Despite billions of dollars in settlements from drug companies and distributors, thousands of patients still die each year from overdoses of prescription opioids.
Centers for Disease Control and Prevention guidelines, state regulations and quality improvements in health systems may no longer be enough to reduce dangerous opioid prescribing. But authorities have a promising new tool at hand: low-cost letters that apply different amounts of social persuasion to clinicians to adhere to prescribing recommendations, including telling them when a patient has died.
As health economists, we separately participated in two recent studies that showed the payoffs from straightforward and inexpensive mailings.
In one, researchers followed up on a trial in San Diego County looking at 809 clinicians who had prescribed opioids to 166 people who, unknown to the doctors, had fatally overdosed. Half of the prescribers were randomly selected to receive a personal letter from the county’s chief deputy medical examiner notifying them that one of their patients died from an overdose. The letter also provided information about safer prescribing. The other half did not receive a letter and were used as a control group.
The initial study found that in the three months after receiving the letter, opioid prescribing decreased by nearly 10 percent compared to the control group. The recent follow-up study found that after one year, those who received the letter wrote 7 percent fewer prescriptions than clinicians who hadn’t received the notification, showing that the letter had long-term effects on prescribing behavior.
Another study enrolled 12,000 clinicians in Minnesota who prescribed opioids with benzodiazepines or gabapentinoids, which can increase the risk of overdose. One segment of the prescribers in the study received a letter from the Minnesota Board of Pharmacy advising them of a new requirement to check the state’s prescription monitoring database, which can flag patients in possible danger of overdosing, before prescribing opioids. Search rates rose by 9 percent among the group of doctors that received the letter, and the effect persisted for at least eight months. The letters also encouraged clinicians to sign up with the database, a prerequisite for searching. The letters clearly led to higher engagement among clinicians with the prescription monitoring program.
Such databases, which exist in one form or another in all states, need clinician participation to bend the curve of opioid addiction and deaths. Drug overdose deaths involving prescription opioids rose from 3,442 in 1999 to 17,029 in 2017, declined briefly to 14,139 in 2019 and then jumped to 16,416 in 2020. Significantly, approximately half of the people who die from a prescription drug overdose have also used illicit fentanyl within the past year. More than 80 percent of those who use heroin report that they started on prescription opioids and in 2020 an estimated 9.3 million Americans misused prescription pain relievers.
The volume of prescribed opioids, measured as morphine milligram equivalents, peaked in 2011 but has only declined moderately since then. Well-meaning clinicians are still prescribing way too many opioids. On their own they see relatively few deaths because their patients are alive, resulting in a “survivorship bias” that can lead clinicians to believe that the opioid crisis is not impacting their own practice. If they think that the crisis is happening elsewhere, clinicians may underestimate the risk.
The studies about the impact of letters show that clinicians can be effectively prodded to participate in, and search, state databases and to reduce prescribing. Unfortunately, relatively few jurisdictions are doing so. One of the leaders is Los Angeles County, where the coroner routinely tracks patients who die of overdoses back to prescribing clinicians, and is continuing to gather data on the results. Some bipartisan discussions have occurred in Washington about a nationwide effort but no legislation has emerged.
States and counties don’t need to wait for federal action, or for more data. Letters that make clinicians aware of their patients who have died by overdose, and of the necessity to participate in prescription monitoring programs, are low-cost and not intrusive. They can make clinicians front-line allies in the fight against a deadly and enduring social ill.
Jason Doctor is chair of the Department of Health Policy and Management at the USC Sol Price School of Public Policy and co-director of the Behavioral Sciences Program at the USC Schaeffer Center for Health Policy & Economics. Mireille Jacobson is Co-Director of the Aging and Cognition Program at the USC Schaeffer Center and Associate Professor at the USC Leonard Davis School of Gerontology.