Opioid-Sparing Shoulder Surgery Represents Cultural Shift

Significant progress has been made in the decade since the American Academy of Orthopaedic Surgeons called on physicians to help lead a cultural change to limit the potential overuse and abuse of opioid pain medications. One of the strategies having success is the use of multimodal anesthesia for pain management in the perioperative setting.

“The opioid-sparing pain management protocols we’ve developed and are using for major shoulder procedures at Cleveland Clinic Weston Hospital and our ambulatory surgical center in Coral Springs have greatly reduced patient reliance on narcotics for postoperative pain relief,” states Gregory Gilot, MD, an orthopaedic surgeon with Cleveland Clinic in Florida who specializes in shoulder arthroscopy and replacement and rotator cuff disorders. “It constitutes a substantial and necessary shift in mindset among clinicians and patients alike.”

Public health emergency

The opioid crisis was declared a public health emergency by the U.S. Department of Health and Human Services in 2017 and has since been renewed as an ongoing emergency. It continues to negatively impact the lives of millions of Americans and claimed nearly 82,000 lives in 2022, according to the latest report from the Centers for Disease Control and Prevention (CDC).

In addition to being highly addictive and the risk of life-threatening respiratory depression and overdose from misuse, the long-term use of opioids can lead to cognitive impairment, mood and anxiety disorders, as well as social consequences.

Decline in opioid prescribing

In 2022, the CDC issued guidelines about the prescribing of opioids in an effort to improve the effectiveness and safety of pain treatment while reducing risks associated with opioid pain therapy. According to CDC data, opioid prescriptions filled in the United States has since dropped from 153 million in 2019 to approximately 125 million in 2023.

An analysis of retail pharmacy data also found a 35.6% reduction in opioid prescribing among U.S. surgeons between 2016 and 2022. Despite these gains, researchers determined the average opioid prescription by surgeons in December 2022 involved the equivalent of 44 pills containing 5-mg hydrocodone.

Furthermore, patients undergoing orthopaedic surgery are prescribed some of the highest amounts of opioid-based medications due to the level of pain these surgeries can generate. An analysis of 2020-2021 claims data for more than 1 million major surgical procedures identified common orthopedic procedures, including shoulder arthroscopy, as 4 of the top 5 procedures for highest postoperative opioid prescribing among individuals aged 45 to 64 years.

“A decade ago it was standard practice for a patient to leave our hospital following joint replacement surgery with a prescription for 40 pills of oxycodone,” recalls Dr. Gilot. “Today we use a multimodal pain management approach. Most of my patients only need acetaminophen or anti-inflammatories to manage their postoperative pain, though they may receive a prescription for 12 pills of tramadol for breakthrough pain.”

Proven pain relief

Research by Dr. Gilot and a team at Weston Hospital found preoperative and postoperative patient education and multimodal pain management significantly reduced the use of opioids after arthroscopic rotator cuff repair (RCR) – considered one of the most painful orthopaedic procedures and often associated with higher opioid consumption – while maintaining excellent patient satisfaction and outcomes.

In the 48 hours following surgery, just 15% of opioid intervention group (OIG) patients reported use of rescue opioids compared with 100% of control group patients. At 2 weeks, none of the OIG patients reported opioid use compared to 90% of control group patients.

Another similar study by the Cleveland Clinic team demonstrated complete elimination of opioid use by 2 weeks after shoulder arthroplasty using a patient engagement model with non-opioid multimodal pain management.

Multimodal pain management

Standardized pain management protocols for shoulder surgeries at Weston Hospital and the Coral Springs Family Health and Surgery Center include a combination of pharmacologic and nonpharmacologic treatments to manage pain at various levels:

• Physical measures (ice, immobilization).
• Non-narcotic analgesics.
• Non-steroidal anti-inflammatories (NSAIDs).
• Mental techniques.
• Regional anesthesia.
• Long-acting local anesthesia (liposomal bupivacaine).
• Narcotics.

“The majority of our patients are comfortable with this pain management approach as long as we set the expectation,” says Dr. Gilot. “I rarely need to prescribe opioids, though it's very hard to eliminate it completely.”

Pharmacogenetics and pain response

Philipp Streubel, MD, a shoulder surgeon with the Orthopaedic Surgery Department at Cleveland Clinic in Florida, notes that pain is influenced by multiple factors, including biologic, psychological and social, and that there is a great deal of variability in the effectiveness of pain treatments as a result. “I have some patients that require no narcotics whatsoever while others still need some narcotics for rescue,” he says.

That’s why Dr. Streubel is leading a team of researchers to examine how patient genetic makeup influences response to pain after shoulder surgery. The pharmacogenetics study will use next generation genetic sequencing to look at 18 different genotypes involved in drug metabolism or neurotransmitter regulation. These include catechol-o-methyltransferase (COMT) and cytochrome P450 2D6 (CYP2D6), among many others.

“If there are genetic factors that we can identify prior to surgery to determine who is at higher risk of having more significant pain, then we can take a preventive approach to minimize breakthrough pain using other tools,” states Dr. Streubel.

Study design

The study is currently underway at Weston Hospital and the Coral Springs surgery center and will include 70 patients 18 years or older who are undergoing elective shoulder surgery. Recruitment began last year and is expected to take another two to three years to complete. Study participants will undergo specific therapeutic interventions:

• Regional block by fellowship trained anesthesiologist.
• Standardized general anesthesia (opioid-sparing).
• Arthroscopic rotator cuff repair or shoulder replacement surgery.

Postoperative pain will be treated in the post-anesthesia care unit with a shoulder-specific ice machine, acetaminophen, NSAIDS, tramadol and rescue narcotics. At home, patients may use ice, acetaminophen, aspirin, gabapentin and/or tramadol for pain relief.

Postoperative pain will be assessed and the amount of narcotics will be measured at specific intervals. These variables will be analyzed with regards to the patients’ genetic makeup to identify possible genes that may predispose them to experiencing greater pain and increased narcotic use.

“We will look at side effects and other known factors that play a role in the effectiveness of pain management techniques, such as a history of depression or anxiety, educational level, and so on,” explains Dr. Streubel. “Ultimately, we want to identify relevant risk factors, compare the weight of risk factors, and design interventions based on those risk factors.”

A cultural shift

Dr. Gilot and Dr. Streubel are both heartened by the progress that has been made in reducing opioid therapy for pain management in orthopaedic surgery, but acknowledge the work continues.

“Pain used to be considered a fifth vital sign, and if anybody had pain, you had to attack it and eliminate it,” says Dr. Gilot. “Now the philosophy is different. We are here to treat pain, not cure it. It is a cultural shift in pain management.”

Dr. Streubel agrees, noting pain is a normal part of any postoperative course and a more acceptable part of the recovery, not something to be avoided at all costs.

“We have discussions with patients about the fact that they are going to have some pain and that it is a normal part of the healing process,” Dr. Streubel adds. “This shift in understanding requires participation from patients to help modulate their pain without relying on opioids. Counseling and patient education play an incredibly important role in the process.”