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Al-Mohrej OA, Prada C, Madden K, Shanthanna H, Leroux T, Khan M. The role of preoperative opioid use in shoulder surgery-A systematic review. Shoulder Elbow 2023; 15:250-273. [PMID: 37325382 PMCID: PMC10268141 DOI: 10.1177/17585732211070193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 09/20/2023]
Abstract
Background Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. Methods EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Results Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Conclusion Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients. Level of evidence Level IV, Systematic review.
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Affiliation(s)
- Omar A Al-Mohrej
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Section of Orthopedic Surgery, Department of Surgery, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
| | - Carlos Prada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kim Madden
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Harsha Shanthanna
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Timothy Leroux
- Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Joksimovic SL, Lamborn N, Jevtovic-Todorovic V, Todorovic SM. Alpha lipoic acid attenuates evoked and spontaneous pain following surgical skin incision in rats. Channels (Austin) 2021; 15:398-407. [PMID: 33843451 PMCID: PMC8043189 DOI: 10.1080/19336950.2021.1907058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 01/19/2023] Open
Abstract
Our previous studies have implicated CaV3.2 isoform of T-type Ca2+ channels (T-channels) in the development of postsurgical pain. We have also previously established that different T-channel antagonists can alleviate in vivo postsurgical pain. Here we investigated the analgesic potential of another T-channel blocker and endogenous antioxidant molecule, α-lipoic acid (ALA), in a postsurgical pain model in rats. Our in vivo results suggest that single and repetitive intraperitoneal injections of ALA after surgery or preemptively, significantly reduced evoked mechanical hyperalgesia following surgical paw incision. Furthermore, repeated preemptive systemic injections of ALA effectively alleviated spontaneous postsurgical pain as determined by dynamic weight-bearing testing. We expect that our preclinical study may lead to further investigation of analgesic properties and mechanisms of analgesic action of ALA in patients undergoing surgery.
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Affiliation(s)
- Sonja Lj. Joksimovic
- Department of Anesthesiology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Nathan Lamborn
- Department of Anesthesiology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Slobodan M. Todorovic
- Department of Anesthesiology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
- Neuroscience Graduate Program, Graduate Program in Pharmacology, and Graduate Program in Biomedical Sciences, University of Colorado Denver, Anschutz Medical Campus and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
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3
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Chang K, Silva S, Horn M, Cary MP, Schmidt S, Goode VM. Presurgical and Postsurgical Opioid Rates in Patients Undergoing Total Shoulder Replacement Surgery. Pain Manag Nurs 2021; 23:128-134. [PMID: 34538730 DOI: 10.1016/j.pmn.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 07/02/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose of this study was to describe the pre- and postsurgical opioid prescription rates and average morphine milligram equivalents (MME) per day in patients undergoing total shoulder replacement (TSR) procedures. METHODS Patients undergoing TSR were identified from the electronic health records (EMR). In addition to patient demographics, opioid prescription 12-months presurgery and postsurgery were recorded. Patients were categorized into two groups: patients with no opioid prescriptions within 12 months before surgery and patients with an opioid prescription after surgery. McNemar tests were conducted to test for significant presurgical to postsurgical changes in opioid rate changes. The Wilcoxon signed rank test was used to test for significant pre- to postsurgical changes in average MME/day/person, and bivariate logistic regression analyses and covariate-adjusted logistic regressions were used to predict postsurgical opioid prescriptions. RESULTS Overall, 1,076 patients underwent TSR. More than 900 patients received presurgical opioid prescriptions. There was a significant increase (p = .0015) in pre-surgical to postsurgical prescription rates. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a pre-surgical non-opioid patient than an opioid patient (p < .0001). Among those prescribed an opioid, the median dosage was <50 MME/day and over 82% of patients were at low overdose risk. Patients with comorbidities and without pre-surgical alcohol use were more likely to receive postsurgical opioids. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a presurgical non-opioid patient than an opioid patient (p < .0001). More than 80% of patients undergoing TSR received presurgical opioids. Among those prescribed any opioid, the median dosage was <50 MME/day and greater than 82% of patients were at low overdose risk. CONCLUSIONS Although presurgical non-opioid patients were more likely to receive a postsurgical opioid prescription, based on dosage, most patients were at low risk for an opioid-related overdose or death according to CDC guidelines.
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Affiliation(s)
- Kuangshrian Chang
- Duke University, School of Nursing, Durham, North Carolina and II Old Dominion University College of Health Sciences, Norfolk, VA
| | - Susan Silva
- Duke University, School of Nursing, Durham, North Carolina and II Old Dominion University College of Health Sciences, Norfolk, VA
| | - Maggie Horn
- Duke University, Department of Orthopedic Surgery, Doctor of Physical Therapy Division, Durham, North Carolina; Duke University, Department of Population Health Sciences, Durham, North Carolina
| | - Michael P Cary
- Duke University, School of Nursing, Durham, North Carolina and II Old Dominion University College of Health Sciences, Norfolk, VA; Duke Center for the Study of Aging and Human Development, Durham, North Carolina
| | - Shawna Schmidt
- Duke University, School of Nursing, Durham, North Carolina and II Old Dominion University College of Health Sciences, Norfolk, VA
| | - Victoria M Goode
- Duke University, School of Nursing, Durham, North Carolina and II Old Dominion University College of Health Sciences, Norfolk, VA; Johns Hopkins University, School of Nursing, Baltimore, Maryland.
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Kopechek KJ, Roebke AJ, Sridharan M, Samade R, Goyal KS, Neviaser AS, Bishop JY, Cvetanovich GL. The effect of patient factors on opioid use after anatomic and reverse shoulder arthroplasty. JSES Int 2021; 5:930-935. [PMID: 34505108 PMCID: PMC8411060 DOI: 10.1016/j.jseint.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Prolonged opioid use can lead to suboptimal outcomes after total shoulder arthroplasty (TSA), and thus, reduced consumption is desirable. Our primary aims were to determine if differences in total morphine equivalent doses existed owing to (1) age less than or greater than 65 years, (2) sex, and (3) TSA type - reverse or anatomic total shoulder arthroplasty. We also characterized potential risk factors for (1) visiting another provider for pain, (2) pain control 6 weeks postoperatively, and (3) needing an opioid refill. Methods A retrospective cohort study of 100 patients who underwent TSA (reverse total shoulder arthroplasty N 1 = 50; anatomic total shoulder arthroplasty N 2 = 50) between 1 July 2018 and 31 December 2018 was performed. Demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Primary hypotheses were evaluated with Wilcoxon-Mann-Whitney testing. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values. Results There was a difference (P = .009) in total morphine equivalent doses used (in 5-milligram oxycodone tablets) between patients who were younger than 65 years of age (median: 83 tablets, interquartile range: 62-140) and those who were older than 65 years of age (median: 65 tablets, interquartile range: 52-90). Unemployment (aOR = 4.68, CI: 1.5-14.2, P = .006) and age less than 65 years (aOR = 4.18, CI: 1.6-11.2, P = .004) were independent risk factors for inadequate pain control 6 weeks postoperatively. Two independent risk factors for needing an opiate prescription refill after discharge were unemployment (aOR = 4.56, CI: 1.5-13.8, P = .007) and preoperative opiate use (aOR = 3.95, CI: 1.4-11.0, P = .009). Conclusion After TSA, morphine equivalent dose usage is higher for patients younger than 65 years of age, and several risk factors exist for requiring a refill and having inadequate pain control 6 weeks postoperatively. Prospective studies using these data to guide interventions may be beneficial.
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Affiliation(s)
- Kyle J Kopechek
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Austin J Roebke
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mathangi Sridharan
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Richard Samade
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kanu S Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew S Neviaser
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Tucker DW, Homere AJ, Wier JR, Bougioukli S, Carney JJ, Wong M, Inaba K, Marecek GS. Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use. Injury 2021; 52:1234-1238. [PMID: 32948328 DOI: 10.1016/j.injury.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. DESIGN Retrospective Cohort Study. SETTING Academic Level-1 Trauma Center. PATIENTS 96 Patients with blunt or ballistic fractures. INTERVENTION Inpatient narcotic pain management after orthopaedic fracture management. MAIN OUTCOME MEASUREMENTS Morphine equivalent units (MEU). RESULTS Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. CONCLUSION Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Andrew J Homere
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Julien R Wier
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Sofia Bougioukli
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Monica Wong
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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6
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Bloom DA, Manjunath AK, Gotlin MJ, Hurley ET, Jazrawi LM, Virk MS, Kwon YM, Zuckerman JD. Institutional reductions in opioid prescribing do not change patient satisfaction on Press Ganey surveys after total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:858-864. [PMID: 32712454 DOI: 10.1016/j.jse.2020.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control. PURPOSE The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press Ganey satisfaction surveys. METHODS A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press Ganey survey information and no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into 2 groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to morphine milligram equivalents (MME) for direct comparison between different opioid medications. RESULTS A total of 201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group were 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5 mg), whereas after the initiation of the protocol, they were 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5 mg); P < .0001. Average satisfaction with pain control did not change significantly between pre-protocol and post-protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P = .82). CONCLUSION A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press Ganey survey.
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Affiliation(s)
- David A Bloom
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
| | - Amit K Manjunath
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Matthew J Gotlin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Mandeep S Virk
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Young M Kwon
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
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7
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Werner BC, Kew ME, Brockmeier SF, Gowd AK, Romeo AA, Agarwalla A. Postoperative opioid usage is greater following hemiarthroplasty compared to reverse total shoulder arthroplasty for proximal humerus fractures. SEMINARS IN ARTHROPLASTY: JSES 2020. [DOI: 10.1053/j.sart.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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9
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Sahoo S, Derwin KA, Zajichek A, Entezari V, Imrey PB, Iannotti JP, Ricchetti ET. Associations of preoperative patient mental health status and sociodemographic and clinical characteristics with baseline pain, function, and satisfaction in patients undergoing primary shoulder arthroplasty. J Shoulder Elbow Surg 2020; 30:e212-e224. [PMID: 32860879 PMCID: PMC7907259 DOI: 10.1016/j.jse.2020.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores. METHODS We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores. RESULTS A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs. CONCLUSION In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.
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Affiliation(s)
- Sambit Sahoo
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen A. Derwin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexander Zajichek
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Vahid Entezari
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph P. Iannotti
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric T. Ricchetti
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA,Address for Correspondence: Eric T. Ricchetti, M.D. Department of Orthopaedic Surgery, Orthopaedic & Rheumatologic Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code A40, Cleveland, Ohio 44195, USA, Telephone: 216-445-6915, ,
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Jivraj NK, Raghavji F, Bethell J, Wijeysundera DN, Ladha KS, Bateman BT, Neuman MD, Wunsch H. Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study. Anesthesiology 2020; 132:1528-1539. [PMID: 32243330 PMCID: PMC8202398 DOI: 10.1097/aln.0000000000003265] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. METHODS The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. RESULTS Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. CONCLUSIONS The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
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Affiliation(s)
- Naheed K Jivraj
- From the Department of Anesthesiology and Pain Medicine (N.K.J., D.N.W., K.S.L., H.W.) Interdepartmental Division of Critical Care Medicine (H.W.), University of Toronto, Toronto, Canada the Institute of Health Policy Management and Evaluation, Toronto, Canada (N.K.J., D.N.W., K.S.L., H.W.) the University of Limerick, Limerick, Ireland (F.R.) the Sunnybrook Research Institute, Toronto, Canada (J.B., H.W.) the Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada (D.N.W., K.S.L.) the Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B.) the Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (M.D.N.) the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada (H.W.)
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11
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Sheth U, Mehta M, Huyke F, Terry MA, Tjong VK. Opioid Use After Common Sports Medicine Procedures: A Systematic Review. Sports Health 2020; 12:225-233. [PMID: 32271136 PMCID: PMC7222661 DOI: 10.1177/1941738120913293] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.
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Affiliation(s)
- Ujash Sheth
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Mitesh Mehta
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Fernando Huyke
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Michael A. Terry
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Vehniah K. Tjong
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
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12
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A Review of Inpatient Opioid Consumption and Discharge Prescription Patterns After Orthopaedic Procedures. J Am Acad Orthop Surg 2020; 28:279-286. [PMID: 31633659 DOI: 10.5435/jaaos-d-19-00279] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Tailoring opioid prescriptions to inpatient use after orthopaedic procedures may effectively control pain while limiting overprescription but may not be common in the current orthopaedic practice. METHODS A retrospective review identified opioid-naïve patients admitted after any orthopaedic procedure. Daily and total prescription quantities as well as patient-specific factors were collected. The total opioids used the day before discharge was compared with the total opioids prescribed for the day after discharge. Refill rates were then compared between patients whose daily discharge prescription regimen far exceeded or approximated their predischarge opioid consumption. RESULTS Six hundred thirteen patients were included (ages 18 to 95 years). The total opioids prescribed for the 24 hours after discharge significantly exceeded the opioids consumed the 24 hours before discharge for each orthopaedic subspecialty. The excessive-prescription group (409 patients) received greater daily opioid (120 oral morphine equivalents [OMEs] versus 60 OMEs; P < 0.01) and total opioid (750 OMEs versus 512.5 OMEs; P < 0.01) at discharge but was more likely to refill their opioid prescription within 30 days of discharge (27.6% versus 20.1%; P = 0.043). DISCUSSION Opioid regimens prescribed after an orthopaedic surgery frequently exceed inpatient opioid use. Opioid regimens that approximate inpatient use may help curb overprescription and are not associated with higher refill rates compared with more excessive prescriptions. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Standardized, Patient-specific, Postoperative Opioid Prescribing After Inpatient Orthopaedic Surgery. J Am Acad Orthop Surg 2020; 28:e304-e318. [PMID: 31356424 DOI: 10.5435/jaaos-d-19-00030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioid-related mortality has increased over the past 2 decades, leading to the recognition of a nationwide opioid epidemic and prompting physicians to reexamine their opioid prescribing practices. At our institutions, we had no protocol for prescribing opioids upon discharge after inpatient orthopaedic surgery, resulting in inconsistent and potentially excessive prescribing. Here, we report the results of the implementation of a patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery. METHODS The opioid taper calculator is a tool that creates a patient-specific opioid taper based on each patient's 24-hour predischarge opioid utilization. We implemented this taper for patients discharged after inpatient orthopaedic surgery at our two institutions (Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus). We compared discharge opioid quantities between orthopaedic patients postimplementation and quantities prescribed preimplementation. We also compared discharge opioid quantities between orthopaedic and nonorthopaedic surgical services over the same time period. RESULTS Nine-months postimplementation, a patient-specific taper was used in 74% of eligible discharges, resulting in a 24% reduction in opioids prescribed at discharge, along with a 35% reduction in variance. Over the same time frame, a smaller reduction (9%) was seen in the opioids prescribed at discharge by nonorthopaedic services. The most notable reductions were seen after total joint arthroplasty and spinal fusions. Despite this reduction, most patients (65%) reported receiving sufficient opioids, and no substantial change was observed in 30-day postdischarge opioid prescription refills after versus before protocol implementation (1.58 versus 1.71 fills per discharge). DISCUSSION Using the opioid taper calculator, a patient-specific taper can be successfully used to standardize opioid prescribing at discharge after inpatient orthopaedic surgery without a substantial risk of underprescription. LEVEL OF EVIDENCE Level II.
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Kolade OO, Ghosh N, Fernandez L, Friedlander S, Zuckerman JD, Bosco JA, Virk MS. Study of variations in inpatient opioid consumption after total shoulder arthroplasty: influence of patient- and surgeon-related factors. J Shoulder Elbow Surg 2020; 29:508-515. [PMID: 31495705 DOI: 10.1016/j.jse.2019.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization. METHODS The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption. RESULTS Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P < .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P < .001), age < 60 years (P < .01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences. CONCLUSION There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.
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Affiliation(s)
- Oluwadamilola O Kolade
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Niloy Ghosh
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Laviel Fernandez
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Scott Friedlander
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Joseph D Zuckerman
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Joseph A Bosco
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Mandeep S Virk
- Shoulder and Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
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A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e109. [PMID: 31773081 PMCID: PMC6860138 DOI: 10.5435/jaaosglobal-d-19-00109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns.
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Laumonerie P, Blasco L, Tibbo ME, Renard Y, Kerezoudis P, Chaynes P, Bonnevialle N, Mansat P. Distal suprascapular nerve block-do it yourself: cadaveric feasibility study. J Shoulder Elbow Surg 2019; 28:1291-1297. [PMID: 30846221 DOI: 10.1016/j.jse.2018.11.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/24/2018] [Accepted: 11/30/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND A bone landmark-based approach (LBA) to the distal suprascapular nerve (dSSN) block is an attractive "low-tech" method available to physicians with no advanced training in regional anesthesia or ultrasound guidance. The primary aim of this study was to validate the feasibility of an LBA to blockade of the dSSN by orthopedic surgeons using anatomic analysis. The secondary aim was to describe the anatomic features of the sensory branches of the dSSN. MATERIALS AND METHODS An LBA was performed in 15 cadaver shoulders by an orthopedic resident. Then, 10 mL of methylene blue-infused 0.75% ropivacaine was injected around the dSSN; 2.5mL of red latex solution was also injected to identify the position of the needle tip. The division and distribution of the sensory branches that originate from the suprascapular nerve were described. RESULTS The median distance between the dSSN and the site of injection was 1.5 cm (0-4.5 cm). The most common injection site was at the proximal third of the scapular neck (n = 8). Fifteen dSSNs were stained proximal to the origin of the most proximal sensory branch. All 15 dSSNs gave off 3 sensory branches that innervated the posterior glenohumeral capsule, the subacromial bursa, and the coracoclavicular and acromioclavicular ligaments. CONCLUSIONS An LBA for anesthetic blockade of the dSSN by an orthopedic surgeon is a simple, reliable, and accurate method. Injection close to the suprascapular notch is recommended to involve the dSSN proximally and its 3 sensory branches.
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Affiliation(s)
- Pierre Laumonerie
- Department of Orthopedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France; Anatomy Laboratory, Rangueil University Hospital, Toulouse, France.
| | - Laurent Blasco
- Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Yohann Renard
- Anatomy Laboratory, Faculty of Medicine, Reims, France
| | | | - Patrick Chaynes
- Anatomy Laboratory, Rangueil University Hospital, Toulouse, France
| | - Nicolas Bonnevialle
- Department of Orthopedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Pierre Mansat
- Department of Orthopedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
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