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Published On January 22, 2019

POLICY

Sins of the Past

The California Death Certificate Project is finding the physicians associated with opioid overdoses. Is it justice or a witch hunt?

Medical authorities have struggled with how to atone for the opioid crisis, in which the industry played such a pivotal role. Efforts to curb opioid prescribing have proliferated, but punishing the physicians who overprescribe has been a more delicate topic. One of the more controversial efforts, launched by the Medical Board of California in 2015, is the California Death Certificate Project. It set out to find the physicians whose scripts directly contributed to the death of their patients.

When a state medical board disciplines a physician, it’s generally responding to an outside complaint or lawsuit. In California, however, the board has taken on the detective work itself. It requested all of the state’s death certificates between 2012 and 2013 in which prescription opioids were implicated as a cause of death. Looking at 2,700 cases, and helped by a prescription drug database, the board identified 450 cases in which there were excessive prescriptions for opioids within the last three years of a patient’s life. The board has closed 100 of these cases, but the rest are still under investigation.

So far, the board has seen accusations filed against 23 physicians. Sanctions can include the revocation of a medical license, public reprimand or a range of other penalties. One physician was prohibited from practicing for 30 days and permanently barred from prescribing any controlled substance, and also required to perform 100 hours per year of non-medical community service and take courses on prescribing procedures. He has since stopped practicing medicine.

Many California physicians have taken issue with the board’s actions. “Looking back to 2012, when guidelines for opioid prescribing were very different than they are today, is not an appropriate way to help physicians modify their opioid prescribing,” says ophthalmologist David Aizuss, president of the California Medical Association. Aizuss notes that in 2001 the California Legislature mandated that every physician in the state take 12 hours of continuing medical education on appropriate prescribing for pain “because physicians were thought to be under-treating patients for pain.”

Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, also notes that in the earliest days of the epidemic, and until recently, “doctors got a lot of misinformation telling them that opioids were safer than over-the-counter analgesics and that the risk of addiction was less than 1% on long-term opioids. These messages came not only from drug companies, but also from pain specialists, medical societies and state medical boards.”

Retroactively disciplining physicians for aggressive opioid prescribing in 2012 isn’t fair, agrees Kolodny. “But if a doctor in 2018 escalates an opioid dose and that patient dies, there should be an investigation,” he says.

As word began to circulate that the California board was sending notification letters to doctors, telling them that they were under investigation, many began referring their patients to pain specialists. Some of those specialists, in turn, have been overwhelmed by the demand for their services and are sending patients back to primary care physicians—who no longer want to manage their patients’ pain. “Patients are becoming pawns in the middle of this dragnet,” Aizuss says.

There may be another way. In a recent study published in Science, a team led by Jason Doctor, chair of the Department of Health Policy and Management at the University of Southern California, brought the past to bear in a less threatening way. Physicians who had a patient die from an opioid overdose in the previous year received a personal letter from the county medical examiner telling them of that finding.

“The letter was empathetic and designed to help doctors see the real risks of opioids in terms of the outcomes their patients are experiencing,” says Doctor. “Physicians know excessive opioid prescribing is a huge problem nationally, but many think that it’s other doctors who prescribe too much. By giving them feedback about their own patients, we let them know it is occurring in their practice too.”

The 404 California clinicians who received the letter, which included the latest CDC guidelines on safe opioid prescribing, reduced their opioid prescriptions by 10% within four months. That was in contrast to a control group of 447 clinicians who received no letter and slightly increased their opioid prescribing. Those who received the letter were also less likely to start a new patient on opioids and wrote fewer high-dose prescriptions.

Stopping physicians who prescribe too many opioids is an important goal. But for Kolodny, the people whose lives are ruined by these prescriptions should remain the highest priority. “We really have to deal with the victims,” says Kolodny. “We need to treat their addiction.” The process of bringing someone back from an opioid addiction is slow, uncertain and expensive. “We have begun to mobilize outpatient programs to help people who are addicted to opioids,” he says, “but we don’t have nearly enough of them.”