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    What Do Surgeons Need to Know About Pain Management After Shoulder Surgery?

    Dr. Vani Sabesan answers ICJR’s questions about multimodal pain management following shoulder procedures, the role of patient education, and how state laws are changing opioid prescribing habits.

    ICJR: You’ve done a lot of research on pain management following shoulder procedures, particularly in shoulder arthroplasty and arthroscopic rotator cuff repair. What do surgeons need to know that they may not know now? 

    Vani J. Sabesan, MD: Education is key. Whether it’s a video, discharge paperwork, or in-person discussions with your patients, the more you communicate with them about the risks of opioids, alternate pain management options, and expectations postoperatively, the better they do. These discussions can significantly impact patient satisfaction, reduce or eliminate opioid use, and facilitate good outcomes. 

    Surgeons also need to realize that the less they prescribe, the less apt patients are to take all their opioids, which can result in less chronic use and dependence. I usually prescribe anywhere from 8 to 21 opioid pills after shoulder surgery, but only for breakthrough pain. Typically 12 pills – or 3 days’ worth – is enough, but on average, my patients take only 2 to 4 opioid pills after surgery.

    In a study we published last year, we evaluated a patient-engagement model and a non-opioid multimodal pain management protocol, with opioids prescribed for breakthrough pain, in shoulder arthroplasty patients. [1] We found that only 24% of these patients had taken any opioids for breakthrough pain in the first 48 hours after surgery and that all had stopped taking opioids by 2 weeks after surgery. Comparatively, all patients in the control group took opioids in the first 48 hours and 80% of them were still taking the opioids 2 weeks after surgery.

    Patients in both groups had good outcomes and were satisfied with their procedure, demonstrating that it is possible to reduce opioid use in shoulder arthroplasty patients if we take the time to educate them about pain and pain management.

    ICJR: What protocol do you follow for managing pain in shoulder arthroplasty patients? How about for arthroscopic rotator cuff repair – is it different or basically the same?

    Dr. Sabesan: Our pain management protocol integrates a number of practices, including: [1]

    Preoperative Analgesics/Anesthetics

    • Gabapentin
    • Acetaminophen
    • Ultrasound guided interscalene block with 0.5% ropivacaine

    Intraoperative Analgesics/Anesthetics

    • Intravenous dexamethasone and ketorolac, unless the patient has contraindications
    • Local infiltration of liposomal bupivacaine at incision closure, unless the patient has contraindications

    Postoperative/Discharge Analgesics

    • Ketorolac for 48 hours
    • Acetaminophen for 48 hours
    • Ibuprofen and acetaminophen after 48 hours as needed and if not contraindicated
    • Oxycodone with acetaminophen for breakthrough pain

    Preoperative/Postoperative Patient Education

    • Counseling and handouts on pain expectations after surgery and prescription and over-the-counter alternatives to opioids
    • A brief educational video
    • Discharge instructions that included information on the opioid crisis, alternatives to opioids for pain management, and a detailed pain management plan

    Postoperative physical therapy as ordered by the surgeon

    This algorithm does not significantly change based on the type of shoulder surgery, and given our research, does not change much based on comorbidities except for patients who have sustained a fracture or who are on chronic opioids preoperatively. In addition, patients with smaller upper extremity surgeries receive fewer opioids for breakthrough pain.

    ICJR: Multimodal pain management protocols often include NSAIDs to reduce opioid usage, but there are concerns about delayed healing with NSAID use. What does the latest research show about healing in shoulder surgery patients who take NSAIDs perioperatively?

    Dr. Sabesan: There is limited focused clinical literature on the direct impact of NSAIDs and healing in shoulder surgery, especially rotator cuff surgery. Some basic science literature has demonstrated negative impact for soft tissue healing; however, recent literature with a clinical focus (including the 2021 Neer Award-winning paper by Tangtiphaiboontana et al, which has not yet been published) has not reported these negative effects. [2]

    More research needs to be done to truly understand the impact of NSAIDs on healing for specific shoulder surgeries. However, short-term use to manage acute postoperative pain and use of alternate non-narcotic pain management options can be safe and not negatively impact outcomes and recovery. The rule of thumb is if you educate your patient and share the decision with them, patients minimize their opioid consumption on their own. They learn that alternative non-narcotic pain medications can be equally as effective. Less is more.

    ICJR: Do you get pushback from patients who think they need more opioids at discharge? Is preoperative counseling about pain the answer?

    Dr. Sabesan: No, we don’t get any push back. And yes, preoperative counseling is key. Our protocol incorporates more of a team approach or collective decision-making with the patient. We have a frank discussion about postoperative pain and our multimodal approach to pain management and then ask the patient, based on what we’ve just discussed, what they think is a reasonable number of opioid pills to prescribe. We also prescribe specific non-opioid medications for pain control, as mentioned above.

    ICJR: What role do state laws – in your case, Florida – play in prescribing opioids to manage pain in postoperative shoulder surgery patients?

    They have a significant impact: They force physicians and patients to accept limits on postoperative opioid prescriptions and amounts while also removing any possible complaint that the physician is “withholding” care or treatment.

    Florida’s law limiting opioid prescriptions – one the of the most restrictive in the country – was implemented on July 1, 2018. We can prescribe only a 3-day supply of Schedule II opioids for acute pain management, although we can extend it to a 7-day supply if we can document an exception to the 3-day limit. [3]

    It seems to be working: A study from the University of Florida showed that as expected, the average opioid prescription for acute pain decreased from a 5.4-day supply before the law was enacted to 3 days after it was enacted. [4,5] What was unexpected was a 16% decrease in new opioid users in the month immediately after the law was enacted, with decreases continuing in subsequent months. And there was an immediate decrease in prescriptions for hydrocodone, which had previously been the most commonly prescribed Schedule II opioid. [4,5]

    ICJR: Do residents and fellows receive adequate training on principles of pain management, particularly on the use of opioids following shoulder procedures? Has the opioid epidemic changed that, or are there still gaps in their knowledge? How can those gaps be closed?

    Dr. Sabesan: Residents and fellows learn from their attendings or mentors, so we as surgeons need to take the lead. And I think we are doing better in this area. In addition, given emphasis on legislation and restrictions around opioid prescription in most states, residents and fellows are generally more aware of issues with opioid use and misuse postoperatively. 

    This will help us positively impact the opioid epidemic over time, but we need to stay diligent and consistent with our efforts as orthopaedic surgeons. Continued patient and provider education will close the gaps in knowledge and practice. Establishing best practices in this area sets the bar for all of us. 

    Author Information

    Vani J. Sabesan, MD, is a shoulder and elbow surgeon with Atlantis Orthopaedics, Lake Worth, Florida.

    Disclosures: Dr. Sabesan has no disclosures relevant to this article.

    References

    1. Sabesan VJ, Chatha K, Koen S, Dawoud M, Gilot G. Innovative patient education and pain management protocols to achieve opioid-free shoulder arthroplasty. JSES Int . 2020 May 4;4(2):362-365. doi: 10.1016/j.jseint.2020.01.005. eCollection 2020 Jun.
    2. Lim JW-A, Liow MH, Tan AHC. Post-operative non-steroidal anti-inflammatory drugs do not affect clinical outcomes of rotator cuff repair. J Orthop. 2019 Jun 5;17:113-115. doi: 10.1016/j.jor.2019.06.009. eCollection Jan-Feb 2020.
    3. Florida State Senate. Florida statutes § 456.44(1). Regulation of professions and occupations: health professions and occupations, general provisions—controlled substance prescribing. Published July 1, 2018. Accessed online February 3, 2021.
    4. Hincapie-Castillo JM, Goodin A, Possinger M-C, Usmani SA, Vouri SM. Changes in opioid use after Florida’s restriction law for acute pain prescriptions. JAMA Netw Open. 2020.
    5. Hincapie-Castillo JM, Easey T, Hernandez C, et al. Changes in quantity of opioids dispensed following Florida’s restriction law for acute pain prescriptions. Pain Med. 2021 Jan 27:pnab017. doi: 10.1093/pm/pnab017. Online ahead of print.