Patients who undergo reverse shoulder arthroplasty RSA typically present either without having used narcotics pre-operatively or with chronic pre-operative opioid use (defined as opioid use for at least 60 days duration within 1 year of their index RSA surgery). The aim of this study was to determine the factors associated with pre-operative opioid use and postoperative chronic post-operative opioid dependence after RSA and to analyze the relationship between continued narcotic use and clinical outcomes.
Using an institutional arthroplasty database from 2010-2014 there were 289 patients who underwent RSA. Of these, 230 (80%) had a minimum of 2-year follow-up and were included for this study. 59 (20%) patients with incomplete PROMs or less than 2-year follow up were excluded. There were 202 (88%) primary and 28 (12%) revision RSA. Patients were divided into those who were not taking any narcotics prior to their index RSA surgery (opioid naïve, n =139, 60%) and those with chronic pre-operative opioid use (n = 91, 40%). The latter group was then subdivided into those who discontinued opioid use within 1 year after surgery (n = 26, 29%) and those with chronic post-operative opioid use (opioid use for over one year post-operatively, n = 65, 71%). All patients were studied preoperatively with a physical examination, multiple patient reported outcomes measures (PROMs) including VAS for pain, ASES score, Simple Shoulder Test, modified Constant Score, SF-36 physical and mental domains, and radiographs. These were all repeated at 1-year and 2-year follow-up. Statistical significance and clinical significance were set at p<0.05)
Of the 91 patients with preoperative opioid use, 65 (71%) continued to use opioids at least 1 year from surgery while the remaining 26 (29%) stopped using opioids altogether after surgery. Only 3 of 139 preoperatively opioid naïve patients (2%) required chronic post-operative opioid use. The pre-operative opioid naïve group had statistically significantly better (p < 0.05) PROM scores (ASES, L’Insalata, SST, Modified Constant, and VAS for pain) compared to the chronic pre-operative opioid use group. The subgroup of 26 patients with chronic pre-operative opioid use who discontinued opioids postoperatively, had statistically significantly better (p <0.05) PROM scores compared to those with pre-operative opioid use that continued chronic opiate use after surgery. Younger pre-operative age was the most significant factor (p=0.042) associated with chronic post-operative opioid use. Variables not found to be associated with chronic post-operative opioid use included revision surgery, BMI, diabetes, sex, worker’s compensation, preoperative enrollment in pain management, and history of depression or anxiety.
Our incidence of preoperative opioid use in RSA candidates (40%) is consistent with what is previously reported in the literature (35-42%). Nearly one third of these patients (29%) will discontinue opioid use post-operatively. In these patients, the clinical results are improved and similar to those who did not use narcotics pre-operatively. Risk factors for chronic post-operative opioid use include younger age and thus patients under the age of 65 should be counseled prior to RSA.