doc
Spring 2016 • Kentucky
shoulder arthroplasty in patients with a history of preoperative
opioid use for shoulder arthritis. Preoperative opioid was associated with significantly worse preoperative and postoperative
shoulder function scores relative to patients without a history
of preoperative opioid use.8,9 Patients with preoperative opioid
use can respond very well to shoulder replacement surgery,
but it has been shown that they do not reach the same level of
improvement compared to nonopioid patients. Furthermore,
patients without preoperative opioid use have been shown to
have significantly better postoperative patient satisfaction after
total shoulder arthroplasty compared to patients with preoperative opioid use.8
The American Academy of Orthopaedic Surgeons (AAOS)
recently issued a position statement in response to the rise in
opioid prescribing to help guide physicians that manage musculoskeletal conditions.10 The AAOS recognized the need for
physicians to manage musculoskeletal pain, while understanding
the direct and indirect contributions to the opioid burden in the
United States.
The AAOS called for a culture change among physicians,
patients, and caregivers regarding opioid prescribing and pain
control in musculoskeletal conditions. Proposals included standardized opioid prescribing protocols, limits on the duration
and amount of opioid pills prescribed, and avoiding the use of
extended-release opioids. The AAOS recommended avoiding
opioids for the routine management of pre-surgical pain, nonoperative, or chronic musculoskeletal conditions. Objective risk
assessment tools were suggested to help better identify patients
at risk for greater opioid use as well as opioid use tracking.
Improved care coordination and physician collaboration was
recommended. Orthopaedic surgeons and other musculoskeletal
specialists can help to better communicate and collaborate with
primary care physicians and other specialties regarding the treatment of musculoskeletal conditions.
The negative consequences of nontherapeutic opioid use
are apparent. The detrimental effects of therapeutic opioid use,
especially in the management of musculoskeletal conditions, are
now more clearly identified. Additional work is needed to better
understand and treat pain associated with musculoskeletal conditions. The association between therapeutic opioid use and worse
patient outcomes has been highlighted. Additional efforts are
needed to explore the complexities of pain and outcomes in the
management of these common conditions.
About the Author
Brent J. Morris, MD is an orthopedic surgeon and fellowship-trained
shoulder and elbow specialist at Lexington Clinic Orthopedics Sports Medicine Center and the Shoulder Center of Kentucky. Dr.
Morris received his medical degree from the University of Kentucky
College of Medicine and completed an orthopedic surgery residency
at Vanderbilt University. He completed a shoulder and elbow fellowship at Texas Orthopedic Hospital in affiliation with the University
of Texas Health Science Center at Houston. Dr. Morris has presented
research nationally and internationally and has published extensively
on various orthopedic topics including the impact of opioids on orthopedic patients.
Resources
1. Manchikanti L, Singh A: Therapeutic opioids: A ten-year
perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician
2008;11(2 suppl):S63-S88.
2. Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND,
Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of nonmalignant pain in the United States,
2000-2010. Med Care 2013;51(10):870-878.
3. Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V,
Grider JS, Boswell MV. Opioid epidemic in the United States.
Pain Physician 2012;15(3 suppl):ES9-ES38.
4. Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic
opioid use prior to total knee arthroplasty. J Bone Joint Surg Am
2011;93(21):1988-1993.
5. Lee D, Armaghani S, Archer KR, Bible J, Shau D, Kay H, Zhang
C, McGirt MJ, Devin C. Preoperative opioid use as a predictor of
adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am 2014;96(11):e89.
6. Armaghani SJ, Lee DS, Bible JE, Shau DN, Kay H, Zhang C,
McGirt MJ, Devin CJ. Increased preoperative narcotic use and its
association with postoperative complications and length of h