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The Journal Gazette

Tuesday, September 04, 2018 1:00 am

The right prescription?

Study suggests bold approach to curb opioids

Christer Watson

We are in the middle of the opioid epidemic. Solving this problem will take a combination of time and creative action. We shouldn't wait for other areas of the country to generate those creative ideas first. The epidemic is bad here, so we should be the most creative in fighting it.

I was thinking of that when I read about a creative study in the journal Science. The goal was to find a way to reduce opioid prescriptions, hoping that this would in turn reduce overdose deaths.

A group of doctors and public health officials from the University of Southern California and the San Diego area performed the study. They used a database of recent deaths caused by opioid overdoses.

There were 170 people who had received prescriptions. Because people will frequently get prescriptions from multiple doctors, there were 861 doctors and nurses who had given prescriptions to these people.

These doctors and nurses were divided into a control group and an experimental group.

Nothing was done to the control group, as usual. Doctors and nurses in the experimental group were sent a letter from the San Diego County medical examiner (the rough equivalent here in Allen County is the coroner's office). It had the letterhead of that office and was signed by the medical examiner.

The letter 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.”

After covering official guidelines on opioid prescriptions, the letter ends with: “Learning of your patient's death can be difficult. We hope that you will take this as an opportunity to join us in preventing future deaths from drug overdose.”

Wow. In the technical world of such communications, this letter is brutal.

Note that it doesn't threaten the doctor or nurse with a formal reprimand. It doesn't threaten their license. It just lets them know in very personal terms the role they may have played in their patient's death.

Not surprisingly, the doctors and nurses receiving this letter changed their behavior. They, on average, prescribed fewer opioids.

One way this was measured was by adding up all the opioid prescriptions, in milligrams, given out in one day.

This number dropped from 72.5 to 65.7.

The high and extremely high dose prescriptions given out also went down somewhat.

These results are a contrast to somewhat similar efforts to nudge doctors and nurses to change their prescribing.

For example, in another study letters were sent to all doctors or nurses who prescribed at high volumes. There was no measured effect of those letters.

The authors of this new study speculated on why their letters were more effective.

It could be that the letter is more meaningful because the personal information makes it easier for the doctors and nurses to remember. It could also be that the personal letter indicates that their prescribing behavior is being watched.

I'm not sure how I would feel about that if I were the doctor or nurse. If a family member died of an opioid overdose, however, I would feel pretty good if their doctors at least were told of the death.

Regardless, the process feels like a more intelligent approach than a simplistic rule that doesn't account for all the patient details that a doctor or nurse knows.

The study authors also point out that these records are all already collected. Every county is required to report opioid deaths. Each state also has a prescription drug monitoring program.

These letters could almost be automatically sent out. The local office that could do that is the Allen County Coroner's Office.

Based on this study and where we are in the opioid epidemic, they should start sending letters now.


Christer Watson, of Fort Wayne, is a professor of physics at Manchester University. Opinions expressed are his own. He wrote this for The Journal Gazette, where his columns appear the first and third Tuesday of each month.