Jeremiah P. Tao, MD, FACS and Sanja G. Cypen, MD

Curtailing overprescription is one part of combating the opioid crisis. Among ophthalmologists, oculoplastic surgeons may prescribe opioids at the highest rate. This pattern is attributed to more invasive orbitofacial interventions and cosmetic surgery in which patient satisfaction is often inversely correlated to pain. Quality improvement opportunities exist in opioid prescribing among oculoplastic surgeons.

Sanja G. Cypen

Xie and colleagues described opioid prescribing patterns at an academic oculoplastic surgery practice surrounding the enactment of Michigan opioid laws. These laws, aimed at the state’s worsening opioid epidemic, require prescribers to review a patient’s opioid history in a database and obtain signed informed consent after providing education on the safe use and disposal of opioids. The authors found 50% of oculoplastic surgical patients were prescribed opioids after the laws were enacted compared with 88% before them. They also report a reduction in mean morphine milligram equivalents (MME) prescribed that appears to be a function of more patients receiving none.

Ostensibly, these data validate the legislation. Yet, as the authors indicate, they report association not causation for a change in opioid prescribing at only one institution. The study was not controlled for already increasing opioid prescribing stewardship due to elevated awareness of the opioid crisis during the study period. Furthermore, one conclusion might be plainly that doctors, by human nature, are averse to added time and paperwork. To be hypercritical, the legislation could cause many prescriptions to be omitted for dubious reasons.

There remain important indications for opioids. Besides mitigating postoperative pain, they may improve hemodynamic stability and decrease risk for hemorrhagic complications. The proportions of patients receiving postoperative opioid prescriptions and mean MMEs may need greater context. Other meaningful outcomes are pain scores, actual opioid needs and consumption, complications, and, at the end of the day, opioid misuse and mishandling.

Regulation of opioid prescriptions is sensible because these drugs continue to ruin lives and communities. In particular, tracking systems forestall redundant dispensing, doctor shopping and abuse. While patient education surrounding any prescription is expected of doctors, pharmacists and an entire care team alike, a formal law adding administrative burden to prescribers may be draconian.

Xie and colleagues should be commended for drawing attention to the continuing opioid epidemic. Their data are thought-provoking, but greater context is needed before concluding that the Michigan opioid laws are a bellwether. Decisions surrounding opioid prescriptions are multifaceted and complex. Transparency on what opioids a patient has already been prescribed is important. Non-opioid analgesic alternatives should be considered, when appropriate. Understanding opioid needs or lack thereof after specific types of surgeries may be key surrounding perioperative prescriptions. Lastly and broadly, pain and patient satisfaction should be dissociated as major determinants of quality of care. Measures that address these would meaningfully improve the opioid crisis and would be just what the doctor ordered.

References:

Charlson ES, et al. Ophthalmic Plast Reconstr Surg. 2019;doi:10.1097/IOP.0000000000001266.

Wladis EJ, et al. Ophthalmic Plast Reconstr Surg. 2020;doi:10.1097/IOP.0000000000001484.