Following trends by geographic variation in practice patterns, perceptions toward opioids, and patient population
This article was reviewed by Yoshihiro Yonekawa, MD
With the ongoing opioid epidemic becoming a serious public health issue nationwide, Yoshihiro Yonekawa, MD, Wills Eye Hospital, wanted to know to what effect retina specialists contribute. During the 2020 American Society of Retina Specialist (ASRS) virtual annual meeting, Yonekawa calculated the mean number of opioid prescriptions written annually, finding male ASRS members and those who practice in Southern U.S. states prescribe more opioids than ASRS members in other areas of the country. The group also found that, as a whole, ASRS members prescribe opioids at a lower rate than the national mean of all prescribers (3% versus 6.8%, respectively).
In 2018, opioids were involved in 70% of all drug overdose deaths in the United States.1 Of these, 32% were from prescriptions.2 Although the overall opioid prescribing rate in the United States has been declining since 2012, the amount of opioids prescribed per person is currently 3 times higher than it was in 1999.3
“We wanted to know: Are retina surgeons contributing to the opioid addiction and overdose crisis through their prescribing patterns? And, if so, how are retina specialists trending over time?” Yonekawa said. Jonathan Prenner, MD, Rutgers Robert Wood Johnson Medical School, noted during the discussion that retinal specialists “feel a little isolated from the opioid epidemic, given the closed ecosystem that we live in.”
In 2020, however, “as we all painfully know, the world is experiencing the coronavirus pandemic, and the smaller epidemics within it may be getting worse because of the viral public health crisis,” Yonekawa said. “The opioid epidemic was already a national issue, and the current pandemic may be making things worse. Post-procedural opioid prescription does play a role in this.”
Study design and results
Using the 2013-2016 Medicare Part D prescriber database, Yonekawa et al evaluated the opioid prescription patterns of 1,815 ASRS members by dividing the U.S. census regions into four sections—Northeast, Midwest, South, and West. They then mapped the geographic variation in prescribing patterns. Finally, the group performed a regression analysis to identify risk factors associated with a higher number of opioid prescriptions.
There are substantially more men than women in the overall prescription patterns identified: 87% were men and 13% were women (although this does not necessarily represent the percentages of opioid prescribers, Yonekawa said). The majority of practices were located in the South (37%). Between 2013 and 2016, ASRS members wrote nearly a million opioid prescriptions (918,076). In 2016 alone, ASRS members wrote 15,610 prescriptions with 70% writing at least one. On average, ASRS members wrote 11 opioid prescriptions a year.
“About two-thirds of us wrote for 1 to 10 opioid prescriptions, a quarter wrote 11 to 50 opioid prescriptions, and 6% wrote for more than 50,” Yonekawa said. “This 6% accounted for 31% of the total number of opioid prescriptions.”
The total number of opioid prescriptions written by ASRS members did trend downward over time, with an 18% decrease between 2013 and 2016. The highest number of prescriptions were written in Wisconsin, Tennessee, Texas, Oklahoma, Louisiana, Idaho, and South Dakota.
“Physicians in the South were more likely to prescribe more opioids, and this is a trend seen in other fields also,” Yonekawa said. “We’re not sure why, but it might be different practice patterns, perceptions toward opioids, and patient population.”
Although the researchers found that ASRS members wrote fewer opioid prescriptions than the national mean, they recommend retina specialists reconsider their prescribing habits given the high risk of addiction.
Prenner said the percentage of ASRS members who prescribed opioids “was higher than I would have expected. What factors did you find meaningful in terms of influencing prescribing patterns?” First, Yonekawa said, is that database is comprised of Medicare recipients, “so younger patients are not fully accounted for, which means the actual numbers are likely much higher.”
Southern-based retina physicians prescribe more opioids, but that is not unique as other specialties have similar breakdowns, he said.
“We’re not sure why that is,” Yonekawa said, but it may have to do with geographic practice patterns overall. In his own practice, he has stopped the use of opioids altogether. For scleral buckling, which tends to be more uncomfortable than vitrectomy procedures, “we do a sub-Tenon's block at the start or end of the case. Otherwise, we use over the counter medication if necessary, Tylenol if it’s not contraindicated, and we tell patients to cycle it with nonsteroidal anti-inflammatory drugs (NSAIDs) as needed.”
For patients already on chronic pain medications, he said, those patients are usually in close contact with their pain specialists.
“We communicate with the pain specialist and have them prescribe what they think is best so that they can monitor them closely, because we're not pain experts,” Yonekawa said.