Pre-operative narcotic use is associated with worse outcomes following primary anatomic and reverse shoulder...

Pre-operative narcotic use is common among patients undergoing shoulder arthroplasty and has been associated with worse baseline function and higher pain. However, its effect on long-term post-operative outcomes and ongoing narcotic use after anatomic and reverse total shoulder arthroplasty remains unclear. The purpose of this study was to evaluate the impact of pre-operative narcotic use on post-operative pain, function, and narcotic persistence following primary shoulder arthroplasty.

A retrospective review of a single institution's shoulder and elbow surgery repository identified patients who underwent primary anatomic total shoulder arthroplasty or reverse shoulder arthroplasty by a single fellowship-trained surgeon from 2006 to 2023 with a minimum of 2-year follow-up. Patients were categorized based on their response to the pre-operative questionnaire item, "Do you take narcotic pain medication (codeine or stronger)?" Patient demographics, comorbidities, complications, and patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES], Simple Shoulder Test, Single Assessment Numeric Evaluation [SANE], visual analog scale pain) were collected pre-operatively and at most recent follow-up (minimum 2-year follow-up). Outcomes and changes in patient-reported outcome measure scores were compared between pre-operative narcotic users and non-users.

A total of 1,689 primary shoulder arthroplasty patients met inclusion criteria with a median follow-up of 53 months (range 22-192 months). Of those, 389 (23%) reported pre-operative narcotic use. Narcotic users were more often female (58.9% vs. 48.3%, P = .002) and had higher rates of thyroid disease (P = .004), osteoporosis (P = .005), and diabetes (P = .025). Both groups demonstrated substantial improvement after surgery; however, post-operative ASES (71.0 vs. 82.2), Simple Shoulder Test (7.75 vs. 9.07), SANE (72.6 vs. 80.2), and visual analog scale pain (2.40 vs. 1.41) were significantly worse among narcotic users (all P < .001). Improvement from baseline patient-reported outcome measures was similar between groups except for greater improvement in ASES function and SANE among non-users. Persistent narcotic use at most-recent follow-up was higher in pre-operative users (31.9% vs. 4.8%, P < .001). Multivariable regression analysis noted pre-operative narcotic use is an independent predictor of worse post-operative outcome scores.

Patients using narcotics pre-operatively experience meaningful improvement after shoulder arthroplasty but achieve inferior post-operative outcomes and are significantly more likely to continue narcotics long term. These findings reinforce the need for counseling and opioid-sparing strategies in patients undergoing anatomic total shoulder arthroplasty or reverse shoulder arthroplasty.