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Doctors prescribe fewer opioids after receiving a letter about a patient’s overdose death, study finds

REUTERS/Jim Bourg
Despite regulatory and educational efforts to get U.S. physicians to prescribe fewer opioids, the rate at which opioid prescriptions are being given to patients has remained essentially flat over the past 10 years — and far higher than it was in the late 1990s.

A new study, published in the August issue of Science, suggests that a rather simple intervention, tried out on doctors in California, may get physicians to be more cautious about prescribing opioid medications. 

The study found that when physicians were sent a letter informing them of the overdose death of a patient to whom they had prescribed opioids, their subsequent opioid prescribing decreased.

The drop was relatively modest, but significant enough to potentially save some of the estimated 16,800 Americans who die of prescription opioid overdoses each year in the United States. 

Some kind of action is needed. Despite regulatory and educational efforts to get U.S. physicians to prescribe fewer opioids, the rate at which opioid prescriptions are being given to patients has remained essentially flat over the past 10 years — and far higher than it was in the late 1990s. 

That’s a serious problem, with tragic consequences. For the opioid epidemic now raging across the United States — the one that has claimed more than 350,000 lives since 1999 — is being driven by the use of both prescription and illicit opioids. 

Physicians know that fact, but they tend to see the problem as happening elsewhere, not in their own clinic, partly because they’re seeing only the patients who keep coming back to their clinic.

“Clinicians may never know a patient they prescribed opioids to suffered a fatal overdose,” said Jason Doctor, the study’s lead author and an associate professor of health policy and management at the University of Southern California, in a released statement. “What we wanted to evaluate is whether closing that information gap will make them more judicious prescribers.”

A “Dear Doctor” letter

To make that evaluation, Doctor and his USC colleagues decided to conduct a randomized trial. First, they identified 861 clinicians in San Diego County who had prescribed opioids to 170 patients who had subsequently had a fatal overdose between July 2015 and June 2016. All the prescriptions were filled less than 12 months before the patients died. 

The researchers then randomly divided the clinicians into two groups. The “intervention” group was sent a signed letter from the county medical examiner informing them of the overdose death of one of their patients. The “control” group got no letter.

The letter included the patients’ name, age and address. It also described the annual number and types of prescription drug deaths seen by the medical examiner, as well as information on five safer prescribing strategies recommended by the Centers for Disease Control and Prevention’s guideline (such as not prescribing opioids with benzodiaphenes, a sedative that raises the risk of an overdose).

The researchers then examined the prescribing patterns of all the clinicians, both before and in the three months after the letters were sent. Compared with the clinicians who did not get a letter, those who did lowered their prescribing of opioid medications by almost 10 percent.

The letter-receiving clinicians were also 3 percent to 4.5 percent less likely to write prescriptions for the highest doses of opioids, which are the ones most likely to be involved in overdose deaths.

‘Nudging’ doctors to correct course

The study involved clinicians in a single, large California county. Whether letters from a medical examiner would have the same effects on clinicians elsewhere in the U.S. is unclear. Also, the study looked at only three months of post-letter prescribing patterns. It’s unknown if the reduced prescribing of opioids would continue past that period.

Still, the findings show that this particular intervention can be effective. It’s also relatively easy and inexpensive to implement, particularly since each state already has a prescription drug monitoring program that tracks prescriptions to people who die.

“Interventions that use behavioral insights to nudge clinicians to correct course are powerful, low-cost tools because they maintain the autonomy of the physician to ultimately decide the best course of care for their patient,” said Doctor. “In this case, we know opioids, though beneficial to some patients with certain conditions, come with high risks that the doctor may not fully grasp when observing patients in the clinic.”

“Providing information about harm that would otherwise go unseen by them gives physicians a clearer picture,” he added.

FMI: The study can be read online at Science’s website.

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