Following Knowledge of Patient Fatal Overdose From Medical Examiner, Opioid Prescribing Decreased

The opioid epidemic that’s gripping the nation has resulted in more than 350,000 deaths from 1999 to 2016, and deaths among illicit and prescription opioids users increased between 2015 and 2016. Researchers at the University of Southern California attempted to reverse those alarming trends by sending San Diego-area physicians, who had a patient die of opioid overdose within 12 months of receiving a prescription, a letter from a local medical examiner informing them of the death.

The dose of reality seemed to have worked. Milligram morphine equivalents in prescriptions filled by patients after the letters were sent decreased by 9.7% and physicians who received the letters were 7% less likely to start new patients on opioids.

Michael Menchine, MD, an associate professor of clinical emergency medicine at Kent School of Medicine of USC and one of the study’s authors, recently spoke about the study’s compelling findings, which showed the pen might be mightier than the pill.

How did you come up with this creative intervention to address the opioid epidemic?

I'm an emergency physician and it's very difficult for doctors like me to get feedback about what happens to patients once they leave the hospital. We hypothesized that well-intentioned physicians are driving a lot of the opioid overuse because they simply don't receive information about the end results of the prescriptions they write. It’s one thing to read about the opioid epidemic, but it’s quite another for physicians to realize how close they are to it. Our ultimate hypothesis was that physicians who understood how close they were to the problem would alter their prescribing behavior. That’s when we came up with the idea of the letter-writing campaign.

What did the letter say and what was its tone?

The tone was fairly bland—we didn’t want to use jarring language. The letters came from the medical examiner, someone with credibility in the field. We felt that sending the letter from a definitive authority would provide the nudge needed to impact physicians’ prescribing practices. We also felt it was important to not accuse the physicians of any wrongdoing. The letters simply stated that they had prescribed opioids to a patient who subsequently died of overdose.

Importantly, the letters also provided a link to the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids. We weren’t trying to give the physicians the impression that they were being watched. Instead we wanted to appeal to their professionalism. We felt that showing them the negative result would start to move the needle on their prescribing habits.

Why do you think the letters were so impactful?

If we had sent threatening letters, that might have initiated short-term change, but how would that have played out over the long term? Well-intentioned physicians can easily rationalize the number of opioids they prescribe, so we wanted the letters to have a tone of helpfulness and to include a solution. It's very important to show physicians social norms so they have a sense of how they're performing relative to their communities, but that method has a downside if the social norm is to overprescribe opioids. Being informed of overprescribing might not have much of an impact if there’s no patient harm attached to it.

When physicians receive letters informing them that one of their patients had died due to an opioid overdose, they have to come to terms with that. We saw that physicians generally reacted by making immediate changes to their prescribing practices. In general, we didn't get negative feedback. In fact, many physicians said they wish they could receive more of this kind of feedback about their patients’ outcomes, whether it’s related to opioids or other medications.

Is this intervention scalable in other communities?

Yes, it is. We intend to roll out a similar program in Los Angeles County and we’ve had a lot of interest from medical examiners around the country who want to do the same. I think this concept could rapidly become a standard of care, particularly in big cities where patients disappear for a variety of reasons—changes of insurance, seeing other physicians, going to a hospital across town. But there are other needed to help guide physicians when they’re prescribing opioids.

For example, pushing information from the Prescription Drug Monitoring Program to physicians through electronic medical records at critical points of care would be helpful. But even with the technical infrastructure in place, we still don’t know how to send that information to providers in real-time alerts as they’re writing prescriptions to high-risk patients, when it would be most useful.

Are you concerned physicians might revert back to potentially problematic prescribing patterns after receiving the letter?

That’s a legitimate question, but patients are learning that they don’t need opioids to manage minor pain. Physicians who change their prescribing patterns might think patients will react negatively, but I don’t think that will be the case. Our letter makes physicians realize that their standard way of prescribing opioids isn’t right, and that they might be contributing to patient harm in some small way. In this paper, we saw prescribing rates decrease by 10%, and I believe those physicians won’t lose any patients as a result. I hope physicians realize that it’s completely acceptable to limit their use of opioids.

The letters we sent were needed to shake them out of their comfortable prescribing patterns and suggest improved practice. That kind of nudge appealed to their professionalism and, for that reason, has a chance of sustained success.

—Dan Cook

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