There’s plenty of blame to go around for the opioid crisis. Drug traffickers, greedy pharmaceutical companies and inadequate treatment centers contribute. So do the prescribing practices of individual doctors.
I remember a pendulum swing in the medical community’s view of pain management. When I was in medical school 40 years ago, doctors held back on the use of opioids because they feared their patients might become addicted.
During my residency, another view emerged: When a terminally ill cancer patient is suffering, who cares about addiction? Give people what they need to control the pain.
Reasonable though it was, that view put us on a slippery slope. As discussed in a recent article published in the journal Science and reviewed in the Los Angeles Times, the acceptance of long-term, high-dose opioids for cancer pain “led to calls to address noncancer pain with the same agents.”
Drug companies responded to the perceived need by developing new opioid drugs such as Oxycontin. These drugs were marketed to doctors as safe, effective and unlikely to cause addiction. Published studies based on very small samples supported that questionable contention. The result was an “overly enthusiastic use of opioids to alleviate pain.” For some people, prescription opioids became a gateway to heroin.
Almost 2 million Americans are addicted to opioids. On average, 174 people die every day. Medical examiner offices and treatment centers are underfunded and overwhelmed.
To combat this epidemic, “physicians will have to put aside years of conventional wisdom,” says Dr. David Clark, a Stanford University pain medicine specialist.
According to the report in Science, “most opioid prescription deaths occur among people with common conditions for which prescribing risks outweigh benefits.” Attempts by regulatory agencies to change prescribing practices have met with limited success. So the authors of the Science study tried a new approach – a personal letter from the medical examiner.
The authors hoped the shock of a patient’s death would emphasize to doctors that the opioid crisis doesn’t stem “only from other doctors’ poor management.”
“I have to imagine (the letters would be) gut-wrenching,” said Sean Michael, an emergency physician who studies prescribing habits.
According to the Los Angeles Times, Michael’s research indicates that most doctors share a delusion: They believe they’re “less likely than their peers to prescribe opioids, or to do so in ways that have been found unsafe.”
“(A letter) tells them, ‘I might be part of the problem here,’” Michael said.
Another potential motivator: Even a non-accusatory letter is proof that another medical professional is watching.
Letters went to 388 doctors who had prescribed a drug responsible for an overdose death within a year of the prescription date. Styled as a “courtesy communication,” each letter informed the doctor of a patient’s death, stated the numbers and types of drug deaths the medical examiner saw annually and discussed prescription drug monitoring programs and U.S. Centers for Disease Control and Prevention guidelines for safe prescription strategy.
A control group of 447 doctors whose patients died from the same drugs got no letter. All the doctors’ prescribing habits were then tracked for three months.
Doctors who received a letter reduced their opioid prescriptions by about 10 percent relative to those who didn’t. They started 7 percent fewer new patients on opioid drugs. They wrote prescriptions for the highest recommended doses less frequently.
A 10-percent drop in opioid prescriptions may not be much, but neither is it inconsequential – particularly if you or somebody you love falls within the 10 percent.
Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland. Reach her at firstname.lastname@example.org.