Some Doctors Are Getting Letters Scaring Them Into Prescribing Fewer Opioids

After their patient’s death is determined to be caused by prescription opioids, some doctors are receiving letters about a “complaint” regarding their prescribing practices — a move some doctors say has deterred them from prescribing opioids or working with pain patients at all.

The California program, called the “Death Certificate Project,” seeks to stop accidental deaths due to prescription opioids by matching death certificates that list prescription opioids as a cause with the medical provider(s) who prescribed controlled substances to the patient within three years before the patient’s death. Providers are found using California’s prescription drug database, California Controlled Substance Utilization Review and Evaluation System (CURES), which keeps track of what providers are prescribing. Providers then receive letters from the Medical Board of California (MBC) notifying them that their patient died due to prescription medication overdose and that a “complaint” has been filed against them due to their prescribing.

Providers who receive letters must respond to the MBC, documenting their treatment of the patient. The MBC reviews their case and decides whether or not to move forward with an investigation and potential disciplinary action.

When the project launched in 2015, the MBC reviewed certificates of death filed in 2012 and 2013 and ultimately selected 522 healthcare providers who had written an opioid prescription filled by the deceased patient. These providers include MDs, nurse practitioners, physician assistants, and osteopathic physicians.

As MedPage reported on Thursday, 450 of these providers were MDs, and as of last week, 216 of these cases had been closed, either for insufficient evidence, no violation, the license had already been revoked or surrendered or the physician had died. The rest are awaiting further review of their cases or for their investigation to be completed.

Some doctors who received letters told MedPage they had changed their own prescribing practices or didn’t want to treat pain patients anymore. They called the letters “terrifying,” and “upsetting,” saying they felt “shamed.” One physician, Brian Lenzkes, said after receiving a letter last December, he’s not taking any more pain patients and now refers them to pain specialists.

“When you hear a bunch of doctors all at the same time all getting the same letter, and you realize they’re going through the same thing, you see why some are saying [to patients], ‘Sorry, if you have a lot of medical conditions, we’re not going to take care of you,’” he added.

After receiving complaints that the letter was too harsh, the MBC revised it. Letters sent this summer said the review was “routine” and that “just because a patient death occurred, it does not automatically mean the physician deviated from the standard of care.”

In a statement to The Mighty, the MBC said its mission and the mission of the Death Certificate Project is “consumer protection.” The MBC said it is taking a “proactive approach” that has been successful in identifying cases in which opioids were “inappropriately prescribed” and educating doctors about the misuse of opioids.

When asked to respond to criticism that the program could scare off doctors from prescribing opioids to patients who need it, the MBC said they expect doctors to address patients’ needs while adhering to the “standard of care.”

Prescribing of opioids is one of the many options doctors have available to treat patients’ pain. Using the Board’s Guidelines For Prescribing as a resource, the Board expects licensed doctors to determine the appropriate treatment(s) and medication(s) to address each individual patient’s unique needs, while adhering to the standard of care. Doctors should maintain accurate medical records documenting their rationale for each prescribing decision. The Death Certificate Project uses valuable data to combat the growing opioid epidemic and is evidence of the Board’s commitment to consumer protection and education.

North Carolina has a similar program called the Safe Opioid Prescribing Initiative that targets physicians who have had opioid-related patient deaths or have a lot of patients on 100 milligrams of morphine equivalents per day. Research has shown this tactic can have a real-world effect on doctors’ prescribing practices. Earlier this month, the journal Science published a study in which physicians who prescribed opioids to patients who later died of a prescription opioid overdose received letters alerting them of the patient’s death and information about “safe prescribing.” Researchers found that doctors who did receive letters went on to prescribe 10 percent fewer opioids than doctors in the control group, which did not receive letters.

Policies intended to fight the opioid crisis, like limiting prescriptions and prosecuting doctors, can make doctors wary of prescribing opioids and it harder for patients with chronic pain to get medication, severely limiting their quality of life. As Mighty contributor Rachel Burchfield explained, chronic pain patients, like herself, suffer as a result of these policies.

I don’t want to be on narcotics. I have so many goals, and none of them include narcotics, but they also don’t include severe, widespread joint and nerve pain. I also understand why there are strict rules on medications like narcotics. I wouldn’t want them to be easily available to everyone. But that doesn’t mean that those who are truly, legitimately suffering – whether it be acute (post-op, injury, car wreck) or chronic (fibromyalgia, arthritis, Ehlers-Danlos syndrome, CRPS, etc.) – should have to continue to struggle when there are actually medications that could make a difference!

Thought the program is intended to help fight the opioid crisis, studies show fentanyl is now involved in a majority of fatal opioid overdoses — from 14 percent in 2010 to 46 percent in 2016. The majority of people who are prescribed opioids take them as prescribed and do not become addicted or abuse their medication. One study of 135,000 people who went to the emergency room with an opioid overdose in 2010 found that just 13 percent had chronic pain.