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Effect of chronic narcotic use on episode-of-care outcomes following primary anatomic total shoulder arthroplasty

Mayer, Megan N., MDa; Mulligan, Ryan P., MDb; Villarreal, Arturo D., MDa; Lonergan, Timothy M., MDa; Brolin, Tyler J., MDa; Azar, Frederick M., MDa; Throckmorton, Thomas W., MDa

doi: 10.1097/BCO.0000000000000751
Original Research
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Background: Bundled-care payments for total shoulder arthroplasty (TSA) make early outcomes relevant because they typically are tied to a 90-day episode-of-care. The purpose of this study was to determine the effect of chronic preoperative narcotic use on early postoperative pain relief, narcotic use, length of hospital stay, readmissions, and complications in patients with primary TSA.

Methods: Chronic narcotic use was defined as use of narcotic pain medication for at least 3 mo before surgery. Narcotic use was converted to oral morphine equivalents (OME) for in-hospital use, discharge medications, and prescriptions at 2-, 6-, and 12-week visits. Statistical analyses used Fisher’s exact test for dichotomous variables and Student’s t-test for continuous variables. Differences with P<0.05 were considered statistically significant.

Results: Of 152 patients with primary TSA, 27 were chronic preoperative narcotic users and 125 were not. There were no statistically significant differences between groups with regard to age, gender, laterality, or body mass index. At 2 wk postoperatively, there was no significant difference in visual analog scores VAS; however, at 6 and 12 wk, chronic narcotic users had significantly higher VAS and a significantly higher cumulative narcotic requirement. There were no significant differences in length of hospital stay, complications, or readmission rates.

Conclusions: Chronic preoperative narcotic use is a risk factor for a more difficult postoperative course after TSA compared to that in narcotic-naïve patients. Chronic opioid users, however, do not necessarily require additional perioperative resources, which is relevant to risk stratification in the emergence of bundled payment programs for TSA.

Level of Evidence: Level III, prognostic case-control study.

aUniversity of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN

bDuke University, Durham, NC

Financial Disclosure: Dr. Throckmorton reports financial relationships outside this work with Zimmer, Biomet, Gilead, and Elseiver. Dr. Azar reports financial relationships outside this work with 90point6, Iovera, Zimmer, and Elsevier. The other authors have no disclosures.

Correspondence to Thomas W. Throckmorton, MD, University of Tennessee-Campbell Clinic, Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, 1211 Union Avenue, Suite 510, Memphis TN 38104 USA Tel: +901-759-3270; fax: +901-759-3278; e-mail: tthrockmorton@campbellclinic.com.

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INTRODUCTION

With an aging population, joint arthroplasties are common procedures to treat end-stage joint degeneration for which conservative measures have failed. Anatomic total shoulder arthroplasty (TSA) has a strong track record in the treatment of end-stage glenohumeral pathology with an intact rotator cuff.1 With the success of TSA, attention has shifted to how preoperative patient risk factors and comorbidities can influence outcomes.

Multiple studies have investigated the influence of some preoperative factors in other areas of orthopaedic surgery, including smoking,2 depression,3,4 and preoperative narcotic use.2,4–7 Others have evaluated the role of chronic preoperative narcotic use and its influence on outcomes of total knee5,7–9 and hip8–11 arthroplasty, trauma surgery,12,13 rotator cuff repair,2 and spine surgery.4,6,14,15 Preoperative chronic narcotic use has been tied to worse postoperative outcomes,11,14,16,17 more difficult pain control,5,11,18 prolonged opiate use,5,8,9,12,14 decreased return to work,19 and increased length of stay4,7,20 after orthopaedic surgical procedures when compared to opiate-naïve patients.

While one study showed improved patient-reported outcomes and range of motion after TSA in patients with chronic opioid use, there was significantly less improvement than in their opiate-naïve counterparts.17 There is a paucity of information regarding the effect of preoperative opioid use on early outcomes of anatomic TSA. Further, the evolution of bundled care payments for TSA make early outcomes highly relevant, as these plans typically are tied to a 90-day episode of care, making the ability to identify factors that may negatively influence postoperative outcomes and, thus, reimbursement highly important. This knowledge also would allow surgeons to initiate interventions to assist and counsel patients with modifiable preoperative risk factors.

We proposed to investigate the effect of chronic preoperative narcotic use on postoperative pain relief, narcotic use, length of hospital stay, and complications in the global postoperative episode of care in patients undergoing primary TSA. We hypothesized that patients with a history of chronic narcotic use would have inferior pain relief and require more postoperative resources, including narcotic pain medications, than the control group of narcotic-naive patients.

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MATERIALS AND METHODS

After institutional review board approval, a retrospective database search was performed for patients undergoing primary anatomic TSA at our institution. Patients were included if they were 18 yr of age or older and had primary anatomic TSA. Patients with revision shoulder arthroplasty, hemiarthroplasty, reverse TSA, and arthroplasty for tumor or trauma were excluded. All included patients had an interscalene block with an indwelling catheter for pain control. Patients receiving single-shot blocks were excluded to preserve a consistent pain management program. A records search identified 152 TSA procedures performed by a single fellowship-trained shoulder and elbow surgeon. In addition to the indwelling interscalene catheter, postoperative pain was treated in the hospital with oral and intravenous narcotics, and patients were subsequently discharged with oral narcotic prescriptions. Upon discharge, narcotic pain medications were prescribed by protocol with 2 wk of long-acting oxycodone supplemented with instant release oxycodone-acetaminophen as needed for breakthrough pain. Subsequent narcotic prescriptions were provided as needed at follow-up visits until 3 mo postoperatively, at which point patients were transitioned to nonnarcotic medications. Primary study endpoints were postoperative narcotic use in oral morphine equivalents, visual analog pain scores (VAS), and change in VAS relative to preoperative scores. Secondary endpoints were hospital length of stay, complication rates, and reoperation rates.

The use of chronic preoperative narcotics was determined for each patient, and patients were divided into two groups: chronic pain medication users and nonusers. Chronic narcotic use was determined from the medical record and was defined as the use of narcotic pain medication for a minimum of 3 mo before surgery, excluding atypical medications like tramadol. This definition is consistent with other previous studies.11,12,21 There were 27 shoulders in the chronic preoperative narcotic use cohort and 125 shoulders without chronic narcotic use. Review of records was completed to determine VAS pain scores preoperatively and postoperatively, length of hospital stay, and complications. Narcotic use was converted to oral morphine equivalents (OME) for in-hospital use, discharge medications and prescriptions given at 2-, 6- and 12-week visits. This was complemented by query of a statewide narcotic prescriptions database.

All TSAs were done with the patient in the beach-chair position under general anesthesia. A deltopectoral approach, biceps tenodesis, and subscapularis tenotomy were used. After final implant insertion, all shoulders exhibited appropriate head height, version, motion, and stability. The subscapularis and rotator interval were closed with nonabsorbable suture.

Postoperative rehabilitation was standardized by a protocol consisting of sling immobilization and passive range of motion for the first 6 wk. During postoperative weeks 6 through 12, gentle activities in front of the body and continued passive range of motion in physical therapy were permitted. Isometric strengthening was begun at 10 wk, with unrestricted use of the arm at 12 wk.

Statistical analyses were performed using Fisher’s exact tests for dichotomous variables and Student’s t-test for continuous variables. Differences between groups with P<0.05 were considered statistically significant.

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RESULTS

One hundred fifty-two patients (152 shoulders) met inclusion criteria, 27 in the chronic preoperative narcotic-use cohort and 125 in the non-narcotic cohort (Table 1). There were no statistically significant differences between groups regarding age (60.7 vs. 63.1, P=0.25), gender (P=0.09), or body mass index (34.5 vs. 32.9, P=0.30). Comorbidities also were compared, and the chronic narcotic-use group had significantly more smokers than the non-narcotic group (P=0.002); there were no other significant differences in comorbidities between groups (Table 2).

TABLE 1

TABLE 1

TABLE 2

TABLE 2

At 2 wk postoperatively, there was no statistically significant difference in VAS scores between chronic preoperative narcotic users and nonusers, although there was a trend toward higher VAS scores among narcotic users. At 6 and 12 wk, however, chronic narcotic users had significantly higher VAS scores (Table 3). There were no statistically significant differences in VAS score improvements at 2, 6 or 12 wk in either group (Table 3).

TABLE 3

TABLE 3

During the global postoperative period, chronic preoperative narcotic users had significantly higher cumulative OME compared to nonusers as inpatients and at 2 wk, 6 wk, and 12 wk (Table 3).

There were nine complications and five readmissions that occurred in the overall study population. There was a 7.4% complication rate (2/27) and 7.4% (2/27) readmission rate in the chronic narcotic-use cohort, which included seizure and urosepsis. In the group without chronic preoperative narcotic use, the complication and readmission rates were 5.6% (7/125) and 2.4% (3/125), respectively, which included one patient with a greater tuberosity fracture after a fall, two cardiac complications, one biceps tendon rupture, two patients with hemidiaphragm paralysis after interscalene blocks, and one death. The differences in complication rates and readmission rates were not statistically significant, and there was no difference in length of stay between groups (Table 4).

TABLE 4

TABLE 4

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DISCUSSION

With a shift in health care policy toward value-based care and episode-of-care bundled payments, increasing attention is being paid to factors that may influence patient events and resource utilization in the global period after shoulder arthroplasty. The purpose of this study was to determine the effect of chronic preoperative narcotic use on early postoperative pain relief, narcotic use, length of hospital stay, reoperation rate, and complications in patients undergoing primary TSA. We found that patients chronically using preoperative narcotic pain medication had significantly higher VAS scores and narcotic requirements after anatomic TSA. This is consistent with a previous study by Morris et al.17 that found patients using opioids preoperatively had worse preoperative metrics, had improved postoperative outcomes, but not to the same extent as narcotic-naive patients.17 This is similar to our results in which we noted that both groups demonstrated improvements, particularly in VAS metrics, which were above the minimal clinically significant difference noted by Tashjian et al.22 Nevertheless, patients using chronic preoperative narcotics did not achieve the same level of improvement as narcotic-naive patients.

Other previous studies have had negative associations between preoperative opioid use and postoperative outcomes. After total knee arthroplasty, Zywiel et al.,7 found more complications and reoperations and longer recovery in preoperative opioid users. Franklin et al.,5 also found that preoperative narcotic use was associated with increased pain at later time points postoperatively and greater dissatisfaction after total knee arthroplasty. Worse outcomes after total hip arthroplasty in preoperative opioid users were also shown by Pivec et al.11 and after some spine surgeries by Lawrence et al.14 However, in our study, there were no significant differences between groups regarding length of stay, complication rate, or readmission rate. These results indicate that chronic preoperative narcotic use can be identified as a risk factor for a more difficult postoperative course after TSA; however, these patients do not necessarily require significant additional perioperative resources.

As patient satisfaction and outcomes will likely continue to have increasing influence on reimbursement, and because multiple studies have shown a direct correlation between increased pain and decreased patient satisfaction,23–26 this study supports patient counseling preoperatively on expectations. As narcotic use is a potentially modifiable risk factor, chronic opioid users should be made aware that they will likely have more difficulty with pain control postoperatively. Additionally, there may be some benefit to helping patients wean their opioid use prior to surgery, though this was not investigated in this study. However, in a study by Nguyen et al.,27 they compared clinical outcomes after total knee and hip arthroplasty in opioid-naive patients, chronic opioid users and chronic opioid users who weaned their use by at least 50% prior to surgery. They found that patients who weaned opioid use had drastic improvement in outcomes, comparable to outcomes of nonusers. Therefore, we speculate that in addition to preoperative counseling on expectations, it may be beneficial to refer patients who are willing to a program to wean their opioid use prior to arthroplasty to optimize their outcomes.

There are some weaknesses inherent within this study. First, this is a retrospective review, with all the attendant limitations of that study design. Second, the method of accounting for narcotic use also has limitations. Narcotic consumption as inpatients was consistent as it was based on inpatient records. For all written prescriptions, consumption was assumed, which may have overestimated the narcotic use in some instances because some patients may not have used their entire quantity. In other cases, however, the narcotic consumption may be underestimated if additional pills were obtained by means undetectable by the statewide prescription database. Nevertheless, this method of tracking narcotic use is well-accepted in the literature.4,8,18,21,27,28 Additionally, the narcotic-use cohort did have a significantly higher proportion of tobacco use than the control group. Therefore, the interplay of smoking and chronic narcotic use in this study is difficult to determine and represents a confounding variable in our analysis. Finally, the proportion of female to male narcotic users approached, though did not obtain, statistical significance (P=0.09). This could hint at a difference in pain perception between males and females that may be noted as a potentially confounding factor

In conclusion, patients using chronic preoperative narcotic pain medication had significantly higher VAS scores and narcotic requirements after anatomic TSA. However, there were no significant differences between groups regarding length of stay, complication rate, or readmission rate. These results indicate that chronic preoperative narcotic use can be identified as a risk factor for a more difficult postoperative course after TSA compared to narcotic-naive patients. However, these patients do not necessarily require significant additional perioperative resources, which is relevant to risk stratification in the emergence of bundled payment programs for TSA.

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Keywords:

total shoulder arthroplasty; preoperative narcotic use; outcomes; 90-day episode of care; postoperative narcotic use; complications

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