Addressed directly to the doctor, the letter arrived in a plain business envelope with a return address of the San Diego County medical examiner’s office.
Its contents were intended, ever so carefully, to focus the physician on a national epidemic of opioid abuse — and his or her possible role in it.
“This is a courtesy communication to inform you that your patient [name, date of birth inserted here] died on [date inserted here]. Prescription drug overdose was either the primary cause of death or contributed to the death,” the letter read.
In the blandest of clinical language, the “courtesy communication” went on to inform the doctor of how many medication-related deaths the San Diego County medical examiner sees each year (between 250 and 270). It offered five prescribing tips (or “evidence-based interventions”) proven to help lower overdose death rates. And it steered the doctor to an online program designed to help medical professionals who are “dedicated to avoiding prescribing controlled substances when they are likely to do more harm than good.”
The letters — signed by San Diego County’s chief deputy medical examiner, Dr. Jonathan Lucas, who has since become Los Angeles County’s chief medical examiner — were part of an experiment to gauge how to reduce the prescribing of drugs implicated in fatal overdoses.
At a time when legally prescribed opioids and other medications are claiming 174 lives a day in the United States, the research aimed to test a new way to get physicians to rethink their prescribing habits.
Medical societies, state boards and the federal government have sought for several years to educate doctors and dentists about the risks of prescribing opioids, with limited results. The new research is among the first to take a different tack: Get physicians, who are inclined to view the opioid crisis as stemming from other doctors’ poor management, to understand how their own decisions may contribute in small ways to a national epidemic. And then give them tools to guide a change in behavior.
The study, written by a group of researchers led by Jason Doctor of USC's Leonard D. Schaeffer Center for Health Policy and Economics, was published Thursday in the journal Science.
Dated Jan. 27, 2017, the letter went out to 388 doctors. All had prescribed at least one of several drugs with known risks to a patient within a year of that person’s overdose death. The letters were careful not to suggest that the death was directly attributable to the doctor’s actions: Of the 82 deceased patients named, most had received prescriptions from several sources.
An additional 447 physicians found to have prescribed the same range of drugs to 85 patients who died of overdose got no such letter. But like their colleagues who got the letter, this comparison group’s prescribing practices were tracked over the next three months in an effort to discern whether the communication had made a difference.
Compared with the doctors who did not get a letter, those who did reduced their prescribing of opioid medications by almost 10% over the three-month study period. Doctors who got the “courtesy communication” started 7% fewer patients on a regimen of prescription opioids. And they were between 3% and 4.5% less likely to write prescriptions for the highest doses of opioid medication — those implicated most often in fatal overdoses.
Lucas acknowledged that such a shift may seem marginal. But he called it “just a piece” of a broader raft of initiatives that can nudge physicians in the direction of safer prescribing practices. With time, consistent messaging and a bit more insight into the role that they may play in the epidemic, doctors increasingly will rethink their prescribing of opioid medications, he said.
“It’s sort of a process,” said Lucas, who reported that he got only five or six calls from physicians wanting to follow up on the letter with him. Given the growing awareness of the issue, he said, “if we had extended the study period out to a year or so, we probably would have seen a bigger difference.”
In a first-of-its-kind initiative, San Diego County soon will be routinely sending “courtesy letters” that notify doctors when an overdose of certain drugs has claimed the life of a patient.
Los Angeles County is exploring the feasibility of sending similar letters to physicians, Lucas said.
“We are definitely thinking about it,” he said Thursday. “It’s the right thing to do.”
Few experts doubted that the letter got doctors’ attention — at least in the short term.
“I have to imagine it’s gut-wrenching,” said Dr. Sean Michael, a University of Colorado emergency physician who has studied opioid prescribing habits but was not involved in the new research. “The job that everybody is trying to do on a daily basis is the exact opposite of this outcome. The intention when people wrote these prescriptions was to try to help someone, not to accidentally kill them. But that’s the problem: The edge is so narrow and the risk is so high with these medications.”
Knowing that those prescribing decisions may have contributed to a patient’s death appears to challenge a comforting delusion that Michael’s research shows is shared by most doctors — that they are less likely than their peers to prescribe opioids, or to do so in ways that have been found unsafe.
“It tells them, ‘I might be part of the problem here,’” Michael said. “It turns out that a decent proportion of them are probably prescribing more than their peers and don’t have the insight to recognize that.”
Whether getting such a letter will spark long-term change is a matter still to be studied.
Stanford University pain medicine specialist Dr. David Clark is hopeful. But, he said, it could take years for the letters’ effects to reverberate through a doctor’s practice.
“You don’t change doctors’ prescribing habits — or patients’ consumption habits — overnight,” said Clark, who teaches anesthesiology, perioperative and pain medicine at the VA Palo Alto Health Care System. “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,” he said.
Dr. Andrew J. Schoenfeld, an orthopedic surgeon at Brigham & Women’s Hospital in Boston who has studied the opioid prescribing habits of surgeons, said that notifications of a patient’s death might help doctors who are on the receiving end of that pushback.
“It gives a doctor something objective to present to a patient and say, ‘I’m not just deciding out of the blue that we should reconsider your opioid medication use,’” said Schoenfeld, who was not involved in the new research. “It helps answer that question from patients, ‘Why now?’”
Physicians also will have to put aside years of conventional wisdom — much of it fostered, funded and promulgated by the makers of opioid narcotics — that the medications are safe and effective for a wide range of pain conditions, Clark said.