Opioid requirement after rotator cuff repair is low with a multimodal approach to pain

Abstract

Background: Current practices may aim to blunt rather than understand postoperative pain. Perhaps the most common serious complication of arthroscopic rotator cuff repair (ARCR) is persistence of opiate medication intake. Patients still receive upwards of 80 oxycodone 5 mg pills, or 600 morphine milligram equivalents (MMEs), leading more than 20% of opioid-naïve subjects to continue to fill opioid prescriptions beyond 180 days after surgery. Developing evidence-based guidelines for narcotic prescription after ARCR presents an opportunity for orthopedic surgeons to address the opioid epidemic.

Purpose: The purpose of this study was (1) to prospectively determine the requirements for opiate medications after ARCR, and (2) to create an evidence-based guideline for postoperative prescription, in contrast to the anecdotal or expert panel recommendations that currently exist. We further investigated whether a liposomal bupivacaine (LB) interscalene never block (ISNB) would reduce pain and opiate consumption compared with standard bupivacaine ISNB (control) for ARCR.

Methods: The study enrolled 100 patients who underwent primary ARCR surgery. Patients were provided with postoperative "pain journals" to document their daily pain on a numerical rating scale, satisfaction with pain management using the Likert scale, and track their daily oxycodone 5 mg pill consumption during the 14-day postoperative period. Enrolled patients were further randomized to receiving an LB (experimental) or standard bupivacaine (control) ISNB.

Results: A total of 77% of all patients required fewer than 15 pills postoperatively. The LB group consumed an average of 1.7 fewer pills (13.0 MMEs) on postoperative day (POD) 1 (P = .02) and reported statistically lower pain during PODs 1 and 2 (P = .01 and P = .006), as well as cumulatively throughout the study period (P = .03). In addition, LB patients remained opioid-free at a higher rate (44% vs. 15% in controls, P = .03).

Conclusion: With a multimodal approach, the majority of patients undergoing ARCR can manage postoperative pain with 15 or fewer oxycodone 5 mg tablets (112.5 MMEs) and maintain a high degree of satisfaction. The addition of an LB ISNB may further reduce the consumption of postoperative narcotics compared with a standard ISNB. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after ARCR.

Keywords: Narcotics; bupivacaine; cuff; liposomal; pain; reduction; repair; rotator.