T

he letters arrived from the San Diego County medical examiner’s office, informing clinicians that one of their patients had died from a prescription drug overdose.

These letters appear to have had an impact — prescriptions of addictive painkillers dropped.

In a small, randomized trial, researchers showed that this intervention — aimed at making the abstract issue of safe prescribing individually tangible — led to a slight reduction in the amount of opioids these clinicians prescribed. What’s more, prescribers who received the letters doled out fewer of the most powerful doses and appeared to start fewer patients on opioids compared with doctors who did not receive the letters.

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Authors of the study published Thursday and experts not involved with the research urged other communities around the country to adopt the same strategy.

“Hearing about one person’s death can be really impactful,” said Jason Doctor, the lead author of the study and an expert in behavioral science and policy at the University of Southern California. “People often don’t change their behavior unless they have a really salient, personal experience.”

The approach described in the new paper, which was published in the journal Science, was easy to implement, inexpensive, and relied on existing tools, the authors said. Medical examiners’ offices already track overdose deaths for health authorities, and prescribing histories can be looked up through prescription drug monitoring programs, which almost all states have. (Missouri, the last holdout state, has attempted to start one, though its status is in flux.)

In effect, the letters simply served to close the information gap between medical examiners and prescribers.

“I think it’s a no-brainer,” said Dr. Andrew Kolodny, co-director of Brandeis University’s Opioid Policy Research Collaborative, who was not involved with the study. “If a prescriber’s patient ultimately loses their life to a drug overdose, that prescriber should be notified — there should be that feedback.”

Still, such an effort wouldn’t be feasible everywhere, said Dr. Kim Collins, a forensic pathologist in South Carolina and 2018 president of the National Association of Medical Examiners. Depending on a jurisdiction’s policies and coroner and medical examiner system, pathologists can’t always disclose causes of death of individual patients.

“If there was a way to do that, it would be great,” said Collins, who was not involved with the study. “But by law you just can’t do it in every location.”

Freewheeling prescribing of painkillers helped fuel the opioid epidemic that now kills tens of thousands of Americans a year. Many became addicted by using prescribed drugs — either their own or those diverted from someone else — before turning to street drugs such as heroin.

Although prescribing rates have fallen in recent years, efforts such as sending general letters to frequent prescribers haven’t always been shown to be effective. Top-down recommendations sometimes meet resistance from patients as well as prescribers, who bristle at attempts they think threaten their autonomy or relationships with patients.

For the study, the researchers took a more subtle tack.

They focused on 170 people whose primary or contributory cause of death was a prescription drug overdose (many had both prescription and illicit drugs in their systems) and who had received a prescription for a controlled substance in the year before their deaths. Then, using California’s prescription monitoring program, called the Controlled Substance Utilization Review and Evaluation System, or CURES, they identified hundreds of clinicians — nurse practitioners, dentists, doctors, and others — who had prescribed the controlled substances.

More than 380 of those prescribers received a letter signed by Dr. Jonathan Lucas, San Diego County’s chief deputy medical examiner.

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

“I think it’s a no-brainer. If a prescriber’s patient ultimately loses their life to a drug overdose, that prescriber should be notified — there should be that feedback.”

Dr. Andrew Kolodny, co-director of Brandeis University’s Opioid Policy Research Collaborative

The letter included recommendations for safer prescribing, including using CURES, avoiding providing both opioids and benzodiazepines, and reducing the length and strength of opioid prescriptions.

“We did not want it to be a punitive letter,” Doctor said. “We just wanted to make them aware of the death.”

The awareness seems to have changed behavior, though marginally. While the 438 prescribers in a control group — those who didn’t get a letter — kept prescribing roughly the same amount of opioids each day, those who received the letter reduced their opioid prescriptions within a few months from an average of 72.5 morphine milligram equivalents a day to 65.7 MMEs. (A standard Vicodin pill is 5 MMEs.)

“It would have been nice to see more of an impact, though it’s hard to get patients’ prescriptions down,” Kolodny said.

The reduction was modest, Doctor acknowledged. But both he and Kolodny said a small initial reduction might be responsible on the prescribers’ part. Some advocates argue that slashing prescriptions too rapidly can hurt patients who legitimately need painkillers and even leave them vulnerable to seeking illicit drugs (though experts debate just how pervasive a problem this actually is).

“On the plus side, you could say this means that the doctors didn’t overreact and cut off all their prescriptions,” Kolodny said.

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Letter recipients also reduced their prescriptions of high-dose opioids (50 MMEs and 90 MMEs a day) more than practitioners in the control group. And they seemed to be slightly less likely to start a new patient on opioids than other doctors, though limitations in what the researchers could track in CURES made it difficult to know whether these patients were truly getting their first opioid prescription.

The authors identified several possible reasons why prescribing declined among those sent a letter: There was a sense that they were being monitored; they were no longer just exposed to patients who returned to appointments and were uneventfully using the medicines; and “people rely upon knowledge that is impactful, recent, and easy to retrieve from memory,” they wrote.

Doctor and his colleagues are continuing to track if the letters have a long-term effect on prescribing, and moving ahead, he said he hoped medical examiners would consider starting such a campaign. He proposed adding information about medication-assisted therapy — which is the gold standard for treating opioid addiction — to the letters.

“It’s not going to be a silver bullet,” Doctor said about the approach. But, he added, “I’m hoping that counties will start using this, maybe even health systems will start asking for this type of data. Even states could apply this.”

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  • I would have hoped to see better reporting in a school newspaper. Do y’all actually have to believe what you wrote, or is aiming your words at a nerve just an experiment? We’ve been over the following point and it has been disproven. Move on please.

    “Freewheeling prescribing of painkillers helped fuel the opioid epidemic that now kills tens of thousands of Americans a year. Many became addicted by using prescribed drugs — either their own or those diverted from someone else”

    • Thank you for noticing that! I was thinking the same thing. Very poorly written article, low on supporting evidence too

  • Thank you, “Tired MD” and Dr. Peterson! Your comments could not be more correct.

    This comment is from one “Exhausted Retired Nurse Left to Suffering in Agony” thanks to ppl like Kolandy, his PROP proponents, the infinite numbers of the ill informed, the media, the opiate hysteria frenzy led in by the bureaucrats, zealots, politicians, CDC, DEA, and FDA. I could cite others, but enough for now…

    I have a rare genetic dz, a known hallmark of which includes severe, chronic, intractable pain. For 27 yrs., I was opiate maintained…I led a reasonably functional life, a life woth quality and purpose …until July ’17 when the tapering began. I saw the writing on the wall from the “opiate hysteria,” was well aware of what was happening to Bd certified pain practitioners and their countless numbers of long standing, successfully opiate maintained,chronic, intractable pain pts. Pts. who had a life, could function, had an acceptable pain level. Pts left without pain practitioners, pain clinicians practice doors shuttered…OR pain practitioners living in fear if they continued to treat their cpp’s with opiates, the FDA would be witch hunting and threaten their livelihoods.

    I’ve undergone 61 major surgeries trying to be fixed for a congenital genetic rare dz. I’m in my 60’s today. I’m do done with all surgeries, all invasive procedures, blocks, pt, talk therapy, music therapy, acupuncture, aquatherapy, iontophoresis, botox injections into muscles, the whole 9 yds. ALL I wanted when I consulted my pain practitioner 28 yrs ago was palliative care, just treat the pain. The agreement was as long as I lived, my pain would be managed. I would not be allowed to suffer any longer. Well…thank you CDC “guidelines” turned Holy graille law. Guess what? The hinges to the doors of he’ll opened and I’m back for indefinite residency. For 27 yrs., I had same Pain pract., used same pmcy, never breeched any pain contracts, never diverted my meds, took each med exactly as directed, never missed 1 single follow up appt w/ my Doc and I traveled anywhere from 4-7 hrs. to maintain the same Doc. Me and others like me were not and are not the ones who croaked b/c of being multi substance abusers, addicts to illicits and diverted opiates or opiates inappropriately prescribed.

    I am and have been a non stop, tireless professional pain advocate and CPP advocate most especially this past year. Believe me, having met with Senators and Congressmen and women, they “don’t get it.” They’re clueless as to the absolute pain crisis created. We are the scapegoated victims of the illicit Fentanyl crisis ( mostly from China), heroin importation ( mostly from Mexico, 85%, the multi substance abuser addicts, incl Imodium, synthetic marijuana, meth, cocaine, gray death, benzos, gabapentin and God knows what else!

    I tapered my nearly 1200 mg total dose of long and short acting morphine ( same dose for the past 12 yrs) to 0…on my own. No addict here, not now, not ever. So, my return to the residence of hell is my location, same place I resided 28 yrs ago at the time I spent 6 days at a prominent multi disciplinary pain center– where all involved in my evaluation agreed opiate maintenance was appropriate to try. It worked. I had a decent life. It’s gone. I grieve for the quality of life I had, the ability to be self sufficient, independent. I have no intention of “existing” as life is now. I stopped ALL meds, ALL medical care 13 months ago. Grateful I have no dependents, no family. I hope for the sake of the 8-12 mil on opiates being tapered into discontinuance somebody with a brain and political powers will realize “Pain lives matter.”

    Save the Sub and Bup for the addicts, the Methodone too. As one pain Doc I highly respect said addressing my situation: ” If you agree to say you’re an ‘addict,’ and enter ” treatment,” maybe you would be given Methodone to alleviate the nightmare of your pain.

    Sign me as:
    “Residing in hell, at least for this moment.”

    P.S. Perhaps I’ll just sign out when the genocide happens which is happening at a steady pace. Maybe the stress of no sleep for days, living on horrid pain will do me in next time as result of another stroke…I hope the sink is big enough to cleanse all the blood from countless hands and Regs…creators of suffering and real daily hell

    • I’m so sorry. So many people have been abruptly cut off their pain medications. It seems to be a Genocide of disabled patients in pain. Millions have been abandoned by their physicians, so afraid of the DEA they are not prescribing anymore. The pain continues with withdrawals on top, people are dying. Now surgical, cancer, hospice patients are denied pain relief. This is so horrific. Andrew Kolodny stated it will take a generation for us to die off. Wired article 2005, The Bitter Pill, discussed him and his practice of pushing promoting Suboxone.

  • Kolodny has never practiced medicine. He may be a licensed psychiatrist and addictionologist; he is not trained to comment on the treatment of pain including opinions related to rehabilitation, rheumatology, surgery, or any number of specialties he pretends to be an expert in. He is famous for being famous and the media is complicit in creating this monster. Stop using him as a go-to every time you want a quote. It’s irresponsible to use the same person for every single article. Bad journalism.

    He would leave all of us screaming in pain if he could, except for patients who suffer from addiction, who he would treat with opioids.

    • Correction: that was an incomplete and incorrect statement that Kolodny has never practiced medicine and a tired typo. That should have read “He has never practiced pain medicine to my knowledge.” Yet he is portrayed as THE expert. Pain medicine and addictionology are not the same thing.

      And the Goldwater rule does not apply to him obviously. He insinuates patients he’s never met are addicts when they are brave enough to come forward to talk about legitimate pain being undertreated. That’s also libel, and it’s shocking that journalists participate in it. It has serious consequences for patients.

      Kolodny “hawked” (his word) Suboxone while working for the Health Dept. and now I believe they have a national contract with correctional facilities. It’s referred to as “prison heroin”. He ran the private group PROP and heavily influenced the CDC Core Group’s Pain Treatment Guidelines. PROP tried to force the FDA to follow their agenda but didn’t completely succeed there yet. I wonder how many pain patients have been forced into mandatory treatment at the chain of rehabs—Phoenix House—he was the CMO of. Not sure whether the allegations there happened during his tenure or after, but it’s all documented. Some conflicts of interest there.

      Funny, if one of the few small organizations that supports patients with truly horrible conditions accepts any funds from a pharmaceutical company that makes an opioid, it’s a scandal, but the pharmaceutical companies that make the opioids used for addiction treatment seem to have different legal and ethical standards for donations. Also “not” a conflict of interest—funding from big business rehab, medical devices, nonopioid pain treatments—pharmaceutical and otherwise. All those together with compounded medications are under- or unregulated and are seriously injuring and killing patients while making some people very wealthy and while we are all busy arguing about opioids.

      Yes, Kolodny sounds like a great reference for any article to me. Lazy journalism. Look up last article, see who was quoted, and ask that person again. Why bother really looking into them.

      Of course opioids were overprescribed for some things for some time and still are in some areas. We do need to prevent and treat addiction and overdose. And it’s just as important to treat pain, including the use of opioids when necessary. It’s very important we protect access to opioids for those who need them and that is not happening.

      Feedback and learning is critical in medicine. I’d want to know if anyone I gave a controlled substance to ever overdosed.

  • Dr Andrew Kolodney is a unabashed pharmacological nihilistic. 5 mg of MS is inconsequential except to a neonate or infant. Patient comingling of both prescribed and illicit substances and then blaming the ethical prescriber for the fatal consequences is like blaming the gas station attendant for a fatal car wreck. Let’s swing the pendulum back to sanity and stop the hysteria by focusing specifically on high-dose inappropriate opiate prescribers and lack of law enforcement success in illicit drug interdiction. Talking heads like Dr Andrew Kolodney inflame but never resolve issue by fostering on a cult of outrage. Please cease providing a public podium for individuals regularly exhibiting such corrosive and extreme viewpoints.
    J Petersohn MD
    Clinical Associate Professor
    Dept of Anesthesiology and Perioperative Medicine
    Drexel University
    Philadelphia, PA.

    President, New Jersey Society of Interventional Pain Physicians

    • Once you become sick enough to lose the ability to practice, your opinion no longer matters to anyone, despite the fact that having seen things from both sides makes one extremely well positioned to provide helpful information. We who are the patients with systemic, life-threatening, severely painful conditions must depend on physicians like you, Dr. Petersohn, to bring sanity and honesty to this debate. Thank you for taking the time to comment here. I hope you are sharing your opinions with elected officials and other media sources. Many lives depend on it. Thank you again.

  • No body even questions why this is considered an improvement. The “opioid crisis” was was created by the Pharma industry, illegal practices and diversion of drugs to the black market. They want to keep us distracted from the Facts.
    Prescriptions are down, and prescribing is no longer the issue, many Physicians opted out of prescribing opiates at all. States enacted their own Laws, Databases and tracking. None of this was evaluated in order to focus attention where it belongs, or evaluate whether it worked.

    The most striking issue here is that Physicians have no idea of the outcomes of most of their patients. This is by design, the system is broken. The adverse events have been censored. The Industries profiting here made sure that Physicians would not be able to track any of their treatment decisions. Tracking outcomes, Physicians were told, could lead to Liability.
    Physicians have to rely on industry provided advertising because there is not much else. The Profit Driven, Free Market healthcare system relies on this kind of secrecy. The number of people who die due to the drugs the pharma industry marketed as alternatives, are not available. The deaths due to NSAIDs and repackaged Cox 2 inhibitors, already proven to be deadly, are not being counted. Physicians were told by marketers that Antidepressants, Anti Seizure drugs, and anti psychotics were alternatives, so they freely prescribed multiples of these.
    The AMA made sure that Physicians did not have to take CE Classes on either pain or addiction, even as the death rates rose. No one bothered to keep the public informed either. Every municipality has different reporting requirements, this is due to years of under-funding by Congress, on the advice of industry insiders. Even CMS has to work backwards from the data, often death information is not included.
    The industry made sure that reporting requirements, remain loose or up to interpretation. They did not want people to know exactly how many deaths there are or, what pharmaceuticals are involved. Most areas consider any trace of opiates to be an opiate overdose, even when multiple drugs are involved. Over the years I have noticed that when people “overdose” on these other drugs, their prescribing physicians is never informed. The FDA ignored patients reporting adverse events with drugs like Fentanyl. That started as soon as Pharma marketed it as better than other opiates. A Physician patronized me for explaining the danger.

    Here in Post Fact America, a small study like this gets a lot of attention, better than looking at the facts. We are being mislead to believe they are doing something, when people are dying from street drugs, suicide and the epidemic of despair. The flip side is that people with chronic pain are being stigmatized and dehumanized by these well meaning journalists. The data from 4 years ago is much more compelling that the data now, so they use it. They continually attack the few legitimate prescribers s they don’t have to look up facts. Surgeons are running out of surgically necessary medications, while people with chronic pain are re-framed as Addicts.

    This is further proof that we need Universal Healthcare, like every other developed country. Then there would be no incentive to keep Physicians in the dark, about any outcomes. If the system worked we would have had the data in 2001! No one noticed it is not there! The Pharma industry decided that was unprofitable. The Medical Industry decided along with pharma decided that even surgical outcomes are censored. CMS is very limited in their collection of data, thanks to these industries!

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