Proceed with caution! Performing shoulder arthroplasty in pre-operative opioid dependent patients

Referenced article: Brandner et al. Impact of opioid dependence on outcomes following total shoulder arthroplasty.

Opioid usage in the United States remains a challenging problem for orthopaedic surgeons to navigate.

As shoulder arthroplasty continues to increase at an exponential rate, along with the transition to outpatient surgeries, the need to treat postoperative pain, maximizing patient satisfaction, and minimizing complications, shoulder surgeons have a difficult path to traverse.  Surgeons now need to think outside of the box on ways to mitigate postoperative complications while managing postoperative pain. One low hanging fruit is to look at pre-operative patient factors that increase the rate of complications post-operatively.

This retrospective database study of primary anatomic and reverse shoulder arthroplasties evaluated the impact of pre-operative opioid dependence on post-operative outcomes. The secondary outcome was to see if there was an increased incidence of opioid dependence in patients over the years. The authors separated the database into 2 cohorts. The first cohort included chronic opioid users or those with opioid use disorders with the second cohort having no opioid dependence. The authors found that patients with opioid dependence had a higher risk of complications within 180 days, readmission, dislocation, bleeding, and GI complications. Not surprisingly, there was also a higher hospital economic cost also associated with opioid dependence along with discharge to a facility compared to non-opioid dependent patients. Lastly the authors found that there was an increase in incidence of opioid dependent patients from 2.4% to 3.9% over the years. While not specifically investigated in this study, one can assume that opioid dependent patients are likely also to require higher pain medications with likely worse overall pain control.

While these patients also tended to be younger and have more comorbidities, the independent impact of pre-operative opioid dependence cannot be ignored. It is imperative that we identify these patients prior to surgery.  These patients need an honest discussion the pre-operative setting regarding their increased risks of complications, readmission, revision and dislocation.  Ideally, there would also be a pre-operative focus on education and opportunities to decrease opioid dependence prior to surgery. Syed et al² found that pre-operative education detailing the risk of narcotic overuse and abuse led to a significantly decreased number of narcotic pill usage at 3 months after rotator cuff surgery. A novel area of opportunity that has yet to be extensively researched includes the psychological aspects of pain and opioid dependence.  Early studies have shown that neurofeedback training is an effective therapeutic method for opioid dependence³.  Initial investigative studies looking at the effectiveness of biofeedback on adolescent surgical patients and opioid consumption are ongoing, and it will be very interesting to see the effectiveness and feasibility of implementing this non pharmacological approach to treating pain.

Currently, in my own practice, each surgical patient has a discussion with my nurse regarding opioid use as well as my opioid practice. We also have a frank discussion regarding their increased risk of post-surgical complications that is then documented. If patients have a history of opioid dependence, they are encouraged to reach out to their current physician managing the pain and see if there is opportunity to decrease the dependence.  Occasionally, I have enlisted my pain management specialists to help a patient wean off narcotics prior to surgery if the patient is interested.  All my patients agree to an opioid contract and my practice has evolved into a protocol that the majority of patients are treated with a multi-modal non-opioid pain regimen at the time of discharge.

In conclusion, treating patients with pre-operative opioid dependence remains a difficult problem. With the continued concerns regarding the opioid epidemic and insurance reimbursement linked to complications, surgeons need to be cognizant of the associated complications and opportunities to improve patient care.  We should all proceed with caution!

 

References:

1. Brandner GT, Guareschi AS, Eichinger JK, Friedman RJ. Impact of opioid dependence on outcomes following total shoulder arthroplasty. J Shoulder Elbow Surg. 2024 Jan;33(1):82-89. doi: 10.1016/j.jse.2023.05.040. Epub 2023 Jul 7. PMID: 37422130
2. Syed UAM, Aleem AW, Wowkanech C, Weekes D, Freedman M, Tjoumakaris F, Abboud JA, Austin LS. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg. 2018 Jun;27(6):962-967. doi: 10.1016/j.jse.2018.02.039. Epub 2018 Mar 26. PMID: 29599038.
3. Dehghani-Arani F, Rostami R, Nadali H. Neurofeedback training for opiate addiction: improvement of mental health and craving. Appl Psychophysiol Biofeedback. 2013 Jun;38(2):133-41. doi: 10.1007/s10484-013-9218-5. PMID: 23605225; PMCID: PMC3650238.
4. Orgil Z, Johnson L, Karthic A, Williams SE, Ding L, Kashikar-Zuck S, King CD, Olbrecht VA. Feasibility and acceptability of perioperative application of biofeedback-based virtual reality versus active control for pain and anxiety in children and adolescents undergoing surgery: protocol for a pilot randomised controlled trial. BMJ Open. 2023 Jan 25;13(1):e071274. doi: 10.1136/bmjopen-2022-071274. PMID: 36697053; PMCID: PMC9884985.