Risk factors for opioid use after total shoulder arthroplasty

Khazi, Zain; Lu, Yining; Patel, Bhavik H.; Cancienne, Jourdan M.; Werner, Brian C.; Forsythe, Brian

doi:10.1016/j.jse.2019.06.020

Cited by 48 publications

(30 citation statements)

References 38 publications

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“…3,17 However, this method of determining preoperative and prolonged postoperative narcotic use and the association between them has been proven reliable over multiple prior studies. 8,15,22,23 Our measure of prescriptions also does not account for outside sources of narcotics, nor is it able to quantify the amount of narcotic a patient actually ingested whenever they filled a prescription. Finally, we used prolonged postoperative opioid use as a proxy for pain control as opposed to another clinical measure like the numeric rating scale or visual analogue scale.…”

Section: Discussionmentioning

confidence: 99%

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use

et al. 2020

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The aim of the study was to compare trends and differences in preoperative and prolonged postoperative opioid use following spinal cord stimulator (SCS) implantation and to determine factors associated with prolonged postoperative opioid use. Methods: A database of private-payer insurance records was queried to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-C3655) from 2008-2015. Our resulting cohort was stratified into those with prolonged postoperative opioid use, opioid use between 3-and 6-month postoperation, and those without. Multivariate logistic regression was used to determine the effect preoperative opioid use and other factors of interest had on prolonged postoperative opioid use. Subgroup analysis was performed on preoperative opioid users to further quantify the effect of differing magnitudes of preoperative opioid use. Results: A total of 2,374 patients who underwent SCS placement were identified. Of all patients, 1,890 patients (79.6%) were identified as having prolonged narcotic use. Annual rates of preoperative (p = 0.023) and prolonged postoperative narcotic use (p < 0.001) decreased over the study period. Significant independent predictors of prolonged postoperative opioid use were age < 65 years (odds ratio [OR], 1.52; p = 0.004), male sex (OR, 1.33; p = 0.037), preoperative anxiolytic (OR, 1.55; p = 0.004) and muscle relaxant (OR, 1.42; p = 0.033), and narcotic use (OR, 15.04; p < 0.001). Increased number of preoperative narcotic prescriptions correlated with increased odds of prolonged postoperative use. Conclusion: Patients with greater number of preoperative opioid prescriptions may not attain the same benefit from SCSs as patients with less opioid use. The most significant predictor of prolonged narcotic use was preoperative opioid use.

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Section: Discussionmentioning

confidence: 99%

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use

et al. 2020

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“… 7 Similarly, in a cohort of 12,038 TSA patients, Khazi et al identified chronic preoperative opioid use as the strongest risk factor for ongoing use at 12 months postoperatively, followed by chronic lung disease, age <65, chronic pain disorders, psychiatric diagnoses, and EtOH abuse also reaching statistical significance. 13 However, given that these prior studies included patients on preoperative opioids, it is difficult to determine risk factors for those who are opioid naïve preoperatively. This is important given iatrogenic opioid dependence is of significant concern.…”

Section: Discussionmentioning

confidence: 99%

“…Given the aim of the study, we only included patients who were “opioid naïve”, which we defined as any patient with no opioid prescriptions filled during the preoperative period (6 months to 6 weeks prior to surgery). Similar to previously published methodology, 13 , 15 opioid prescriptions filled during the surgical period (6 weeks before surgery through the 2 weeks after) were designated as original prescriptions and it was assumed that the intended use of these prescriptions was for perioperative and postoperative pain control. To control for the possibility of patients not filling their prescription through their insurance plan (ie, using a discount pharmacy or rebate program [eg, GoodRx]), those patients without an original opioid prescription were excluded from the study population.…”

Section: Methodsmentioning

confidence: 99%

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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“…Recent studies that did not meet inclusion criteria for this review analyzed the effect of preoperative opioid use on increased opioid consumption over extended postoperative periods. In 2 studies, Khazi et al 11 , 12 examined this effect in patients undergoing TSA, RTSA, and shoulder stabilization surgery. The incidence of opioid use at 1 year postoperatively was significantly higher in patients who used opioids 3 months before surgery as compared with those who did not ( P < .0001 in both studies).…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes Associated With Preoperative Opioid Use in Various Shoulder Surgical Procedures: A Systematic Review

Devano

Smith

Houck

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: The impact of preoperative opioid use on outcomes after shoulder surgery is unknown. Purpose/Hypothesis: To examine the role of preoperative opioid use on outcomes in patients after shoulder surgery. We hypothesized that preoperative opioid use in shoulder surgery will result in increased postoperative pain and functional deficits when compared with nonuse. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were all English-language studies comparing clinical outcomes of shoulder surgery in patients who used opioids preoperatively (opioid group) as well as patients who did not (nonopioid group) with a minimum follow-up of 1 year. Outcomes included range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and visual analog scale for pain. Study quality was evaluated with the Modified Coleman Methodology Score and the MINORS score (Methodological Index for Non-randomized Studies). Results: Included were 5 studies (level 2, n = 1; level 3, n = 4): Two studies were on total shoulder arthroplasty, 2 on reverse total shoulder arthroplasty, 1 on both, and 1 on arthroscopic rotator cuff repair. There were 827 patients overall: 290 in the opioid group (age, 63.2 ± 4.0 years [mean ± SD]; follow-up, 38.9 ± 7.5 months) and 537 in the nonopioid group (age, 66.0 ± 4.7 years; follow-up, 39.5 ± 8.1 months). The opioid group demonstrated significantly worse pre- and postoperative visual analog scale and Constant-Murley score pain scores as compared with the nonopioid group. Mean American Shoulder and Elbow Surgeons scores were significantly lower in the opioid group at pre- and postoperative time points as compared with the nonopioid group ( P < .05 for all). However, both groups experienced similar improvement in outcomes pre- to postoperatively. One study showed that the opioid group consumed significantly more opioids postoperatively than the nonopioid group and for a longer duration ( P < .05). The overall mean Modified Coleman Methodology Score and MINORS score were 64.2 ± 14 and 15.8 ± 1.0, respectively. Conclusion: Opioid use prior to various shoulder surgical procedures negatively affected postoperative pain and functionality. Although the opioid group showed significantly worse scores postoperatively, the groups experienced similar improvements.

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Risk factors for opioid use after total shoulder arthroplasty

Cited by 48 publications

References 38 publications

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use

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

Clinical Outcomes Associated With Preoperative Opioid Use in Various Shoulder Surgical Procedures: A Systematic Review

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