Summary

Preoperative opioid use is a known risk factor for complications and diminished outcomes following rotator cuff repair (RCR), The purpose of this study was to evaluate preoperative opioid use along a spectrum to better understand the role that preoperative opioid use has on postoperative outcomes

Abstract

Introduction

Preoperative opioid use is a known risk factor for complications and diminished outcomes following rotator cuff repair (RCR). The use of preoperative opioids occurs along a spectrum, ranging from patients receiving few to no opioid prescriptions to patients with multiple, recurrent opioid prescriptions. The purpose of this study was to evaluate preoperative opioid use along a spectrum to better understand the role that preoperative opioid use has on postoperative outcomes.

Methods

A consecutive series of patients undergoing arthroscopic RCR from 2018 to 2020 were included. Preoperative opioid use within one year of surgery was determined using the state prescription drug monitoring program (PDMP). Cumulative morphine milligram equivalents (MME) from prescriptions one year prior to surgery and the number of days the last opioid was prescribed before surgery determined. Postoperative outcomes at 3 and 6 months included visual analog scale (VAS) for pain and American Shoulder and Elbow Surgeons Shoulder Score (ASES). The proportion of patients achieving patient acceptable symptom state (PASS) for VAS and ASES were determined. Multivariate generalized estimating equations models were utilized to determine the influence of preoperative opioid use on postoperative outcome scores with receiver operator characteristic (ROC) analysis.

Results

763 patients (47.6% male) with a mean age of 60.2 + 10.0 years were included. 488 patients (64%) had no history of opioid use one year prior to RCR, while 275 (36%) had an opioid prescription one year before RCR. Compared to patients without preoperative opioid use, patients with preoperative opioid use had an average ASES value 7.9 points lower (p<0.001), and average VAS value 1.0 points greater (p< 0.001). PASS for VAS and ASES at 6 months was achieved in 28% and 56% of patients prescribed preoperative opioids compared to 46% and 59% without. There was no association between the number of days from opioid prescription to surgery for ASES score (p=0.23) nor VAS score (p = 0.37). ROC analysis with MME categories of 0-200, 200-500, and >500 MME yielded an area under the curve of 0.74 for PASS ASES and 0.78 for PASS VAS. Compared to patients with preoperative prescription <200 MME, patients prescribed >500 were 35.7% (p=0.03) less likely to achieve ASES PASS. For every 100 preoperative MME prescribed, ASES score decreased by 0.11 (p=0.001) while VAS increased 0.018 points (p<0.001). For every 100 preoperative MME prescribed, the probability of achieving PASS for VAS decreased by 1.8% (p=0.004).

Discussion

Preoperative opioid use is a risk factor for diminished clinical outcome scores and higher pain following RCR in the early postoperative setting. The risk profile is modified by total preoperative opioid prescription MME as higher preoperative opioid use is associated with lower ASES, higher VAS, and lower likelihood of achieving PASS for VAS and ASES. Preoperative opioid prescription threshold values of 200 and 500 MME negatively worsened clinical outcomes to greater degrees. Patients with increasing preoperative opioid use should be counseled that lower clinical outcomes and higher pain levels may occur following RCR.