Risk factors for postoperative opioid use after elective shoulder arthroplasty

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Background

The opioid epidemic remains a serious issue in the United States with significant impact to the medical and socioeconomic welfare of communities. We sought to determine baseline opioid use in patients undergoing shoulder arthroplasty (SA) and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use.

Methods

A Shoulder Arthroplasty Registry identified the number of dispensed opioid medication prescriptions (Rxs) in the first postoperative year in patients who underwent elective primary SA from 2008 to 2014. We used Poisson regression to study the effect of preoperative risks factors on number of dispensed opioid Rxs in the first postoperative year, evaluated quarterly (Q1: days 0-90, Q2: days 91-180, Q3: days 181-270, Q4: days 271-360).

Results

Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age <60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50).

Conclusion

Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies.

Section snippets

Study design, setting, and study sample

We conducted a cohort study using our integrated health care system's Shoulder Arthroplasty Registry (SAR).12 The integrated health care system covers more than 11.7 million lives throughout 8 geographic regions (ie, Colorado, Georgia, Hawaii, Mid-Atlantic, Northern California, Northwest, Southern California, and Washington) in the US.24

The study sample was selected using the SAR and consisted of all elective primary SA procedures for nonfracture indications performed in Hawaii, Northern

Results

The final study sample consisted of 4243 SAs performed in 3996 patients. Procedures were performed at 37 health care centers in 3 regions by 177 surgeons. Of these SA patients, 84.1% (n = 3570) were aged ≥60 years, 51.9% (n = 2201) were women, 80.5% (n = 3406) were white, 57.0% (n = 2176) had a BMI <30 kg/m2, and 45.6% (n = 1773) had an ASA classification >II. During the 1-year preoperative period, 75% of SA patients used opioids (range, 1-79 Rxs). Postoperatively, 92.6% used opioids in the

Discussion

Prior studies have identified the untoward effects of preoperative opioid use on postoperative opioid demand and outcomes in multiple orthopedic patient populations.10, 29, 30, 40, 43, 44 This study confirms previous SA literature demonstrating a significant level of preoperative opioid usage in patients undergoing SA.10, 29, 30 We found the prevalence of preoperative opioid use in patients undergoing SA was 75% the year before surgery. Opioid use diminishes in time after SA but remained at 39%

Conclusion

Preoperative opioid usage in patients undergoing SA was widespread, with three-fourths of patients having at least 1 Rx dispensed in the 1-year preoperative period. We found certain patient characteristics, comorbidities, and surgical types were associated with opioid use after SA. These findings can help surgeons identify those most at risk for prolonged opioid use. It will be important to minimize preoperative opioid use, which surgeons and physicians may have greater ability to control

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Acknowledgment

The authors acknowledge the Kaiser Permanente orthopedic surgeons who contribute to the Kaiser Permanente SAR and the Surgical Outcomes and Analysis Department staff, which coordinates registry operations. The authors also acknowledge William E. Burfeind, BS, for his ongoing support of the Kaiser Permanente SAR database and quality control management.

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    The Kaiser Permanente Southern California Institutional Review Board approved this study (#5527).

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