Reverse shoulder arthroplasty (RSA), a procedure designed for treating diseased rotator cuff tears with arthritis, can be used to improve function and provide pain relief. Opioids are being used more commonly as a non-surgical approach for these patients, but little is known about outcomes for RSA in individuals with a history of preoperative opioid use. “Some studies have looked at preoperative opioid use in hip, knee, and spine surgery, but none have been reported in patients undergoing a shoulder surgery like RSA,” explains Brent J. Morris, MD.
Exploring the Issue
In a study published in the Journal of Shoulder and Elbow Surgery, Dr. Morris and colleagues compared preoperative and postoperative outcomes from 32 RSAs in patients with a history of preoperative opioid use with 36 RSAs performed in patients who did not use these drugs before surgery. There were no differences between patient cohorts with regard to demographics or comorbidities. According to the findings, preoperative opioid use was associated with significantly lower preoperative shoulder function. Lower shoulder function was also observed at the final follow-up assessment at 2 years after RSA for those who took preoperative opioids.
Both groups experienced significant improvements on tests for shoulder function and range of motion measurements from the preoperative to the final follow-up assessment. “The non-opioid group, however, had significantly better outcomes,” says Dr. Morris. The study also noted that the magnitude of improvement between the preoperative opioid group and the non-opioid group was nearly identical.
Examining the Implications
“Our results indicate that improvements can be expected in patients with a history of preoperative opioid use, but these patients shouldn’t expect to reach the same peak outcomes after RSA as those who don’t use opioids before surgery,” says Dr. Morris. “This information is important given that the use of opioids to manage pain is increasing. Clinicians should use this data to improve preoperative counseling and to establish appropriate expectations with patients and their families.”
Dr. Morris anticipates that future research will look at possible opioid dose-dependent effects before and after RSA. “In the meantime, our data show that a history of preoperative opioid use can still yield successful results after RSA with regard to improving pain and function,” he says. “However, it’s important to look at the patient’s preoperative baseline and understand that a ‘one size fits all’ approach will not apply to RSA. Clinicians should ask their patients about opioid use prior to surgery and then inform them that they can expect a successful outcome but not to the degree that is seen in those who don’t use opioids before their procedure.”
Readings & Resources (click to view)
Morris BJ, Laughlin MS, Elkousy HA, Gartsman GM, Edwards TB. Preoperative opioid use and outcomes after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24:11-16. Available at: http://www.jshoulderelbow.org/article/S1058-2746(14)00241-9/abstract.
Morris BJ, Zumsteg JW, Archer KR, Cash B, Mir HR. Narcotic use and postoperative doctor shopping in the orthopaedic trauma population. J Bone Joint Surg Am. 2014;96:1257-1262. Available at: http://jbjs.org/content/96/15/1257.
Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1988-1993.
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. 2000;43:1905-1915.
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-1346.
Chou R, Fanciullo GJ, Fine PG, et al. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
Lawrence JT, London N, Bohlman HH, Chin KR. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine (Phila Pa 1976). 2008;33:2074-2078.