purpose To generate an evidence-based opioid-prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture. Methods Data collected from a randomized controlled trial that compared continuous passive motion (CPM) ( n = 24) to physical therapy (PT) ( n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty-one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use. Results The median total opioid prescription was 437.5-mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5-mg oxycodone). Twenty-two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age <60 years and inflammatory arthritis. The total opioid consumption appeared similar between the CPM and the PT group. Seventy-five percent of patient’s home opioid requirements would be satisfied using the following guideline: Patients undergoing contracture release for osteoarthritis or post-traumatic contracture should be given a prescription for 10 pills of 5 mg oxycodone or its equivalent at discharge. Patients with inflammatory conditions or those taking preoperative opioids should be prescribed 30 pills of 5 mg oxycodone or its equivalent. Conclusion This study suggests that most patients undergoing arthroscopic release of elbow contracture use relatively few opioid pills after surgery. Use of an evidence-based guideline could decrease opioid prescriptions substantially, while still effectively treating patients’ pain.

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“…Previous studies in the orthopedic literature have focused predominantly on lower extremity surgical procedures, most notably total hip and total knee arthroplasty. 23,25 Relatively little research has been done in regard to patients undergoing elective upper extremity surgery, particularly total shoulder arthroplasty (TSA) and rotator cuff repair (RCR). Menendez et al 27 assessed discharge records from the Nationwide Inpatient Sample (2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011) and found that the rate of in-hospital falls has been steadily increasing despite shorter hospital stays.…”

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confidence: 99%

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk

Kaiser

Shanley

Denninger

et al. 2021

Journal of Shoulder and Elbow Surgery

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Introduction: Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations. Methods: A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation. Results: Patients undergoing TSA (n ¼ 80; 65.4 AE 11.4 years) were older than those undergoing RCR (n ¼ 118; 59.0 AE 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; c 2 ¼ 8.9, P ¼ .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P ¼ .11). Discussion: Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk. Conclusion: Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

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Outpatient narcotic consumption following total shoulder arthroplasty

Cited by 15 publications

References 20 publications

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

Patients Use Fewer Opioids Than Prescribed After Arthroscopic Release of Elbow Contracture: An Evidence-Based Opioid Prescribing Guideline to Reduce Excess

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk

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