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Patient factors associated with prolonged opioid use after rotator cuff repair
J Shoulder Elbow Surg Volume 26, Number 5
Paper #15 LIPOSOMAL BUPIVACAINE INFERIOR TO INDWELLING INTERSCALENE NERVE BLOCK FOR POSTOPERATIVE PAIN CONTROL IN SHOULDER ARTHROPLASTY: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Jeffrey T. Abildgaard, MD, Keith T. Lonergan, MD, Stefan J. Tolan, MD, Michael J. Kissenber th, MD, Richard J. Hawkins, MD, Catherine Long, BS, Kyle J. Adams, BS, John M. Tokish, MD, Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, South Carolina, USA Introduction: Pain management following shoulder arthroplasty can include several strategies including peripheral nerve blocks, subacromial/intraarticular injections, and patient controlled anesthesia among others. Local infiltration of liposomal bupivacaine (LB) has demonstrated efficacy in other surgical settings with the potential to avoid complications unique to peripheral nerve blocks. The purpose of this study was to compare LB versus indwelling interscalene nerve blocks (IINB) for postoperative pain control as assessed by pain scores and opiate medication consumption. Materials: This is a prospective, randomized study of 83 consecutive patients that underwent anatomic and reverse total shoulder arthroplasty. 36 patients were randomized to receive LB and 47 patients received an IINB. Postoperative VAS pain levels, opiate consumption as measured with oral morphine equivalents (OME), length of hospital stay, and postoperative complications were recorded throughout hospital admission. Results: Patients that received LB reported higher VAS pain scores immediately postoperative in the post-anesthesia care unit (PACU) (7.25 versus 1.91) as well as the remainder of postoperative day 0 (4.99 versus 3.20). VAS scores remained higher for the remainder of admission however did not reach statistical significance. Opiate consumption was also higher amongst the LB cohort in the PACU (31.79 versus 7.47), on POD 0 (32.64 versus 15.04) and for the total hospital admission (189.50 versus 91.70). Similar complication numbers were noted between groups and length of stay was not statistically different. Conclusion: Use of an indwelling interscalene nerve block provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.
Paper #16 PATIENT FACTORS ASSOCIATED WITH PROLONGED OPIOID USE AFTER ROTATOR CUFF REPAIR
Robert W. Westermann, MD, Christopher Anthony, MD, Nicholas Bedard, MD, Natalie A. Glass, PhD, Matthew J. Bollier, MD, Carolyn M. Hettrich, MD, MPH, Brian R. Wolf, MD, MS, The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA Background: Rising perioperative opioid use in the Unites States is of increasing concern. The purpose of this study was to (1) define the natural history of opioid use after rotator cuff repair (RCR) in the United States and (2) evaluate patient factors that may be associated with prolonged opioid use following arthroscopic RCR. Methods: All arthroscopic RCRs performed in the Humana Inc. database between 2007-2014 were identified using CPT code (29827). Patient factors were evaluated for association with prolonged postoperative opioid use. Patients were considered chronic preoperative opioid users if they had filled at least one opioid prescription at 1-3 months preceding RCR. Patients were considered acute preoperative opioid users if they filled opioid prescriptions only in the one month preceding RCR. Rates of postoperative filling of opioid prescriptions were trended monthly for 1 year. Risk ratios (RR’s) with 95% Confidence Intervals (CI) were calculated to determine significance. Results: During the study period, 35,155 arthroscopic RCRs were performed. Forty-three percent had filled an opioid prescription in the 3 months prior to RCR. Of those who filled a preoperative opioid prescription, 58.9% had filled opioid prescriptions chronically while 41.1% had filled prescriptions only acutely prior to RCR. At 3 months after RCR, chronic preoperative opioid users were 7.45 (CI = 6.95-7.98) times more likely to be filling opioid medications compared to those who had not been prescribed
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opioid medications prior to surgery; acute preoperative opioid users were 3.04 (CI = 2.8-3.29) times more likely to be filling opioid prescriptions at 3 months after RCR. Those with psychiatric diagnoses (RR = 1.94, CI = 1.85-2.04), myalgia (RR = 1.67, CI = 1.6-1.75) and low back pain (RR = 2.09, CI = 2-2.2) were also found to be at risk for filling opioid prescriptions at 3 months postoperatively. Conclusions: Patients who are prescribed narcotics prior to RCR are at increased risk for postoperative opioid demand. Patients with psychiatric diagnoses, myalgia and low back pain may be at increased risk for prolonged opioid use after surgery.
Paper #17 THE DEGREE OF TISSUE INJURY IN THE SHOULDER DOES NOT CORRELATE WITH PAIN PERCEPTION
Aaron D. Sciascia, MS, ATC, PES, Cale A. Jacobs, PhD, Brent J. Morris, MD, W. Benjamin Kibler, MD, Lexington Clinic, Lexington, Kentucky, USA Introduction: Pain is a common patient reported symptom that has been shown to be a significant factor in determining injury treatment and establishing outcomes of treatment. It is usually assumed that the degree of reported pain correlates with the degree of injury, and that adequate treatment of the injury will provide a decrease in the reported pain. However, recent reports suggest that individual patient pain perception may not be highly correlated with tissue injury. This is especially evident in joints such as the knee and shoulder where it has been shown that a patient’s appreciation of pain is not related to the preoperative grade of arthritis (knee) or size of tendon tear (shoulder). The variation in individual patient neurosensory function creates a challenge for clinical experts as one person may have compromised tissue integrity (i.e. rotator cuff lesion) with little to no pain and/or no loss of arm function while another person with a similar condition may have moderate to severe pain with loss of function. This individualistic pain response to similar anatomical conditions would suggest that clinicians should not immediately assume compromised anatomy is the primary culprit as the pain generator. In addition to tissue disruption, a patient may have psychological and psychosocial factors that influence how he or she perceives and copes with pain. Those patients who have a persistent or amplified negative perception of pain, even to relatively minute tissue damage, can be classified as pain catastrophizers. Pain catastrophizing is associated with an exaggerated negative mental state during actual or anticipated painful experiences, and is often associated with poorer postoperative outcomes. Catastrophizing strategies are associated with constant mental awareness of one’s pain, a feeling of helplessness that the pain will not go away, and fear of movement or that the pain will worsen. Therefore, the purpose of this observational study was to screen patients with various causes of shoulder pain to determine the extent of variations in pain behavior (presence or absence of pain catastrophizing) in patients with heterogeneous diagnoses. The hypothesis was that pain catastrophization would not differ based on the presence or absence of joint or tissue derangement. Methods: The Pain Catastrophizing Scale (PCS) was prospectively distributed to consecutive patients visiting our shoulder clinic for an initial evaluation of shoulder pain. The PCS is a self-administered 13-item questionnaire and is used to determine a patient’s individual level of catastrophizing behavior. PCS total scores range from 0 to 52 with a total PCS score ≥30 used to define those with high catastrophizing behaviors. The PCS has 3 subcomponents: rumination, magnification, and helplessness. Rumination scores ≥11, magnification scores ≥5, and helplessness scores ≥13 would identify the specific pain catastrophizing subcomponent behavior. Patients were classified as having joint or tissue derangement (appreciable rotator cuff injury, labral injury, etc.) or no joint or tissue derangement (no appreciable tissue lesions resulting in diagnoses of scapular dyskinesis, muscle strains, tendonitis, etc.). Patients with fractures and adhesive capsulitis were excluded. Independent t-tests compared potential differences in PCS total score and each subcomponent to tissue derangement group
Paper #15 LIPOSOMAL BUPIVACAINE INFERIOR TO INDWELLING INTERSCALENE NERVE BLOCK FOR POSTOPERATIVE PAIN CONTROL IN SHOULDER ARTHROPLASTY: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Jeffrey T. Abildgaard, MD, Keith T. Lonergan, MD, Stefan J. Tolan, MD, Michael J. Kissenber th, MD, Richard J. Hawkins, MD, Catherine Long, BS, Kyle J. Adams, BS, John M. Tokish, MD, Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, South Carolina, USA Introduction: Pain management following shoulder arthroplasty can include several strategies including peripheral nerve blocks, subacromial/intraarticular injections, and patient controlled anesthesia among others. Local infiltration of liposomal bupivacaine (LB) has demonstrated efficacy in other surgical settings with the potential to avoid complications unique to peripheral nerve blocks. The purpose of this study was to compare LB versus indwelling interscalene nerve blocks (IINB) for postoperative pain control as assessed by pain scores and opiate medication consumption. Materials: This is a prospective, randomized study of 83 consecutive patients that underwent anatomic and reverse total shoulder arthroplasty. 36 patients were randomized to receive LB and 47 patients received an IINB. Postoperative VAS pain levels, opiate consumption as measured with oral morphine equivalents (OME), length of hospital stay, and postoperative complications were recorded throughout hospital admission. Results: Patients that received LB reported higher VAS pain scores immediately postoperative in the post-anesthesia care unit (PACU) (7.25 versus 1.91) as well as the remainder of postoperative day 0 (4.99 versus 3.20). VAS scores remained higher for the remainder of admission however did not reach statistical significance. Opiate consumption was also higher amongst the LB cohort in the PACU (31.79 versus 7.47), on POD 0 (32.64 versus 15.04) and for the total hospital admission (189.50 versus 91.70). Similar complication numbers were noted between groups and length of stay was not statistically different. Conclusion: Use of an indwelling interscalene nerve block provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.
Paper #16 PATIENT FACTORS ASSOCIATED WITH PROLONGED OPIOID USE AFTER ROTATOR CUFF REPAIR
Robert W. Westermann, MD, Christopher Anthony, MD, Nicholas Bedard, MD, Natalie A. Glass, PhD, Matthew J. Bollier, MD, Carolyn M. Hettrich, MD, MPH, Brian R. Wolf, MD, MS, The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA Background: Rising perioperative opioid use in the Unites States is of increasing concern. The purpose of this study was to (1) define the natural history of opioid use after rotator cuff repair (RCR) in the United States and (2) evaluate patient factors that may be associated with prolonged opioid use following arthroscopic RCR. Methods: All arthroscopic RCRs performed in the Humana Inc. database between 2007-2014 were identified using CPT code (29827). Patient factors were evaluated for association with prolonged postoperative opioid use. Patients were considered chronic preoperative opioid users if they had filled at least one opioid prescription at 1-3 months preceding RCR. Patients were considered acute preoperative opioid users if they filled opioid prescriptions only in the one month preceding RCR. Rates of postoperative filling of opioid prescriptions were trended monthly for 1 year. Risk ratios (RR’s) with 95% Confidence Intervals (CI) were calculated to determine significance. Results: During the study period, 35,155 arthroscopic RCRs were performed. Forty-three percent had filled an opioid prescription in the 3 months prior to RCR. Of those who filled a preoperative opioid prescription, 58.9% had filled opioid prescriptions chronically while 41.1% had filled prescriptions only acutely prior to RCR. At 3 months after RCR, chronic preoperative opioid users were 7.45 (CI = 6.95-7.98) times more likely to be filling opioid medications compared to those who had not been prescribed
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opioid medications prior to surgery; acute preoperative opioid users were 3.04 (CI = 2.8-3.29) times more likely to be filling opioid prescriptions at 3 months after RCR. Those with psychiatric diagnoses (RR = 1.94, CI = 1.85-2.04), myalgia (RR = 1.67, CI = 1.6-1.75) and low back pain (RR = 2.09, CI = 2-2.2) were also found to be at risk for filling opioid prescriptions at 3 months postoperatively. Conclusions: Patients who are prescribed narcotics prior to RCR are at increased risk for postoperative opioid demand. Patients with psychiatric diagnoses, myalgia and low back pain may be at increased risk for prolonged opioid use after surgery.
Paper #17 THE DEGREE OF TISSUE INJURY IN THE SHOULDER DOES NOT CORRELATE WITH PAIN PERCEPTION
Aaron D. Sciascia, MS, ATC, PES, Cale A. Jacobs, PhD, Brent J. Morris, MD, W. Benjamin Kibler, MD, Lexington Clinic, Lexington, Kentucky, USA Introduction: Pain is a common patient reported symptom that has been shown to be a significant factor in determining injury treatment and establishing outcomes of treatment. It is usually assumed that the degree of reported pain correlates with the degree of injury, and that adequate treatment of the injury will provide a decrease in the reported pain. However, recent reports suggest that individual patient pain perception may not be highly correlated with tissue injury. This is especially evident in joints such as the knee and shoulder where it has been shown that a patient’s appreciation of pain is not related to the preoperative grade of arthritis (knee) or size of tendon tear (shoulder). The variation in individual patient neurosensory function creates a challenge for clinical experts as one person may have compromised tissue integrity (i.e. rotator cuff lesion) with little to no pain and/or no loss of arm function while another person with a similar condition may have moderate to severe pain with loss of function. This individualistic pain response to similar anatomical conditions would suggest that clinicians should not immediately assume compromised anatomy is the primary culprit as the pain generator. In addition to tissue disruption, a patient may have psychological and psychosocial factors that influence how he or she perceives and copes with pain. Those patients who have a persistent or amplified negative perception of pain, even to relatively minute tissue damage, can be classified as pain catastrophizers. Pain catastrophizing is associated with an exaggerated negative mental state during actual or anticipated painful experiences, and is often associated with poorer postoperative outcomes. Catastrophizing strategies are associated with constant mental awareness of one’s pain, a feeling of helplessness that the pain will not go away, and fear of movement or that the pain will worsen. Therefore, the purpose of this observational study was to screen patients with various causes of shoulder pain to determine the extent of variations in pain behavior (presence or absence of pain catastrophizing) in patients with heterogeneous diagnoses. The hypothesis was that pain catastrophization would not differ based on the presence or absence of joint or tissue derangement. Methods: The Pain Catastrophizing Scale (PCS) was prospectively distributed to consecutive patients visiting our shoulder clinic for an initial evaluation of shoulder pain. The PCS is a self-administered 13-item questionnaire and is used to determine a patient’s individual level of catastrophizing behavior. PCS total scores range from 0 to 52 with a total PCS score ≥30 used to define those with high catastrophizing behaviors. The PCS has 3 subcomponents: rumination, magnification, and helplessness. Rumination scores ≥11, magnification scores ≥5, and helplessness scores ≥13 would identify the specific pain catastrophizing subcomponent behavior. Patients were classified as having joint or tissue derangement (appreciable rotator cuff injury, labral injury, etc.) or no joint or tissue derangement (no appreciable tissue lesions resulting in diagnoses of scapular dyskinesis, muscle strains, tendonitis, etc.). Patients with fractures and adhesive capsulitis were excluded. Independent t-tests compared potential differences in PCS total score and each subcomponent to tissue derangement group