Eyeworld

20 February 2018 EW NEWS & OPINION Research highlight by Vanessa Caceres EyeWorld Contributing Writer take that at face value, but patients may not want to write their personal information on that form. Many times, people underreport what they're taking and the amount." As you review a patient's medications in a face-to-face setting, ask them about alcohol, opioid, and drug use. 3. Consider medication adherence problems if a patient is using opi- oids. It may not happen with every- one, but it is a possibility. "Opioids make people tired and forgetful. They don't think as clearly, and they could forget or sleep through a dose of medication," Dr. Riba said. That could be troublesome for a patient with a chronic condition like glau- coma. Consider enlisting the help of a trusted family member or friend who makes sure the patient stays on track with important medication use. 4. Talk to the prescribing doctor if you think opioids are causing seri- ous or long-term eye problems. See if an alternative is available. Also, if you're unsure whether an opioid prescription is appropriate, consult with a colleague in pharmacy or pain management, Dr. Riba advised. They are well versed in this area. EW References 1. Patel S, et al. Association between opioid prescribing patterns and abuse in ophthalmol- ogy. JAMA Ophthalmol. 2017;135:1216–1220. 2. Dieckmann G, et al. Neurotrophic corneal pain: Approaches for management. Ophthal- mology. 2017;124:S34–S47. 3. Gomes JAP, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15:511–538. Editors' note: The physicians have no financial interests related to their comments. Contact information Galor: agalor@med.miami.edu Patel: shriji.patel@vanderbilt.edu Riba: mriba@umich.edu side effects from medications like opioids. Eye side effects In addition to the bigger picture addiction issue and systemic side ef- fects, ophthalmologists must consid- er the side effects that opioids could have on the eye. These can include miosis, which could cause problems with night vision. "There are more risks for problems when driving. That has to be factored in, especially as people get older," said Michelle Riba, MD, professor, Department of Psychiatry, University of Michigan, and associate director, University of Michigan Depression Center, Ann Arbor. Eye movement issues such as nystagmus and strabismus can oc- cur, Dr. Patel said. The effects usually reverse after opioid use is halted. Opioids have also been linked to dry eye, according to a report from the Tear Film & Ocular Surface Society Dry Eye Workshop II. 3 Plus, opioids could negatively affect patients with acute angle glau- coma, Dr. Riba said. Pearls to monitor opioid use, prescribing Ophthalmologists can make a few tweaks to monitor their own pre- scribing of opioids and patient usage as prescribed by other physicians. 1. Review your prescribing pat- terns. There's now an awareness in Dr. Patel's department about phy- sician opioid prescribing patterns; such an awareness of prescribing patterns could help other practices, he thinks. Make sure you're pre- scribing only when they are truly needed. You should also analyze the length of time you're prescribing opioids, Dr. Riba added. 2. Ask patients about opioid use. "A lot of times, patients do a self-report by filling out forms in the waiting room," Dr. Riba said. "We outliers may have valid reasons [for prescribing more]." When opioids are used One reason why ophthalmologists may occasionally prescribe opioids is for post-surgical pain, Dr. Patel said. Some research has found a link between opioid prescriptions written within 7 days of ambulatory surgery such as cataract surgery and the ten- dency to become a long-term opioid user, according to the study. However, ophthalmologists have a number of other treatments to try before resorting to opioids, Dr. Patel said. Plus, pain after cataract surgery is usually minimal, so opi- oids would rarely be needed. How- ever, pain may be a greater concern after other types of ocular surgery, he added. Although some ophthalmolo- gists may consider opioids for neuro- trophic corneal pain—a recent study listed an opioid antagonist and opiate analgesics as a second line treatment for this 2 —Anat Galor, MD, associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, University of Miami, isn't convinced that opioids should be an option in that situation. "I stay away from them," she said. There are the addiction dangers commonly discussed nowadays, and opioids, when used properly, are used for a short time. In contrast, neurotrophic corneal pain tends to be chronic, requiring other medication and non-medication solutions. Dr. Galor will more commonly use medica- tions such as gabapentin for chronic ocular pain. She does see a possible use for opioids related to surgery, such as orbital procedures. Dr. Galor also finds the pendu- lum swing in opioid use intriguing. "In medical school, we were taught to have zero tolerance for patient pain. Now, the thinking is that may- be a little pain is OK. There's been a swing in what's acceptable," she said. A small amount of pain may be tolerable if patients avoid the major Vigilance still required to monitor for overuse, eye effects T here may be an opioid epidemic right now, but ophthalmologists are not adding to the problem. Nearly 90% of ophthal- mologists wrote 10 opioid prescrip- tions or fewer annually, 1 according to a study published in JAMA Oph- thalmology and coauthored by Shriji Patel, MD, Vanderbilt Eye Institute, Nashville, Tennessee. "Overall, ophthalmologists are quite responsible about prescribing opioids," Dr. Patel said. Dr. Patel and coauthor Paul Sternberg Jr., MD, Vanderbilt Eye Institute, analyzed Medicare Part D prescriber data between 2013 and 2015 and tracked prescribing patterns for opioid drugs, including number of prescriptions written, refills, length of prescription supply, and prescriber rates among partici- pating ophthalmologists. The mean number of opioid prescriptions written was seven each year, with an average supply of 5 days. Only 1% of ophthalmologists wrote more than 100 opioid pre- scriptions annually. The largest numbers of opioid prescriptions written by ophthal- mologists were in the states of Arkansas, Alabama, Georgia, Okla- homa, Tennessee, and Texas. This matches the overall opioid prescrib- ing patterns, which are higher in the south, Dr. Patel said. The states with the lowest num- bers of opioid prescriptions written by ophthalmologists were Alaska, Iowa, North Dakota, South Dakota, and Wyoming. Opioids make up about 8% of prescriptions written by ophthal- mologists; however, when account- ing for outliers, the median number compared with total prescriptions was 4%, the study reported. "Overall, the majority pre- scribe well," Dr. Patel said. "The few Study shows ophthalmologists are responsible with opioid prescriptions

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