Narcotic requirements after shoulder arthroplasty are low using a multimodal approach to pain

BACKGROUND: Recent “multimodal” approaches to pain, although understudied, have shown promise in reducing reliance on narcotics in shoulder arthroplasty (SA). Many surgeons report being unsure of how many narcotic pills to prescribe after the surgery. As result, patients are prescribed upwards of 60 oxycodone 5-mg pills for a 6-to-12-week treatment period despite studies showing postoperative pain can be managed without any medication at all. PURPOSE: The purpose of this multicenter study was to prospectively determine the number of opiate pills required after SA to develop generalizable, evidence-based prescription guidelines for surgeons. We hypothesized that opioid prescription would be low using a multimodal approach to pain management. METHODS: The study enrolled 63 patients undergoing SA. Subjects received either an interscalene nerve block with liposomal bupivacaine, standard bupivacaine, or a local infiltration standard bupivacaine field block based on preference. All subjects were provided with postoperative “Pain Journals” to document their daily pain on a Numerical Rating Scale and daily opioid consumption during the 14-day postoperative period. RESULTS: Overall, patients consumed an average of 8.6 oxycodone 5-mg pills (64.5 morphine milligram equivalents) after SA. Seventy-nine percent of patients required 15 or fewer oxycodone 5-mg pills, and 27% successfully managed their postoperative pain with zero opioids. Average pain remained low for patients in all groups. CONCLUSION: With a multimodal approach, most patients undergoing SA can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets, or 112.5 morphine milligram equivalents. The addition of a liposomal bupivacaine interscalene nerve block may further reduce the consumption of postoperative narcotics compared with a standard interscalene nerve block. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after SA.