The question researchers wanted to answer was whether doctors would decrease their prescriptions of opioids if they knew one of their patients died of an opioid overdose. The answer they got was yes at least by a fraction 400. Dear Dr. letters were sent last year in San Diego County as part of the study. The letter was informed the physicians that prescription drug overdose was either the primary cause or contributed to the death of their patient. Nearly two hundred seventy five deaths in San Diego County were attributed to opioid overdoses in 2017. Joining me by Skype is Dr. Jason Doctor lead author of the study. He's director of the Shaefer Center of Health Policy and Economics at the University of Southern California. And Jason welcome to the program. I you. Now receiving one of those letters might be quite a jolt to the doctors and dentists who got them. Were they worded harshly or compassionately. We did not have an intent to change providers are to blame for the death. So we really wrote the letters in a way that was understanding and supportive. What did the letters tell the doctors in addition to the fact that their patient died. So describe the death afterwards. Talk about the types of deaths that the medical examiner sees. Then went into describing some things that can be done to prevent future deaths including looking at the prescription drug monitoring database and also five of the CDC guidelines that pertain to prescription opioids and how those may be relevant to preventing future deaths. Did any of the doctors try to find out why they were getting this letter. Yeah a few doctors did contact the medical examiner afterwards. However I would say that none of those conversations were negative. Most of the doctors wanted more information. They wanted to learn about what happened to the patient they wanted information on the autopsy report. Did the doctors who received these letters actually decrease their opioid prescriptions. So we know for a fact that that did happen. We ran a fairly careful study where we randomized antecedents prescribers to those students to either receive a letter or not because of that we can conclude that there's probably a causal relationship between receiving the letter and using scribing we observe the nine point seven percent reduction in milligram morphine and bubble and opioid prescribing in the group that got them letters as compared to the group that did not get the letters and that physicians who did not get the letters did not change their prescribing at all. Did you expect that the result of the letter would be more than that 10 percent decrease that you got. I was a little bit surprised that it was not large number reduction in reason I say that is because we're dealing with a wide range of prescribers and included dentists nurse practitioners anesthesiologists run pain clinics internal medicine doctors emergency physicians psychiatrists. And when you're dealing with such a diverse group it's often difficult to get them all to change their behavior. However we seem to be able to do that and I think huge different type of health care provider took a letter in their own way and went back and tried to change their habits. Now one of the researchers in this study Dr. Rony leav chief of emergency medicine at Scripps Mercy Hospital found her own name in the data she prescribed opioids to a patient who later died of an overdose. Is it still easy for doctors to do that. It really is. I mean Dr. Lee is a fantastic physician and she's really one of the leaders in the state around reducing opioid prescribing and I commend her for talking about finding her own name in the list. It just goes to show that when you're a busy physician and you're practicing medicine you can miss certain things or not look into a problem as carefully as you should. And I think Doctor Who is very careful saw that she missed an opportunity to help a patient to talk to them about addiction. See why they were getting prescriptions elsewhere. She did not receive a letter. But I think that information was helpful to her as it was to the other physicians in the study. Now an addiction researcher from the University of Alabama was quoted as saying that he was critical of the limited scope of this study saying it could lead to doctors taking patients off opioids too fast. What's your response to that concern. We tried to mitigate that by talking about the need for slow tapers in opioid prescribing. And you know that's something that the CDC guidelines do not condone dropping patients from your practice and we talk about guidelines. We also didn't observe any difference between physicians and the group that received the letters and didn't in terms of rapid reductions in their opioid prescribing after the letter came out. That said I think that's a general concern that is invalid and that needs to be considered. Well right now the drug Fentanyl which is illegal and not a prescription drug is the top opioid killer. Do you see the research that you've done the research among doctors having any impact on that kind of drug abuse. I think it is related. We misperceived these crises as separate but generally people do not just jump into using Fentanyl often they start with prescription opioids and then become dependent and then move to illicit opioids so they either start with the prescription opioids directly from receiving a prescription from a doctor for pain or sometimes because there's this surplus of opioids laying around from liberal prescribing they get them through diversion or through someone else's medicine cabinet and that has the potential to lead to fence and or use down the road. I've been speaking with the Jason doctor he's lead author of a study published in the journal Science. And Jason thank you so much. Thank you.
In a novel experiment, doctors got a letter from the medical examiner's office telling them of their patient's fatal overdose. The response: They started prescribing fewer opioids.
Other doctors, whose patients also overdosed, didn't get letters. Their opioid prescribing didn't change.
More than 400 "Dear Doctor" letters, sent last year in San Diego County, were part of a study that, researchers say, put a human face on the U.S. opioid crisis for many doctors.
"It's a powerful thing to learn," said University of Southern California public policy researcher Jason Doctor, lead author of the paper published Thursday in the journal Science.
Researchers used a state database to find 861 doctors, dentists and others who had prescribed opioids and other risky medications to 170 people who died of an overdose involving prescription medicines. Most states have similar databases to track prescribing of dangerous drugs, where doctors can check patients' previous prescriptions.
RELATED: Words Matter When Talking About Pain With Your Doctor
Most of the deaths involved opioid painkillers, many taken in combination with anti-anxiety drugs. On average, each person who died had filled prescriptions for dangerous drugs from five to six prescribers in the year before they died.
Half the prescribers received letters that began: "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 letters offered guidance for safer prescribing. The tone was supportive: "Learning of your patient's death can be difficult. We hope that you will take this as an opportunity" to prevent future deaths.
Then the researchers watched what happened over three months.
Letter recipients reduced their average daily opioid prescribing — measured in a standard way, morphine milligram equivalents — by nearly 10 percent compared to prescribers who didn't get letters. Opioid prescribing in the no-letter group didn't change.
Recipients put fewer new patients on opioids than those who didn't get letters. They wrote fewer prescriptions for high-dose opioids.
The strategy is original, helpful and could be duplicated elsewhere, said pain medicine expert Dr. David Clark of Stanford University, who wasn't involved in the study. He was surprised the letter's effect wasn't larger.
"It may have been easy for physicians to feel it was somebody else prescribing who got the patient in trouble," Clark said, adding that changing even one patient's care takes time, requiring "very difficult conversations."
Opioid prescribing has been declining in the U.S. for several years in response to pressure from health systems, insurers and regulators.
Yet deaths keep rising. Nearly 48,000 Americans died of opioid overdoses last year, according to preliminary numbers released last month, a 12 percent increase from a year before.
Now illegal fentanyl, another opioid, is the top killer, surpassing pain pills and heroin. Lead author Doctor said reducing the number of prescribed opioids will, over time, close off a gateway to illicit drugs by shrinking the pool of dependent people.
The study didn't analyze whether the deaths were caused by inappropriate prescribing or whether the prescribing changes resulted in patients doing better or worse.
That's a flaw in an otherwise careful study, said addiction researcher Dr. Stefan Kertesz of University of Alabama at Birmingham, who has raised red flags about policies that cause doctors to take patients off opioids too fast and without a plan for treating addiction.
Patients can fall into despair or contemplate suicide if they are involuntarily tapered off opioids without support, he said.
"What actually happens to patients should be our concern, rather than just making a number go down," Kertesz said.
Study co-author Dr. Roneet Lev, chief of emergency medicine at Scripps Mercy Hospital in San Diego, discovered her own name in the data.
Lev prescribed 15 opioid pain pills to an ER patient with a broken eye socket, without knowing the patient got 300 painkillers from another doctor a day earlier. Lev didn't get a "Dear Doctor" letter because the patient's death fell outside the timeline of the study, July 2015-June 2016.
Still, she felt the impact and believes she could have done better. Said Lev: "It was an opportunity to look at all the records on that patient and say, 'Wow, I'm really worried about you.'"
