Friday, August 24, 2018

Death Notification as Behavior Modification: Let's think this through

by Ben Skoch (@skochb)

Opioid Problem. Opioid Epidemic. Opioid Crisis.

Call it what you will (as long as you don’t use the word narcotic, but that’s another article), but the United States has a real issue with opioids right now. It has been much talked about, publicized, criticized, politicized, has left some people ostracized, to a point where the concern has become supersized. Six years ago, a report stated enough opioid prescriptions were written for every adult in the US to have a bottle of pills, about 259 million. Couple that with the report from the CDC that over 42,000 people died from opioid (illicit and prescribed) overdoses in 2016, more than any year on record, and it’s easy to see why the topic has reached a fever pitch in our country.

Many efforts to curb potential causes have been suggested, including a list of “promising state strategies” set forth by the CDC. It is worrisome given the rising number of opioid-related deaths, along with nature of the problem including abuse of both prescribed and illicit opioids, that the current interventions have yet to tame this complex issue.

A recent study published in Science examined a novel approach to influence prescribing patterns of healthcare professionals (including MDs, DOs, NPs, PAs, and DDSs/DNDs) in San Diego County. Over the period of one year (June 2016 to July 2017), the researchers worked with the medical examiner to investigate deaths that were directly related to schedule II, III, or IV drugs. Utilizing CURES database (California's Prescription Drug Monitoring Program (PDMP)), the identified 220 people who died by overdose, with 170 of the 220 having filled at least one opioid prescription in the last calendar year before their untimely deaths. They could also identify each prescriber who wrote prescriptions to each decedent, and on average there were 5.5 prescribers per decedent.

The authors clarify they are not addressing, “appropriate or inappropriate prescribing at the patient level.” The intervention included sending a letter to each prescriber, who wrote an opioid prescription to a decedent in the months leading up to that person’s death, could influence their prescribing patterns. They note the letters were “supportive in tone,” and also identified by name the patient that had died, discussed the value of the state prescription drug monitoring program, and reviewed the CDC’s recommendations for safe prescribing strategies. They examined prescribing patterns three months before, and one to four months after each letter was written. There were 82 decedents (representing 388 prescribers) in the intervention group, and 85 decedents (representing 438 prescribers) in the control group.

What they found, as the authors describe, is that receiving such a letter mentioned above resulted in fewer subsequent opioids dispensed. There was no change in the control group over the observation period (71.6 milligram morphine equivalents (MME) to 71.7 MME), while the intervention arm decreased their prescriptions by almost 10%, from 72.5 MME to 65.7 MME per prescriber per day. In other words, prescribers who got the letter were writing one and a half tabs of 5/325 Norco fewer, or one 5 mg Oxycodone tablet fewer, per day after reading the letter. Among other reasons they propose for why the intervention showed a statistically significant reduction is that, “Clinicians may prescribe with greater care when they perceive that they are being watched, particularly by figures of authority,” citing a 2003 paper out of Current Directions in Psychological Science.

While I believe that the authors of this paper have the right intentions in wanting to help cure our national opioid sickness, I am worried this approach will have significant and long-lasting unintended negative consequences. Yes, I worry that on some level this will make it increasingly difficult for patients who genuinely need these medications to obtain them. Additionally, I wonder if guilting physicians into practice changes is the best way to pursue systemic changes, particularly in a system where physicians are already suffering increasing levels of burnout. Guilt has been well described as a symptom of burnout , so it’s no big leap to think that scaling this intervention to a national level as the authors suggest could severely complicate this issue.

The conclusion of this article correctly highlights several pieces of this picture, each important in viewing and solving the bigger puzzle. I am hopeful that PDMPs at the state level will be functional, easily accessible, and above all helpful to clinicians who are tasked with treating those with legitimate pain sources. I am encouraged by efforts being made to identify instances where we are likely overprescribing and the guidelines being put into place because of those studies. I am hopeful we can find a solution to this growing problem without adding unneeded suffering to both patients and prescribers. I have my doubts, however, that the letters mentioned in the above article are the best way to get there.

Ben Skoch, DO, MBA, a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family Medicine and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

More posts from Ben Skoch here. More Pallimed posts about opioids and pain control can be found here

Doctor et al., “Opioid prescribing decreases after learning of a patient’s fatal overdose.” Science 2018:361, 588-590.

Pallimed | Blogger Template adapted from Mash2 by Bloggermint