Sending Letters About Their Patients' Overdoses Changes Doctors' Prescribing Habits

For a doctor, learning that a patient has died is often an emotional moment. Emergency room physician Roneet Lev wondered if telling doctors when their patients die of an overdose might motivate them to rethink their prescribing behavior.

"I asked other physicians if they would want to know if a patient had died," says Lev. "They said yes. I needed to help make that happen."

Lev, the director of operations of the Scripps Mercy Emergency Department in San Diego, coauthored a study published Thursday in Science that tests this idea.

The study evaluated the effect of sending letters to San Diego area clinicians informing them of the deaths of patients to whom they had prescribed opioids. Half of a group of 861 doctors received such a letter from San Diego's medical examiner, detailing the name, birth date and death date of the patient. The other half got no letter.

Among the letter recipients, opioid prescribing decreased between 6.2 to 13.2 percent compared to those who didn't get a letter.

"What's important about what we've found is that you can do very simple things to change prescribing and make prescribing safer," says coauthor Jason Doctor, an associate professor of health policy and management at the University of Southern California.

Opioid overdoses went up 30 percent between 2016 and 2017. Despite policy efforts to limit prescribing, opioid prescribing rates are still far higher than they were in the late 1990s.

The letter-writing intervention targets the riskiest prescribers, Doctor says.

Physicians are aware of the opioid crisis, but they might see it as happening somewhere outside of their own practice, he says. Putting a face on overdose victims can give them a perspective about what's going on in their own clinics, he says.

"Right now, doctors are getting biased information. They are only seeing patients that are coming back alive to their clinic, not those who die and never return," Doctor says. "A lot of times, they never learn about a patient's death."

The letter provides some safer prescribing guidelines, such as avoiding co-prescribing opioids with benzodiazepines, a sedative which can raise the risk of overdose. Nearly 30 percent of overdoses involving opioids also involve benzodiazepines.

Jason Doctor hopes that other county or state medical examiners will consider the idea of sending overdose letters to physicians, nurses, dentists and other providers who prescribe opioids.

The study noted that the 170 patients in the study who had fatal overdoses had on average gotten opioid prescriptions from five and half prescribers.

This could reflect the problem of doctor shopping, says Amy Bohnert, an associate professor of psychiatry and mental health research at the University of Michigan. That is when a patient seeks several prescriptions for the same ailment to acquire more drugs.

Bohnert, who was not involved in the study, says that doctors don't always know about all the other prescriptions a patient is receiving, so they may unintentionally prescribe an opiod that overlaps with another prescription.

Study coauthor Lev remembers learning of the death of a patient she had prescribed pain medications to. The young woman had come in to the emergency room with a traumatic injury. Lev wrote her a prescription for painkillers, not realizing that this woman was a chronic pain patient who had only one day before been prescribed a large dose of another opioid.

While the small prescription she wrote likely wouldn't have been the turning point for this woman who died 15 months later, it still upset Lev since she hadn't taken the chance to intervene then and there. "The fifteen pills I prescribed her didn't kill her, but it was a missed opportunity," Lev says.

Bohnert says that the approach of sending doctors letter was "clever." It took advantage of existing systems, and could be done for a very low cost.

"It's something that the health departments in each state could feasibly undertake with relatively little cost," she says.

But Bohnert says that while implementation is doable, the effect might diminish over time if doctors keep getting these letters, shrinking the impact they may have on their choices.

Kelly Dineen, an assistant professor specializing in health law and bioethics at Creighton University School of Law, who was not involved in the study, says she is concerned that this intervention misses part of the picture of opioid addiction. She says that when opioid prescriptions are reduced, some patients could end up resorting to using risky illicit drugs instead, because they lack support in finding addiction treatment.

The outcome measure of this study is prescription amounts, but Dineen says she's curious to see if mortality rates fall after doctors get these letters.

Jason Doctor of USC agrees there's a risk that if you cut patients off of addictive painkillers suddenly they may turn to street drugs like heroin.

But he says, in this research, the doctors who got letters weren't much more likely to abruptly drop their patients than the control group. And, in an optimistic result, he says, those who got letters showed a decrease in the number of new patients they introduced to opioids, therefore potentially preventing addiction from starting at all.

San Diego County will be sending out these letters regularly to doctors whose patients fatally overdose, according to Lev.

"The letters are just a small way to make a difference," says Lev.

Sara Kiley Watson is an intern on NPR's Science desk.

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