Abstract
Background
Oral opioid analgesia is commonly used for postoperative pain control in arthroscopic rotator cuff repair (RCR). Concerns about opioid side effects and potential abuse persist. This study aimed to identify risk factors for prolonged opioid use (POU) after RCR and assess its impact on patient-reported outcomes.
Methods
A retrospective chart review included patients over 18 years old who underwent primary arthroscopic RCR and had at least one preoperative and postoperative patient-reported outcomes measurement information system (PROMIS) score. POU was defined as at least one opioid prescription refill more than 30 days postoperatively. Demographic characteristics, clinical outcomes, and PROMIS scores up to one year postoperatively were collected.
Results
A total of 318 patients were included, and 38 had POU. Logistic regression identified opioid refill within 30 days after surgery, younger age, female sex, smoking, higher area deprivation index, and higher preoperative PROMIS depression score was associated with POU. Patients with POU had higher reoperation rates (15.8% vs. 5.4%; P = 0.015) and worse PROMIS pain interference and PROMIS upper extremity scores postoperatively.
Conclusion
Risk factors for POU after arthroscopic RCR include younger age, female sex, smoking, depression, higher area deprivation, and early opioid refill. POU correlated with higher reoperation rates and poorer postoperative outcomes.
Keywords: Rotator cuff repair, opioid, risk factors, shoulder, arthroscopy, outcomes
Introduction
Postoperative pain management is a crucial factor in the recovery of arthroscopic rotator cuff repair (RCR) patients. 1 Postoperatively, 30%–70% of patients reported significant pain following surgery. 2 While patients are generally discharged on the day of surgery, RCR can lead to significant postoperative pain during the acute perioperative period, which may prolong their hospital stay.3–5 Postoperative pain can also delay initiation of physical therapy, which has a significant impact on a patient's range of motion, strength, and functional outcomes. 6 Given the importance of perioperative pain control, multiple studies have examined the use of oral pain medication, perioperative nerve blocks, and cryotherapy.7,8
Oral opioid analgesia is widely used postoperatively in RCR for pain control; however, there is increased concern given the side effects and potential for abuse.9,10 Postoperative administration of large opioid doses can result in sedation, hypotension, and an extended hospital stay. Moreover, prolonged use of opioids after surgery may delay rehabilitation, foster drug dependence, and increase morbidity and mortality rates. 11 Orthopedics is notably one of the leading specialties in the United States for prescribing opioids, with patients undergoing upper extremity procedures often receiving opioid dosages up to 3 times greater than necessary. 12
While most patients recover with the typical postoperative pain management protocols, some patients require prolonged opioid pain medications, necessitating refills from providers. The risk factors and postoperative outcome impact of prolonged opioid use (POU) have yet to be determined. Therefore, the primary objective of this study was to identify preoperative risk factors associated with POU, and the secondary outcome was to assess patient-reported outcomes in relation to extended postoperative opioid use. We hypothesized that chronic preoperative opioid use and worse patient-reported outcomes measurement information system (PROMIS) scores would be significant preoperative risk factors for prolonged postoperative use and poorer outcomes.
Materials and methods
Institutional Review Board approval (IRB #13787) was obtained prior to study initiation. A retrospective review of a prospectively collected database was performed of all patients who underwent primary arthroscopic RCR at a single academic medical center between July 2017 and July 2019 by one of three fellowship-trained orthopedic surgeons. The POU cohort was defined as a new opioid medication prescribed 30 days or more after RCR.13–15 Included patients were > 18 years of age who underwent arthroscopic RCR, had at least one preoperative and postoperative PROMIS score, and had preoperative and postoperative opioid prescription information available. Exclusion criteria included age < 18 years, previous ipsilateral shoulder surgery, primary isolated rotator cuff debridement without repair, open or mini-open RCR, or inability to verify opioid consumption in the statewide database.
The electronic medical record was used to collect demographic data, including age, sex, body mass index, employment status, and smoking status. Additionally, rotator cuff tear size, number of tendons involved, and postoperative clinical outcomes, including reoperations and emergency department visits within 30 days, were collected from the electronic medical record. Tear size was categorized according to the Cofield classification, and tear acuity was not specified. 16 Symptomatic retears were assessed with imaging postoperatively. All patients received a regional nerve block perioperatively. The area deprivation index (ADI) was collected using the University of Wisconsin Neighborhood Atlas. 17 ADI serves as a validated measure of social deprivation, enabling the ranking of consensus block groups in the United States according to socioeconomic disadvantage.18,19 ADI scores range from 0 to 100, with higher scores indicating regions at greater risk of socioeconomic disadvantage, while lower scores denote areas facing fewer socioeconomic challenges. 20
PROMIS Computer Adaptive Testing (CAT) forms were collected for all orthopedic surgery patients at clinic visits via tablet computer. The REDCap (Vanderbilt University, Nashville, TN) platform, a secure, web-based application system, was used to collect and store patient questionnaire scores. PROMIS CAT scores were collected at preoperative, 6-week, 3-month, 6-month, and one-year postoperative follow-up visits. The PROMIS CAT algorithm produces standardized T-scores based on normative United States population data with a mean score of 50 and a standard deviation of 10. Higher PROMIS upper extremity (PROMIS-UE) scores signify enhanced functional ability, whereas higher PROMIS pain interference (PROMIS-PI) scores reflect increased pain that interferes with daily activities. Additionally, higher PROMIS depression (PROMIS-D) scores indicate more severe levels of depression. Multiple studies have determined that PROMIS scores effectively measure RCR pain and functional outcomes.21–23 Minimal clinically important difference (MCID) values for PROMIS-UE, PROMIS-PI, and PROMIS-D were obtained from a previous study by Tramer et al., specifically calculating these values in a rotator cuff repair population using an anchor-based methodology, which is also consistent with previously published orthopedic literature.20,24–26
Preoperative and postoperative opioid usage up to 90 days after surgery was confirmed by reviewing the electronic medical record for opioid requests and cross-referencing them in a statewide controlled substance database. Our institution does not have a set protocol for postoperative pain management, rehab protocols were surgeon-specific, and patients were discharged the same day. The total amount of opioids prescribed was recorded in morphine milligram equivalents (MME). Opioid use was recorded and sorted into two different time frames for preoperative opioid use: 30 days prior to surgery and 31–90 days prior to surgery. Postoperative opioid use was recorded as time of discharge to 30 days, 31–60 days postoperatively, and 61–90 days postoperatively. The time of discharge to the 30-day postoperatively group was further stratified into 0–7, 8–14, and 15–30 days for a sub-analysis.
Statistical analysis
Independent two-sample T-tests were used for continuous variables, represented by means and standard deviations. Pearson chi-square tests were used for categorical data, represented by proportions and percentages. A multiple logistic regression model was used to identify predictors of POU, including age, body mass index, sex, smoking status, tear thickness, tear size, ADI, preoperative PROMIS scores, and timing of opioid refills postoperatively. A post hoc effect size was calculated, which was d = 0.65 for 6-month PROMIS-PI scores.
Statistical significance was set at P < 0.05. Statistics were calculated using IBM SPSS Statistics (Version 29.0, IBM Corp, Armonk, NY).
Results
A total of 318 patients were identified and included in the analysis, with no patients excluded. Of these, 38 (11.9%) patients had POU. The majority underwent double-row repairs (255/318, 80.2%), while 62/318 (19.5%) underwent single-row repairs, and 1/318 (0.3%) had side-to-side repairs. A mean of 3.06 anchors were used during repair. Regarding tear characteristics, 284/318 (89.3%) of patients had full-thickness tears, and 34/318 (10.7%) had partial-thickness tears. Concomitant procedures performed included subacromial decompression in 287/318 (90.3%) of patients, biceps tenodesis in 96/318 (30.2%), biceps tenotomy in 20/318 (6.3%), and distal clavicle excision in 31/318 (9.8%) (Table 1).
Table 1.
Demographics, tear characteristics, and preoperative scores.
| Control (N = 280) % (N) | Prolonged opioid use (N = 38) % (N) | P value | |
|---|---|---|---|
| Age, years (mean ± SD) | 59.0 ± 8.6 | 55.9 ± 8.2 | 0.038* |
| Sex | 0.018* | ||
| Male | 57.1% (160) | 36.8% (14) | |
| Female | 42.9% (120) | 63.2% (24) | |
| Race | 0.244 | ||
| White/Caucasian | 65.4% (183) | 52.6% (20) | |
| Black/African American | 26.4% (74) | 42.1% (16) | |
| Asian | 3.6% (10) | 0% (0) | |
| Other a | 3.2% (9) | 2.6% (1) | |
| Unknown | 1.4% (1) | 2.6% (1) | |
| Body mass index, kg/m2 (mean ± SD) | 30.7 ± 5.8 | 30.4 ± 6.5 | 0.761 |
| Employment | 0.342 | ||
| Employed | 42.5% (119) | 52.6% (20) | |
| Unemployed | 5.4% (15) | 5.3% (2) | |
| Retired | 6.1% (17) | 2.6% (1/) | |
| Other | 20.0% (56) | 7.9% (3) | |
| Unknown | 26.1% (73) | 31.6% (12) | |
| Smoking status | 0.069 | ||
| Never smoker | 58.1% (161) | 42.1% (16) | |
| Former smoker | 35.0% (97) | 42.1% (16) | |
| Current smoker | 6.9% (19) | 15.8% (6) | |
| ADI national percent (mean ± SD) | 54.3 ± 26.7 | 67.0 ± 22.4 | 0.006* |
| Full thickness tear | 87.9% (246) | 81.6% (31) | 0.279 |
| Tear size | 0.019* | ||
| Small | 14.8% (40/270) | 27.0% (10/37) | |
| Medium | 63.3% (171) | 37.8% (14) | |
| Large | 14.4% (39) | 18.9% (7) | |
| Massive | 7.4% (20) | 16.2% (6) | |
| Number of tendons involved | 0.968 | ||
| 1 | 53.9% (151) | 52.6% (20) | |
| 2 | 36.8% (103) | 36.8% (14) | |
| 3 | 9.3% (26) | 10.5% (4) | |
| Last follow-up, months (mean ± SD) | 16.7 ± 17.3 | 13.9 ± 15.8 | 0.316 |
| Preoperative scores (mean ± SD) | |||
| PROMIS-UE | 30.2 ± 6.2 | 27.9 ± 4.6 | 0.008* |
| PROMIS-PI | 62.7 ± 5.3 | 64.1 ± 5.1 | 0.139 |
| PROMIS-D | 47.3 ± 9.1 | 51.6 ± 10.6 | 0.008* |
ADI: area deprivation index; PROMIS: patient-reported outcomes measurement information system; UE: upper extremity; PI: pain interference; SD: standard deviation.
“Other” includes individuals who identify with races not specifically listed above.
* P value with significance (<0.05).
Significantly more patients in the POU cohort had refills within 30 days of surgery (63.2% vs. 31.4%; P < 0.001) compared to the control cohort. The POU group was significantly younger (55.9 ± 8.2 vs. 59.0 ± 8.6 years; P = 0.038) and more likely to be female (63.2% vs. 42.9%; P = 0.018). Average MME postoperatively was 377 (0–600) at discharge, 56.2 (0–675) at 30 days postoperatively, 11.9 ± (0–600) between 31 and 61 days postoperatively, and 7.1 (0–900) from 61 to 90 days postoperatively amongst the 318 patients included in the study. The total mean MME prescribed in the first 30 days was statistically significant between the POU cohort and control group (382.9 [0–600] vs. 139.1 [0–600] MME, P < 0.001). The mean clinical follow-up for the control cohort was 16.7 (0.27–45) months and 13.9 (0.27–58) months for the POU cohort.
The mean ADI national percentile was higher in the POU cohort (67.0 ± 22.4 vs. 54.3 ± 26.7; P = 0.006) compared to the control cohort. There was a significant difference in tear size (P = 0.019), with the POU cohort having more massive tears (16.2% vs. 7.4%) and large tears (18.9% vs. 14.4%). The POU cohort had significantly lower preoperative PROMIS-UE (27.9 ± 4.6 vs. 30.2 ± 6.2; P = 0.008) and higher preoperative PROMIS-D scores (51.6 ± 10.6 vs. 47.3 ± 9.1; P = 0.008) compared to the control group. Additional demographic variables, tear characteristics, and preoperative PROMIS scores are reported in Table 1.
Risk factors
A multiple logistic regression model was used to assess predictors for POU. Patients who had at least one refill within the first 30 days postoperatively were significantly more likely to experience POU (odds ratio [OR]: 4.1, 95% CI: 1.9–8.6, P < 0.001). Within the first month post-op, all 3 time periods (1–7, 8–14, and 15–30 days) were individually significantly associated with POU (OR: 3.85, 95% CI: 1.70–8.72, P = 0.001; OR: 3.92, 95% CI: 1.53–10.16, P = 0.005; OR: 10.66, 95% CI: 2.17–52.38, P = 0.004). There was no statistical difference between any of the 3 time points within 30 days (P = 0.427). The odds of POU decreased (OR: 0.96, 95% CI: 0.92–1.0, P = 0.040) with every year of increasing age. Females had more than twice the odds of POU compared to males (OR: 2.29, 95% CI: 1.14–4.6, P = 0.021). Current smokers also had a higher risk of POU compared to nonsmokers and former smokers (OR: 3.18, 95% CI: 1.11–9.10, P = 0.031) (Table 2). A medium tear size was associated with a significantly decreased risk of POU (OR: 0.32, 95% CI: 0.14–0.79, P = 0.013). Additionally, for every 1% increase in the ADI National Percentage, the odds of POU increased by 1.9% (OR: 1.02, 95% CI: 1.01–1.03, P = 0.007). Preoperative PROMIS-D score was also found to be a significant predictor, with higher PROMIS-D scores indicating an increased likelihood of POU (OR: 1.05, 95% CI: 1.0–1.1, P = 0.036). Preoperative opioid use within 90 days was not statistically significant for prolonged opioid use postoperatively (OR: 1.529, 95% CI: 0.0493–4.741, P = 0.462).
Table 2.
Risk factors for prolonged opioid use using a multinomial logistic regression model.
| Covariate | Level | OR (95% CI) | OR P value |
|---|---|---|---|
| Age | 0.96 (0.922–0.998) | 0.040* | |
| Body mass index | 0.991 (0.935–1.051) | 0.760 | |
| Sex | Female | 2.286 (1.135–4.604) | 0.021* |
| Smoking status | Never | – | – |
| Current | 3.178 (1.110–9.097) | 0.031* | |
| Former | 1.660 (0.794–3.47) | 0.178 | |
| Tear thickness | Full thickness | 0.612 (0.250–1.498) | 0.282 |
| Tear size | Small | – | – |
| Medium | 0.327 (0.136–0.791) | 0.013* | |
| Large | 0.718 (0.248–2.076) | 0.541 | |
| Massive | 1.200 (0.382–3.773) | 0.755 | |
| ADI national percentage | 1.019 (1.005–1.033) | 0.007* | |
| Preoperative PROMIS-UE score | 0.934 (0.860–1.014) | 0.101 | |
| Preoperative PROMIS-PI score | 0.969 (0.886–1.060) | 0.488 | |
| Preoperative PROMIS-D score | 1.045 (1.003–1.088) | 0.036* | |
| Preoperative opioid use within 90 days | 1.529 (.0493–4.741) | 0.462 | |
| Opioid refill within 30 days postoperatively | 4.066 (1.920–8.610) | <0.001* | |
| First postoperative opioid refill within 30 days | None | – | – |
| 1–7 days | 3.85 (1.70–8.72) | 0.001* | |
| 8–14 days | 3.92 (1.53–10.16) | 0.005* | |
| 15–30 days | 10.66 (2.17–52.38) | 0.004* |
ADI: area deprivation index; PROMIS: patient-reported outcomes measurement information system; UE: upper extremity; PI: pain interference; D: depression; OR: odds ratio.
* P value with significance (<0.05).
Postoperative outcomes
The control group had a significantly lower reoperation rate (5.4% [15/280] vs. 15.8% [6/38]; P = 0.015) compared to the POU cohort. Among POU patients, five reoperations were for symptomatic retear, and one was for adhesive capsulitis. Amongst control patients, 14 reoperations were for symptomatic retear, and one was for removal of hardware. No significant differences between symptomatic retear percentage (P = 0.181) and emergency department visits within 90 days of surgery (15 control patients vs. two POU patients; P = 0.981) were found between cohorts (Table 3).
Table 3.
Risk factors and clinical outcomes in prolonged opioid use versus control cohort.
| Control (N = 280) % (N) | Prolonged opioid use (1–3 months) (N = 38) % (N) | P value | |
|---|---|---|---|
| Preoperative opioid use within 90 days | 7.1% (20) | 10.5% (4) | 0.459 |
| Refill within 30 days postoperative | 31.4% (88) | 63.2% (24) | <0.001* |
| Refill within 30–60 days postoperative | 0% (0) | 78.9% (30) | <0.001* |
| Refill within 60–90 days postoperative | 0% (0) | 47.4% (18) | <0.001* |
| Reoperation rate | 5.4% (15) | 15.8% (6) | 0.015* |
| Symptomatic retear rate | 8.9% (25) | 15.8% (6) | 0.181 |
| ED visit within 90 days of surgery | 5.4% (15) | 5.3% (2) | 0.981 |
ED: emergency department.
* P value with significance (<0.05).
Patients in the POU cohort reported significantly higher mean PROMIS-PI scores at 6 weeks (63.46 ± 5.32 vs. 58.99 ± 6.41; P = 0.004), 3 months (61.72 ± 7.23 vs. 56.18 ± 6.67; P < 0.001), and 6 months (58.42 ± 10.56 vs. 52.11 ± 8.69; P = 0.003) postoperative follow-up. The POU cohort had significantly higher PROMIS-UE at the 3-month postoperative visit (34.25 ± 6.52 vs. 29.98 ± 6.89; P = 0.008) but showed no significant difference at the 6-week or 6-month follow-up. No significant difference was demonstrated for mean postoperative PROMIS-D scores at all time points. Mean change in PROMIS-PI was greater in the control group than the POU group at 6 weeks (−3.80 ± 6.25 vs. 0.15 ± 4.27, P = 0.008) and at 3-month follow-up (−6.41 ± 6.83 vs. −2.91 ± 5.47, P = 0.032). No significant differences were obtained for mean change in PROMIS-UE and PROMIS-D difference at any of the follow-up time points (Table 4).
Table 4.
PROMIS outcomes in prolonged opioid use versus control cohort.
| Control mean ± SD | Prolonged opioid use mean ± SD | P value | |
|---|---|---|---|
| Six-weeks follow-up | N = 182 | N = 19 | |
| UE | 28.47 ± 5.57 | 26.46 ± 6.12 | 0.139 |
| PI | 58.99 ± 6.41 | 63.46 ± 5.32 | 0.004* |
| D | 44.50 ± 9.74 | 46.66 ± 11.24 | 0.368 |
| Three-months follow-up | N = 174 | N = 19 | |
| UE | 34.25 ± 6.52 | 29.98 ± 6.89 | 0.008* |
| PI | 56.18 ± 6.67 | 61.72 ± 7.23 | <0.001* |
| D | 44.60 ± 9.80 | 46.15 ± 11.78 | 0.585 |
| Six-months follow-up | N = 160 | N = 20 | |
| UE | 39.31 ± 9.39 | 35.86 ± 11.45 | 0.132 |
| PI | 52.11 ± 8.69 | 58.42 ± 10.56 | 0.003* |
| D | 42.78 ± 8.65 | 45.23 ± 12.74 | 0.263 |
| One-year follow-up | N = 76 | N = 6 | |
| UE | 41.66 ± 9.88 | 33.82 ± 11.86 | 0.093 |
| PI | 51.77 ± 9.07 | 61.8 ± 13.14 | 0.014* |
| D | 42.84 ± 8.74 | 51.08 ± 13.80 | 0.206 |
| Six-weeks follow-up | N = 182 | N = 19 | |
| UE difference | −1.40 ± 6.55 | −2.19 ± 5.39 | 0.611 |
| PI difference | −3.80 ± 6.25 | 0.15 ± 4.27 | 0.008* |
| D difference | −2.81 ± 8.51 | −0.09 ± 10.00 | 0.195 |
| Three-months follow-up | N = 174 | N = 19 | |
| UE difference | 3.60 ± 7.05 | 1.14 ± 6.69 | 0.147 |
| PI difference | −6.41 ± 6.83 | −2.91 ± 5.47 | 0.032* |
| D difference | −2.65 ± 8.60 | −2.89 ± 8.80 | 0.907 |
| Six-months follow-up | N = 160 | N = 20 | |
| UE difference | 9.50 ± 9.79 | 8.15 ± 10.67 | 0.566 |
| PI difference | −10.27 ± 9.00 | −6.17 ± 9.58 | 0.056 |
| D difference | −4.13 ± 9.52 | −6.84 ± 9.62 | 0.232 |
| One-year follow-up | N = 76 | N = 6 | |
| UE difference | 11.89 ± 10.39 | 6.60 ± 11.38 | 0.277 |
| PI difference | −11.37 ± 9.52 | −5.40 ± 10.83 | 0.147 |
| D difference | −5.61 ± 9.19 | −1.07 ± 3.53 | 0.234 |
PROMIS: patient-reported outcomes measurement information system; UE: upper extremity; PI: pain interference; D: depression; SD: standard deviation.
* P value with significance (<0.05).
A total of 82 patients had PROMIS scores available at one-year follow-up, with 6 in the POU group and 76 in the control cohort. At one-year follow-up, the POU cohort reported higher mean PROMIS-PI scores compared to the control cohort (61.8 ± 13.14 vs. 51.77 ± 9.07, P = 0.014). Compared to their preoperative values, no statistical significance was found between groups for the overall change in PROMIS-PI (−11.37 ± 9.52 vs. −5.40 ± 10.83, P = 0.147), PROMIS-UE (11.89 ± 10.39 vs. 6.60 ± 11.38, P = 0.277), and PROMIS-D (−5.61 ± 9.19 vs. −1.07 ± 3.53, P = 0.234) at the one-year follow-up.
The proportion of patients meeting MCID at each postoperative time point is recorded in Table 5. At 6 weeks (26.3% vs. 58.8%; P = 0.007), 3 months (47.4% vs. 74.7%; P = 0.012), and 6 months (50.0% vs. 81%; P = 0.002) postoperatively, significantly fewer patients in the prolonged opioid use cohort achieved MCID for PROMIS-PI scores compared to the control cohort.
Table 5.
Proportion of patients meeting MCID for each PROMIS score at each timepoint.
| PROMIS surveys | Control | Prolonged opioid use | P value |
|---|---|---|---|
| 6 weeks | |||
| PROMIS-UE | 23.5% (42/179) | 10.5% (2/19) | 0.197 |
| PROMIS-PI | 58.8% (107/182) | 26.3% (5/19) | 0.007* |
| PROMIS-D | 38.1% (69/181) | 42.1% (8/19) | 0.734 |
| 3 months | |||
| PROMIS-UE | 54.1% (93/172) | 31.6% (6/19) | 0.063 |
| PROMIS-PI | 74.7% (130/174) | 47.4% (9/19) | 0.012* |
| PROMIS-D | 41.4% (72/174) | 36.8% (7/19) | 0.703 |
| 6 months | |||
| PROMIS-UE | 71.3% (114/160) | 65.0% (13/20) | 0.563 |
| PROMIS-PI | 81.0% (132/163) | 50.0% (10/20) | 0.002* |
| PROMIS-D | 42.2% (68/161) | 60.0% (12/20) | 0.131 |
MCID: minimal clinically important difference; PROMIS: patient-reported outcomes measurement information system; UE: upper extremity; PI: pain interference; D: depression.
MCID calculated using the distribution method with a threshold of 0.5 STD above the mean.
* P value with significance (<0.05).
Discussion
Our study found that younger age, female sex, smoking status, and lower preoperative PROMIS-D were identified as significant risk factors predisposing individuals to extended postoperative opioid consumption after RCR. Interestingly, while preoperative opioid use was not significantly correlated with prolonged postoperative opioid consumption, an opioid refill within the initial 30 days after surgery was a significant predictor of POU. Tear size was minimally correlated with POU, with medium-sized tears demonstrating a lower likelihood of prolonged opioid consumption. We also found POU patients to have significantly worse postoperative PROMIS-PI scores throughout recovery, with less achievement of MCID postoperatively compared to the control cohort.
The demographic-specific trends of our study are consistent with findings reported in other published studies.15,27–30 Previous studies have identified tobacco use as an independent risk factor for POU after elective shoulder surgery.31,32 Rhon et al. 33 identified female gender as associated with higher odds of POU (OR 1.54) in their analysis, and patients of higher socioeconomic status had ∼44% lower odds (OR 0.56) of receiving an opioid prescription one year or later after hip arthroscopic surgery. Day et al. 34 reviewed 55,345 arthroscopic rotator cuff repair cases and found a significantly greater number of opioids were prescribed within 90 days of surgery to younger and female patients (765.1 vs. 725.6 MME for males; P < 0.010). Demographic factors such as younger age, female gender, and socioeconomic indicators have repeatedly emerged as significant determinants of increased opioid use following RCR, as highlighted by the studies referenced.
Our study found ADI to be a significant factor in POU, which has not been formally assessed to our knowledge. Shaikh et al. 35 studied 306 patients who underwent RCR and found that patients with higher ADI scores had significantly worse postoperative forward flexion compared to lower ADI patients (145 ± 32.5 vs. 156 ± 23.4; P = 0.001) and worse odds of reaching MCID for PROMIS physical function (OR: 0.31), pain interference (OR: 0.21), and depression (OR: 0.28); P = 0.001. Similarly, in a retrospective study with 1299 patients undergoing spine surgery, Montgomery et al. 36 found that lower patient income was a risk factor for refilling opioid prescriptions within 3 months post-op (P = 0.01). Given that ADI likely impacts multiple socioeconomic factors, elements such as financial burden, life stress, domestic issues, and psychiatric disorders may also contribute to a higher rate of opioid use.
Our study showed significantly worse preoperative PROMIS-UE and PROMIS-D scores in the prolonged opioid group. Similar results were also shown in previous literature, citing depression and lower American Shoulder and Elbow Surgeons (ASES) scores as prominent risk factors for prolonged opioid usage.32,33,37–39 One study 31 found that patients with psychiatric diagnoses of anxiety and depression were 1.94 times as likely to be filling narcotic prescriptions at 3 months postoperatively. At 6 months postoperatively, those with a psychiatric diagnosis of anxiety or depression were 2.43 times as likely to be filling narcotic prescriptions, with this trend continuing through 12 months postoperatively. Postoperatively, PROMIS-PI scores were worse, with significantly worse achievement of MCID for PROMIS-PI, which was to be expected among a more painful postoperative cohort.
Limitations
Our study is not without limitations. It is important to acknowledge the retrospective design, and therefore, our study is reliant on the accuracy of information recorded in the electronic medical records. We utilized a state opioid database to improve the accuracy of opioid medications prescribed; however, a pain diary may be better suited for monitoring actual patient opioid consumption versus prescription. Additionally, since we utilized multiple surgeons, there is a possibility that provider-specific variation in patient postoperative medication prescriptions impacted our results, which we did not control for. We had a large range of follow-up amongst our cohort, and it's possible that loss to follow-up introduced bias into our study results. We also did not control for demographic or tear characteristics when comparing reoperation and retear rates. Prospective studies that include larger sample sizes and extended follow-up periods could provide more detailed insights into the complex interactions among demographic factors, surgical outcomes, and POU.
Conclusion
Our study found that younger age, female sex, smoking status, and higher ADI scores are significant risk factors associated with prolonged postoperative opioid consumption following RCR. Opioid refills within the first 30 days post-op emerged as a predictor of continued opioid usage postoperatively. Furthermore, our results revealed that patients with retears and subsequently higher reoperation rates could be at risk for POU.
Acknowledgements
None.
Footnotes
Author note: This article is not based on any previous communication with a society or meeting.
Contributorship: MG wrote the first draft of the manuscript. All other authors reviewed and edited the manuscript and approved the final version of the manuscript.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval: Ethical approval for this study was obtained from the Henry Ford Health Institutional Review Board Approval Number 14125.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Informed consent: Written informed consent was obtained from all subjects before the study.
Guarantor: SM
Trial registration: Not applicable because this was a retrospective chart review study.
ORCID iDs: Michael A Gaudiani https://orcid.org/0000-0002-3366-1708
Johnny Kasto https://orcid.org/0009-0000-0339-0428
Jared M Mahylis https://orcid.org/0000-0002-5946-8973
Stephanie J Muh https://orcid.org/0000-0001-6617-4116
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