Change in Postoperative Opioid Prescribing Patterns for Oculoplastic and Orbital Procedures Associated With State Opioid Legislation

Key Points

Question  Is the enactment of statewide legislation, such as the Michigan Opioid Laws, associated with changes in opioid prescribing for oculoplastic and orbital procedures?

Findings  This cross-sectional study including 3781 patients demonstrated a 36.2% reduction in mean total morphine milligram equivalents (MMEs) of opioid prescriptions through the period between June 1, 2017, and September 30, 2018. Changes in MME observed 12 months before or 12 months after this period were not identified.

Meaning  A reduction in opioid prescriptions for oculoplastic and orbital procedures was observed with the enactment of the Michigan Opioid Laws; similar statewide or national legislations may further curtail the prescription opioid epidemic.

Importance  Understanding whether statewide legislation, such as the Michigan Opioid Laws, is associated with reduction in postoperative opioid prescriptions is informative in guiding future legislation.

Objective  To identify changes in opioid prescribing patterns for oculoplastic and orbital procedures associated with the enactment of the Michigan Opioid Laws in 2017 and 2018.

Design, Setting, and Participants  This cross-sectional study included 3781 patients who underwent any of 10 common oculoplastic and orbital procedures between June 1, 2016, and November 30, 2019, at a tertiary care institution.

Exposures  From 2017 to 2018, Michigan enacted a series of laws to address the state’s worsening opioid epidemic. Two major components of this legislation enacted on June 1, 2018, required prescribers to review a report of patients’ opioid use history and obtain signed consent after educating patients on the use and disposal of opioids prior to prescribing.

Main Outcomes and Measures  Demographic information, type of surgery, type and amount of opioid prescriptions, and morphine milligram equivalent (MME) were analyzed. MME was calculated as the product of dose, quantity, and opioid-specific conversion factor for each prescription. Linear interpolation spline regression was used to evaluate the association of prescription MME with time.

Results  Of 3781 patients, 1614 (42.7%) were male. The mean (SD) age at the time of surgery was 63.3 (16.6) years. Of 2026 patients undergoing surgery before June 1, 2018, 1782 (88.0%) were prescribed postoperative opioids; of 1755 patients undergoing surgery after June 1, 2018, 878 (50.0%) were prescribed postoperative opioids (P < .001). There was no difference in age, sex, race/ethnicity, surgery type, or opioids prescribed between these 2 cohorts. Linear interpolation spline regression showed a decrease of 26.025 MMEs (equivalent to a 36.2% reduction of mean MME) between June 1, 2017, and September 30, 2018 (β, −1.735; 95% CI, −0.088 to −0.024; P < .001), stabilizing at a persistently reduced rate of MME prescribed through the end of the study period (October 1, 2018, to November 30, 2019; β, −0.005; 95% CI, −0.039 to 0.016; P = .42). Changes in MME in the 12 months before or 12 months after the period of legislation enactment were not identified.

Conclusions and Relevance  In this cross-sectional study, reduction in opioid prescriptions for oculoplastic and orbital procedures was observed during the enactment period of the Michigan Opioid Laws and appeared to be sustained through the end of the study period. Similar statewide or national legislations aimed at increasing prescriber awareness and patient education on opioid use may help curtail the prescription opioid epidemic.

Opioid-related overdoses resulted in more than 350 000 deaths and accounted for two-thirds of substance-related mortalities in the US between 1999 and 2016.¹ Most people are first exposed to opioids through prescriptions, and prescription opioid overdoses contribute to an increasing rate of opioid-related deaths, which reached an incidence of 21.7 per 100 000 population in 2017.² In 2014, the US Centers for Disease Control and Prevention listed the prescription opioid addiction epidemic as one of its top 5 public health challenges,³ and many states and federal legislatures have since introduced regulations in an effort to curtail the opioid epidemic. In 2017 and 2018, the state of Michigan launched the Michigan Opioid Laws^4,5 to address Michigan’s worsening substance use disorder and drug diversion problem.

Opioids have been found to be overprescribed and underused among various surgical specialties.^6,7 Unused prescriptions for surgical patients can lead to opioid misuse and overdose.¹ Patients can develop opioid dependence after even a short postoperative course of opioids.^8,9 In addition, excessive opioid prescribing can lead to increased drug diversion, further exacerbating opioid-related misuse and mortality. Patel and Sternberg¹⁰ used Medicare prescriber data to show that ophthalmologists prescribe fewer opioids compared with the national mean among all prescribers.¹⁰ However, a 2019 survey study among members of the American Society of Ophthalmic Plastic and Reconstructive Surgery¹¹ showed that postoperative opioids for oculoplastic and orbital procedures were prescribed at a higher rate than for procedures of other ophthalmic subspecialties and than the national mean. Further, recent studies on opioid use in oculoplastic and orbital surgery demonstrated that prescriptions frequently exceeded patients’ needs.^12,13 In this study, we aimed to perform an in-depth examination of opioid prescribing patterns for oculoplastic and orbital procedures and identify changes in prescribing patterns before and after enactment of statewide opioid legislation.

This cross-sectional study was a retrospective review of clinical data of 3781 patients 18 years and older who underwent any of 10 common oculoplastic and orbital procedures as identified by Current Procedural Terminology (CPT) codes at the University of Michigan’s tertiary care institution between June 1, 2016, and November 30, 2019. Clinical data were retrieved from DataDirect¹⁴ (University of Michigan Health System). The study was reviewed by the University of Michigan Institutional Review Board and was determined to be exempt (under policy Exemption 4[iii] at 45 CFR 46.104[d]). The study followed the World Medical Association’s Declaration of Helsinki¹⁵ ethical principles for human subject research.

CPT codes for 10 common oculoplastic and orbital procedures were selected, including brow-lift (code 67900), blepharoptosis repair (code 67904), upper eyelid blepharoplasty (code 15823), canthoplasty (code 67950), ectropion repair (code 67917), entropion repair (code 67924), dacryocystorhinostomy (code 68720), enucleation with orbital implant (code 65105), orbital floor fracture repair (code 21390), and orbitotomy for biopsy or decompression with and without bone flaps (codes 67400, 67414, 67445). Demographic and clinical information were collected, including age at the time of surgery, sex, race/ethnicity, and surgery type. In addition, we collected details on outpatient opioid prescriptions that were ordered for each surgery, including the medication name, dose, quantity, number of refills, and date of prescription. Prescriptions included opioids that were ordered at any time prior to or on the day of surgery (and, where applicable, in the immediate postoperative period). All available opioids were queried, including acetaminophen-hydrocodone, ibuprofen-hydrocodone, tramadol, acetaminophen-tramadol, oxycodone, acetaminophen-oxycodone, aspirin-oxycodone, ibuprofen-oxycodone, hydromorphone, and aspirin-hydromorphone. All prescribers were physician faculty, trainees, or midlevel practitioners at the University of Michigan Medical School. The cohort of prescribers was consistent throughout the study period.

In 2017 and 2018, the state of Michigan enacted a series of opioid laws to address the state’s worsening opioid epidemic.¹⁶ On June 1, 2018, 2 components of this legislation were enacted requiring prescribers, prior to prescribing opioids, to review a report of the patient’s opioid use history and then obtain signed consent from the patient after providing education on safe use and disposal of opioids. These policy changes enabled prescribers and dispensers to track substance use through a centralized electronic database, the Michigan Automated Prescription Program,⁵ and assess patient risk over time.

This study was conducted over a 42-month period from June 1, 2016, to November 30, 2019, around the enactment of the Michigan Opioid Laws in 2017 and 2018. Because the opioid laws were rolled out in multiple phases, we did not confine the analyses to a preimplementation and postimplementation categorical analysis. This time period was selected to provide adequate statistical power to assess changes in opioid prescribing patterns through the entire period of legislation enactment. To our knowledge, no independent institutional policy or guideline changes pertaining to opioid prescribing were concurrently implemented during this time period.

Demographic characteristics and procedure and clinical information were analyzed using descriptive statistics with Stata version 15 (StataCorp). Morphine milligram equivalent (MME) was calculated as the product of dose, quantity, and opioid-specific conversion factor.¹⁷ In contrast to conventional MME calculation, which specifies patient use over 24 hours, we applied the calculation to total quantity prescribed to characterize the amount of opioids initially prescribed by physicians on the day of, prior to, and, when appropriate, immediately after surgery. MME determines the cumulative amount of opioids and allows for comparisons between different medications. Data normality was confirmed by the graphical method, and the independent t test or analysis of variance were used to compare study characteristics. The primary outcome of the study was changes in prescribing patterns of postoperative opioids after enactment of the Michigan Opioid Laws. Linear interpolation spline regression analysis was used to assess the association of prescription MME with time. P values were 2-tailed and not adjusted for multiple comparisons. Significance was set at P < .05.

Of 3781 patients who met inclusion criteria, 1614 (42.7%) were male. The mean (SD) age at the time of at surgery was 63.3 (16.6) years. A total of 2660 (70.4%) were prescribed opioids for postoperative analgesia. Before June 1, 2018, 2026 patients underwent surgery. Of these, 1782 (88.0%) were prescribed postoperative opioids. After June 1, 2018, 1755 patients underwent surgery, and 878 patients (50.0%) were prescribed opioids (88.0% vs 50.0%; P < .001). Demographic information and procedure type are shown in Table 1. There were no differences in age, sex, race/ethnicity, or procedure type between these 2 cohorts.

Characteristics of opioid prescriptions are summarized in Table 2. Of the 2660 patients who received postoperative opioid prescriptions, 2612 (98.2%) had complete pharmacologic information to allow for MME calculation. All prescriptions were sent postoperatively between day 0 and day 18, with most being prescribed on the day of surgery. Although all available opioids were initially queried, we found that only 6 types were prescribed. Acetaminophen-hydrocodone was the most commonly prescribed medication (n = 2279 [87.3%]). The mean (SD) prescription amount was 80.1 (51.4) MMEs for all medications. The highest mean (SD) prescription amount was for acetaminophen-tramadol (337.5 [0] MMEs), followed by hydromorphone (187.0 [123.4] MMEs), oxycodone (175.5 [105.9] MMEs), and acetaminophen-oxycodone (130.3 [77.0] MMEs). The mean (SD) amount of opioids prescribed was higher than the overall mean of 80.1 MMEs for the following procedures: periorbital approach to orbital floor fracture repair (117.1 [61.6] MMEs), enucleation with orbital implant (108.1 [69.6] MMEs), and orbitotomy for decompression with bone flap (91.5 [41.5] MMEs), all 3 of which were orbital procedures. In contrast, soft tissue procedures had a lower mean (SD) amount of opioids prescribed (brow-lift: 73.2 [37.8] MMEs; blepharoptosis repair: 64.7 [30.5] MMEs) (Table 3). No prescribers provided opioid refills in any prescriptions.

Change in MME over time was evaluated using a locally weighted scatterplot smoothing plot (Figure). Based on this, a linear interpolation spline regression analysis was performed. The linear interpolation spline regression demonstrated a statistical rate of change of −1.735 MMEs prescribed per month from June 1, 2017, to September 30, 2018, equivalent to a total decrease of 26.025 MMEs over this 15-month period (β, −1.735; 95% CI,−0.088 to −0.024; P < .001). The interpolation spline regression analysis divided our study period into 3 opioid use cohorts from June 1, 2016, to May 31, 2017; June 1, 2017, to September 30, 2018; and October 1, 2018, to November 30, 2019. The rate of MME prescribed per month appeared to be persistently reduced and sustained through the end of the study period (October 1, 2018, to November 30, 2019: β, −0.005; 95% CI, −0.039 to 0.016; P = .42). On the other hand, linear spline regression analysis did not reveal changes in MME prescribed for the 12 months prior to June 1, 2017 (June 1, 2016, to May 31, 2017: β, −0.005; 95% CI, −0.027 to 0.016; P = .61), nor the 12 months after September 30, 2018 (October 1, 2018, to November 30, 2019: β, −0.005; 95% CI, −0.039 to 0.016; P = .42). Correspondingly, the mean (SD) amount of opioids prescribed decreased from 93.4 (52.9) MMEs for prescriptions sent between June 1, 2016, and May 31, 2017, to 59.6 (44.3) MMEs for prescriptions sent between October 1, 2018, and November 30, 2019, which is equivalent to a 36.2% decrease. MME calculation by surgery type showed a similar pattern of MME decline for each procedure across these 3 sequential periods (eTable in the Supplement).

In 2017, the US Department of Health and Human Services declared the opioid epidemic a public health emergency.¹⁸ Every day, 128 people in the US die of opioid overdose.² Postsurgical opioid prescription, even for a short course, can be associated with conversion to long-term use and dependence.^8,9,19 Ophthalmologists in general prescribe less opioids compared with the national mean among all prescribers.¹⁰ According to recent surveys of ophthalmologists and oculoplastic specialists,^11,20 a significant proportion of the postoperative opioid prescriptions written by ophthalmologists are for oculoplastic and orbital procedures. This is not surprising, as the periorbital and orbital regions contain a dense network of nociceptive receptors, contributing to sensitivity and pain after surgery.²¹ However, clinical details of opioids used in oculoplastic and orbital surgery are lacking.¹²

In this study of 3781 patients at an academic tertiary care center, we examined opioid prescribing patterns before and after the enactment of statewide opioid legislation. We systematically characterized opioid prescribing patterns and detailed the type, amount, and dose information of opioid prescriptions for common oculoplastic and orbital procedures. Our study provides detailed categorization of opioid prescriptions by surgery type. Such information may be helpful for preoperative counseling and informing decision-making on postoperative opioid prescribing. Furthermore, this study provides important and novel insights into opioid prescribing changes associated with statewide opioid legislations that aim to ensure both prescriber awareness of patient opioid use history as well as patient education regarding the potential risks of opioid misuse.

Our findings demonstrate that opioids were prescribed for most oculoplastic and orbital procedures, with higher MME prescribed for orbital procedures (Table 3). Although opioid doses were similar across surgery types, there were variations in the MME prescribed. We did not observe differences in the demographic makeup or procedure types of the cohorts before and after June 1, 2018. Throughout the 2-year enactment period of the laws, we observed a steady decline in opioid prescriptions, as measured by the calculated MME change per month. This likely reflected prescribers’ growing awareness of the evolving opioid epidemic in Michigan and of the Michigan Opioid Laws. Consequentially, prescribers began to adjust their opioid practice patterns during this period, both in anticipation of and in response to the enactment of various components of the state legislation. Importantly, prior to enactment of the Michigan Opioid Laws, we observed that opioid prescribing was at a high but stable rate, suggesting that the subsequent reduction observed during the period of legislation enactment was independent of changes in national trends (Figure). Finally, the reduction in opioid prescription for oculoplastic and orbital procedures appeared to be sustained after the legislation enactment through the end of the study period.

Our study had limitations. First, our data were obtained from a single tertiary care academic institution. While findings may not be generalizable to all practices, this setting allowed us to present the largest series to date studying opioid prescribing patterns in oculoplastic and orbital procedures. Second, while we found a change in opioid prescribing around the period of legislation enactment, these findings do not imply causality. It is conceivable that general increased prescriber awareness of the national opioid crisis played a role in influencing prescribing patterns. Nevertheless, our data show that prescribing patterns were stable for 12 months prior to and after the period of legislation enactment. In addition, aside from the state legislation, no concurrent institutional policies or guideline changes pertaining to opioid prescribing were implemented during the study period. Future case-control studies involving states that have not implemented similar opioid legislations can be conducted to compare differences in prescriber perception and prescribing patterns. Third, opioid prescription data were collected from our electronic medical record system. Patients obtaining opioid prescriptions through means outside of our institution would not have been captured in the data. Furthermore, while no prescribers included refills in their prescriptions, patient-initiated refill requests, patient-reported opioid use, and effectiveness of opioids for pain control were not surveyed. Nevertheless, prior studies demonstrated that while evidence- and guideline-based prescribing led to a reduction in the amount of opioids prescribed, it did not result in increased refill requests.^7,20,22,23 Future studies should assess the adequacy of pain relief and use of nonnarcotic medications as well as further investigate the effect of statewide opioid legislation on the risk of opioid misuse and opioid-related morbidity and mortality.

In summary, enactment of the landmark Michigan Opioid Laws was associated with sustained reduction in postoperative opioid prescriptions for oculoplastic and orbital surgery. Increasing awareness, communication, and education for both prescribers and patients regarding postoperative opioid use and the potential for abuse and diversion are promising tools to prevent opioid overprescription. Enactment of legislations similar to the Michigan Opioid Laws across other states or at a national level may help to further combat the national prescription opioid epidemic.

Accepted for Publication: October 17, 2020.

Published Online: December 10, 2020. doi:10.1001/jamaophthalmol.2020.5446

Correction: This article was corrected on February 17, 2021, to fix the transposition of data for brow-lift and blepharoptosis repair in the second-to-last sentence of the second paragraph of the Results section.

Corresponding Author: Shannon S. Joseph, MD, MSc, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, 1000 Wall St, Ann Arbor, MI 48105-1912 (sjshan@med.umich.edu).

Author Contributions: Drs Xie and S. Joseph had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Xie, A. Joseph, Rudy, Elner, S. Joseph.

Acquisition, analysis, or interpretation of data: Xie, A. Joseph, Rudy, Demirci, Kim, Nelson, S. Joseph.

Drafting of the manuscript: Xie, A. Joseph, S. Joseph.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Xie, A. Joseph, S. Joseph.

Administrative, technical, or material support: Xie, Rudy, Elner, Demirci, S. Joseph.

Supervision: A. Joseph, Kim, Nelson, S. Joseph.

Conflict of Interest Disclosures: Dr Demirci reported support for serving on the advisory boards of Castle Bioscience and Immunocore outside the submitted work. No other disclosures were reported.