Published online Aug 18, 2018. doi: 10.5312/wjo.v9.i8.105
Peer-review started: March 6, 2018
First decision: March 23, 2018
Revised: May 17, 2018
Accepted: May 23, 2018
Article in press: May 23, 2018
Published online: August 18, 2018
While opioid medications have proven an effective method of analgesia after orthopaedic surgery, increased utilization of these medications in the United States has led to an opioid epidemic with higher levels of opioid dependence and abuse. Opioid dependence and abuse have been linked to worse outcomes after shoulder arthroplasty. Previous studies have shown that patients using opioids prior to total knee arthroplasty or rotator cuff repair have a greater risk of prolonged postoperative use. However, no study to our knowledge has analyzed the effect of diagnosed dependence or abuse on postoperative opioid utilization after shoulder arthroplasty.
With opioid dependence and abuse rapidly increasing in the United States, it is imperative to determine their effects on postoperative opioid use. The current study addresses this question within the setting of shoulder arthroplasty, as orthopedic surgeons have been shown to be one of the largest prescribers of opioid medications. The knowledge gained from this study may impact providers’ decisions to proceed with elective surgery, as opioid dependent patients are more likely to continue opioid use postoperatively and therefore perpetuate their dependence on opioid medications. The study will likely encourage future research pertaining to postoperative opioid monitoring in opioid dependent patients as well as the use of risk assessment tools for opioid dependence or abuse.
The purpose of this study was to analyze the impact of diagnosed opioid dependence or abuse on postoperative opioid utilization after anatomic and reverse total shoulder arthroplasty (TSA). Furthermore, the authors sought to identify risk factors for preoperative opioid dependence or abuse. The study results highlight the importance of future research on the topic of identifying these risk factors, preventing the development of operative opioid dependence or abuse prior to orthopaedic surgery, and subsequently limiting postoperative opioid utilization.
Patients who underwent anatomic (RSA) or reverse TSA were identified from within the Humana claims database and were stratified into groups based on whether they had a history of opioid dependence or abuse. Postoperative opioid utilization was tracked on a month-by-month basis up to one year after surgery and was compared between the groups. A secondary analysis was performed to determine risk factors for preoperative opioid dependence or abuse.
Patients with a history of opioid dependence or abuse had significantly higher opioid utilization at all postoperative intervals after both TSA and RSA (P < 0.01), although the difference was not as prominent within the first postoperative month. Furthermore, age less than 65 years, history of mood disorder, and history of chronic pain were found to be significant risk factors for pre-operative opioid dependence or abuse. These results emphasize the importance of identifying patients preoperatively with a history of opioid dependence/abuse, or risk factors for developing opioid dependence/abuse, so that prolonged postoperative opioid use may be prevented. Further research is needed to determine specifically how these risk factors lead to opioid dependence and for establishing consistent postoperative opioid prescription protocols for shoulder arthroplasty.
New findings of the current study include that patients with a history of opioid dependence or abuse prior to shoulder arthroplasty are at least twice as likely to remain on opioids after TSA or RSA. Patients with risk factors such as mood disorders or chronic pain diagnoses were found to be more prone to opioid dependence/abuse and the authors theorize that this subsequently leads to greater post-operative opioid use. The study provided a summarization of the current knowledge by offering similar findings to previous studies showing that opioid use prior to orthopaedic procedures leads to increased postoperative use. It offered original insights into the current knowledge by focusing on patients with diagnosed opioid dependence or abuse and establishing risk factors for these diagnoses. It proposed a new hypothesis that patients with pre-operative opioid abuse or dependence would have greater opioid utilization after TSA. The authors utilized methodology that identified preoperative opioid dependence or abuse, along with its risk factors, through the use of ICD-9 codes and tracked postoperative utilization through National Drug Codes. The authors found the new phenomena of significantly greater postoperative opioid utilization in opioid dependent patients after shoulder arthroplasty, though opioid use was similar within the first postoperative month. The study experiments confirmed the hypothesis that patients with previously diagnosed opioid dependence or abuse would have greater postoperative opioid utilization and that other factors such as mood disorders and chronic pain diagnoses are associated with opioid dependence/abuse. These findings imply that opioid utilization in opioid dependent patients, or those with risk factors for opioid dependence/abuse, must be monitored closely after shoulder arthroplasty in order to prevent prolonged use. Steps should be taken to implement postoperative opioid protocols for shoulder arthroplasty.
Patients with a history of opioid dependence or abuse are at a higher risk of increased postoperative opioid utilization after shoulder arthroplasty. Future research should be directed at the implementation of postoperative opioid protocols and the use of risk assessment calculators for opioid dependence.