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Timothy G. Reish, MD, and Kevin M. Magone, MD, comment on: Leas DP, Connor PM, Schiffern SC, D’Alessandro DF, Roberts KM, Hamid N. Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway. J Shoulder Elbow Surg. 2019;28(9):1716–1722. doi:10.1016/j.jse.2019.01.013.

Article Summary

In this prospective, non-randomized clinical trial, Leas et al evaluated an opioid-free pain management pathway in patients undergoing elective reverse or anatomic total shoulder arthroplasty. The pathway included a single-shot interscalene regional block and general anesthesia.

The researchers enrolled 35 patients over age of 50 (median age 72; range, 66 to 78) in the study. Eighteen patients were female and 17 were male. Nineteen patients underwent reverse total shoulder arthroplasty, while 16 patients underwent anatomic total shoulder arthroplasty.

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Clinical outcome measures included:

• Pre- and postoperative pain levels measured with the visual analog score
• Total opioid consumption
• Opioid-related side effects
• ASES questionnaire
• Simple Shoulder Test
• Veterans RAND 12-item health survey

Patients were also asked to maintain a pain journal to log their pain rating every 8 hours for the first 3 days postoperatively, and then daily until their 2-week postoperative appointment.

For this study, the researchers included patients over age 50 seeking treatment for shoulder osteoarthritis, avascular necrosis, cuff tear arthropathy, or inflammatory arthritis. They excluded patients who were scheduled for revision shoulder arthroplasty or shoulder arthroplasty to treat a fracture, as well as patients with:

• A history of opioid therapy
• Renal or liver insufficiency
• Sickle cell compensation
• A workers compensation claim
• Allergy to non-steroidal anti-inflammatory drugs
• Chronic anticoagulation therapy
• An inability to receive a regional block

The opioid-free pain management pathway consisted of the following:

Preoperatively

• Ultrasound-guided, single-shot interscalene block administered by the anesthesia team
• 300 mg of oral gabapentin 300 mg
• 200 mg of oral celecoxib (meloxicam for those with a sulfa allergy)

Intraoperatively

• Non-opioid anesthetics
• 1000 mg of acetaminophen administered intravenously (IV)
• Periarticular injection of liposomal bupivacaine

In Recovery

• Cryotherapy
• 15 mg of IV ketorolac

Postoperatively on the Floor

• Cryotherapy
• 15 mg of IV ketorolac every 8 hours for 5 doses
• 1000 mg of IV acetaminophen and 500 mg of oral acetaminophen if needed for breakthrough pain
• 200 mg of oral celecoxib daily
• 300 mg of oral gabapentin every 8 hours

Discharge

• 200 mg of oral celecoxib daily for 14 days
• 300 mg of oral gabapentin every 8 hours for 14 days
• 500 mg of oral acetaminophen for breakthrough pain

No opioids were prescribed at discharge or at the 2-week follow-up appointment.

The preoperatively baseline pain level was a 6 (range, 4 to 8) for this patient cohort. Postoperatively, patients reported pain as a 0 (range, 0 to 0) at 6 hours and as a 0 (range, 0 to 3) at 12 hours after surgery. Pain was reported to be a 2 (range, 0 to 5) at discharge. Patients-reported pain was the highest 32 hours postoperatively (4; range, 1 to 5).

Only 2 of 35 patients required postoperative opioid medication: 1 who had a failed interscalene block and 1 who required an IV opioid in the recovery unit. Two oral doses of opioid medication were needed for postoperative pain control on the floor. A total of 12 morphine milligram equivalents were used throughout the study for 35 patients.

The following opioid side effects were report:

• Constipation symptoms (n=13)
• Falls outside of the hospital (n=5)
• Nausea (n=1)

No patients reported gastritis or renal failure at the 2-week postoperative visit.

Thirty-four patients reported that they were satisfied with their pain level and the postoperative pain regimen.

The authors concluded that an opioid-free, multimodal pain control pathway for properly selected patients is a safe and effective method for elective total shoulder arthroplasty.

Clinical Relevance

The US has one of the highest numbers of drug-related overdoses in the word, with nearly 64,000 deaths in 2016, and the country is currently immersed in the largest opioid epidemic in its history. [1] The Center for Disease Control and Prevention has reported that 6% of patients using a prescribed opioid for 1 day and 13.5% of those using a prescribed opioid for 8 days will continue to use that opioid 1 year later. [2] Other studies have reported similar statistics and have indicated that dentists and surgeons are among the highest groups of opioid-prescribing physicians. [3-4]

Aside from the abuse potential and inherently addictive nature of opioids, many of these medications also have unwanted side effects – constipation, bladder dysfunction, delirium, confusion, respiratory depression, increased fall risk, and depression – that can be costly to the healthcare system.

The study by Leas et al aims to create an opioid-free pathway that could decrease opioid consumption among elective shoulder arthroplasty patients. Many studies have utilized opioid-sparing protocols, but this particular pathway removes opioids from the preoperative, intraoperative, and postoperative course. It’s the first study to take this approach to multimodal pain management.

With the increasingly awareness of the problem of over-prescribing opioid pain medications, surgeons need studies like the one done by Leas et al to aid in developing effective protocols and setting pain-level expectations for our patients. Randomized controlled trials need to be done to further delineate appropriate postoperative pathways so that we can continue to reduce the amount of dangerous opioid-containing medications that we prescribe to our orthopaedic patients.

This well done, prospective, non-randomized clinical trial has created a pathway for multimodal pain management after elective total shoulder arthroplasty that avoids the use of opioid pain medication. The authors clearly highlight the medications they used as alternatives to opioids, providing strict dosing schedules for up to 2 weeks postoperatively. We believe this study not only suggests an opioid-free pathway for elective total shoulder arthroplasty, but also offers a building block toward eliminating opioid medication in other areas of orthopaedic surgery.

Author Information

Timothy G. Reish, MD, is a Clinical Assistant Professor in the Division of Sports Medicine, Department of Orthopedic Surgery, at NYU Langone Health, New York, New York. Kevin M. Magone, MD, is a Shoulder and Elbow Fellow in the Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, at NYU Langone Health, New York, New York.

Disclosures: The authors have no disclosures relevant to this article.

Source

This article was originally published as Can Shoulder Arthroplasty Become an Opioid-Free Procedure? in the NYU Langone Orthopedics Journal Watch section of  www.ICJR.net. Republished with permission.

References

1. Beheshti D. Adverse health effects of abuse-deterrent opioids: Evidence from the reformulation of OxyContin. Health Econ. 2019 Dec;28(12):1449-1461. doi: 10.1002/hec.3944. Epub 2019 Nov 12.
2. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 17;66(10):265-269. doi: 10.15585/mmwr.mm6610a1.
3. Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015 May;23(5):267-71. doi: 10.5435/JAAOS-D-14-00163.
4. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med. Sep;49(3):409-13. doi: 10.1016/j.amepre.2015.02.020. Epub 2015 Apr 18.