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August 29, 2018

'Your patient died from an overdose': Is this the way to rein in overprescribing?

Daily Briefing

    Informing doctors when one of their patients dies of a prescription overdose could change providers' prescribing patterns and serve as a low-cost way to combat the opioid epidemic, according to a study recently published in Science.

    Your top resources for combatting the opioid epidemic in one place

    Study details

    For the study, researchers in San Diego County identified 170 patients whose primary or contributory cause of death was a prescription drug overdose. They then used California's prescription drug monitoring program, called the Controlled Substance Utilization Review and Evaluation System, to identify the 861 doctors, dentists, and other medical professionals who had prescribed opioids to the deceased individuals, and sent half of the providers a letter from the county's chief deputy medical examiner informing them about their patients' deaths.

    The letter read, "This is a courtesy communication to inform you that your patient, [name, date of birth] died on [date]. Prescription drug overdose was either the primary cause of death, or contributed to the death."

    The letter also included recommendations for safer opioid prescribing, including avoiding prescribing both opioids and benzodiazepines to patients.

    Jason Doctor, lead author on the study and an associate professor of health policy and management at the University of Southern California, said the researchers did not want the letter to be seen as a punishment. "We just wanted to make them aware of the death," he said.


    The researchers found physicians who received the letters reduced their combined opioid prescribing rate by nearly 10% over the course of the three-month study, from an average of 72.5 morphine milligram equivalents (MMEs) a day to 65.7 MMEs. In comparison, the opioid prescribing rate remained largely the same among the 438 physicians who did not receive the letters.

    Physicians who received the letters also started 7% fewer patients on an opioid regimen and were between 3% and 4.5% less likely to write prescriptions for the highest doses of opioids, the researchers found.

    Some experts tout the study as a way to curb opioid prescriptions

    Doctor said the findings show "that you can do very simple things to change prescribing and make prescribing safer." As it stands, Doctor said, clinicians are "getting biased information. They are only seeing patients that are coming back alive to their clinic, not those who die and never return. A lot of times, they never learn about a patient's death."

    That's why the letters are significant, Doctor said. He added, "People often don't change their behavior unless they have a really salient, personal experience."

    Outside experts also touted the study's findings.

    Andrew Kolodny, co-director of Brandeis University's Opioid Research Collaborative, said the practice of sending such letters to physicians is "a no-brainer," adding that if a patient dies as a result of opioids, "that prescriber should be notified—there should be that feedback."

    Kolodny acknowledged that the results of the study were modest, but said, "[I]t's hard to get patients' prescriptions down." He said the good news is "doctors didn't overreact and cut off all their prescriptions" as a result of the letters.

    David Clark, a pain medicine specialist at Stanford University, said he's hopeful that the letters could change prescribing habits, but noted that it could take years to have an effect. "You don't change doctors' prescribing habits—or patients' consumption habits—overnight," he said. "I imagine if a physician has to change their practice, they have to initiate a long and difficult conversation with a patient … and we all experience pushback." The researchers are continuing to examine the effects of the letters to see if the results change over a longer period of time, STAT News reports.

    Others have concerns

    But other experts expressed concerns.

    Kim Collins, a forensic pathologist in South Carolina and president of the National Association of Medical Examiners, was skeptical of whether all states could legally implement a policy to send such letters to doctors, noting that states have different laws on reporting causes of death. "If there was a way to do that, it would be great," she said, adding, "But by law you just can't do it in every location."

    Kelly Dineen, an assistant professor specializing in health law and bioethics at Creighton University School of Law, said reducing opioid prescriptions might lead some patients to use riskier, illicit drugs.

    Stefan Kertesz of the University of Alabama at Birmingham had a similar concern, saying patients might become suicidal if they're tapered off opioids without some sort of support. "What actually happens to patients should be our concern, rather than just making a number go down," he said (Joseph, STAT News, 8/9; Watson, "Shots," NPR, 8/9; Healy, Los Angeles Times, 8/9; AP/Modern Healthcare, 8/9).

    Your top resources for combatting the opioid epidemic—in one place

    The opioid epidemic is a complex, multi-dimensional public health problem. Use this list of helpful resources on how hospitals and health systems can play a role to treat opioid addiction and prevent further increase in opioid abuse.

    Access our Opioid Resources Here

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