The Orthopaedic and Neurosurgery Specialists Foundation for Clinical Research and Education (ONSF) published study in this month’s Journal of Shoulder and Elbow Surgery the first ever evidenced based guideline for opiate prescription use after rotator cuff surgery.

The Journal of Shoulder and Elbow Surgery published this month (April, 2019) a study by the Orthopaedic and Neurosurgery Specialists Foundation for Clinical Research and Education (ONSF) marking the first ever evidenced based guideline for opiate prescription use after rotator cuff surgery.

Over 250,000 people have rotator cuff surgery each year. The traditional risks of surgery, such as nerve injury or infection, are less than 1%. Two recent studies, however, have demonstrated that between 8-14 % of patients will be on prolonged opiate medication after rotator cuff surgery. These frightening new facts underscore the importance of the new findings.

The ONSF researchers used a well defined and consistent protocol to control post-operative pain. When compared to the group of patients who did not receive the enhanced post-operative pain protocol, the ONSF surgeons found that patients:

• Reported statistically and clinically lower pain scores after surgery
o Patients had less pain and discomfort after surgery
o Patients did not require the higher strength pills used in other studies

• Consumed 64 percent fewer opioids
o Fewer pills directly correlates with a reduced risk of developing dependence
o This study refutes a recent study from New York, based solely on expert opinion, suggesting that 60 pills should be given for the same procedure. Dr. Paul Sethi believes that certain studies are dangerous because physicians rely on published recommendations without understanding the basis (or lack of scientific basis) of the study

• Did not request a refill of their opioid prescription
o Each additional refill increases the risk of opiate dependence by 44 percent
o The first refill more than doubles the risk.

• Stopped taking opioids more quickly
o Information from the Centers for Disease Control and Prevention (CDC) has found that opiate use beyond five days, as well as the need for prescription refills, directly increase the risk of developing opiate dependence.
o Among surgery patients with no history of recent or chronic opioid use, how long a person takes the drugs is a more potent predictor of abuse and overdose than how much medication a patient takes. D. (Harvard medical School, published in BMJ 2018)
o “This post-operative pain protocol helps patients avoid this major risk,” Sethi concluded

There is a paucity of data to guide surgeons on how much pain medication to prescribe after surgery. Historically, surgeons would focus on correctly identifying problems that require surgery, performing successful surgery and avoiding complications from the surgical procedure.

These recommendations cut the use of opiates by 64-75 %, a stark contrast to the current average amounts prescribed, that a recent report – Exposing a Silent Gateway to Persistent Opioid Use – found to be about 93 pills.

No patients in the ONSF research protocol required refills of opiate medications.

High opioid prescribing and/or overprescribing for post-surgical pain carry not only acute risks of opioid-related adverse effects, but also the risk of long-term opioid use. “Through greater use of multimodal, opioid-minimizing pain management strategies, there is an opportunity to keep patients safe from these dangers,” said Paul M. Sethi, M.D.

REFERENCES:
Sethi, Paul M. et al. Journal of Shoulder and Elbow Surgery, Volume 28, Issue 5, 819 – 827 Liposomal bupivacaine reduces opiate consumption after rotator cuff repair in a randomized controlled trial.

Gil, J. A., Gunaseelan, V., DeFroda, S. F., Brummett, C. M., Bedi, A., & Waljee, J. F. (2019). Risk of Prolonged Opioid Use Among Opioid-Naïve Patients After Common Shoulder Arthroscopy Procedures. The American Journal of Sports Medicine, 47(5), 1043–1050. https://doi.org/10.1177/0363546518819780

Leroux, T. S., Saltzman, B. M., Sumner, S. A., Maldonado-Rodriguez, N., Agarwalla, A., Ravi, B., … Romeo, A. A. (2019). Elective Shoulder Surgery in the Opioid Naïve: Rates of and Risk Factors for Long-term Postoperative Opioid Use. The American Journal of Sports Medicine, 47(5), 1051–1056. https://doi.org/10.1177/0363546519837516

“Over the study period, 79,287 patients were identified who underwent elective shoulder surgery, of whom 79.5% were opioid naïve. Among opioid-naïve patients, the rate of post-operative opioid use declined over time, and 14.6% of patients were still using opioids beyond 180 days. The greatest proportion of opioid-naïve patients still filling opioid prescriptions beyond 180 days post-operatively was seen after open rotator cuff repair (20.9%)”

Gabriel A Brat, Denis Agniel, , Andrew Beam, , Brian Yorkgitis, , et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.j5790 (Published 17 January 2018)