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Researchers say letters to doctors about patient opioid overdoses could help reduce prescriptions. Maskot/Getty Images
  • The excessive prescription of high doses of opioids for common pain-related conditions is regarded as one of the contributing factors to the increase in opioid addiction and overdose deaths.
  • Measures to deter the overprescription of opioids, such as state restrictions on opioid prescriptions, have shown limited success in reducing the prescribing of opioids by healthcare providers.
  • A recent study shows that a letter informing healthcare providers about the fatal overdose of their patient to whom they had previously prescribed opioids resulted in a sustained decrease in the prescription of opioids in the one-year period after receiving the letter.

Findings from a recent clinical trial published in JAMA Network Open suggest that a notification letter sent by the county’s medical examiner resulted in a sustained decrease in opioid prescribing in the next 12 months.

The letter notified clinicians of the recent overdose death of a patient to whom they had previously prescribed opioids. The communication also included measures for safely prescribing opioids.

Researchers say this type of letter presents a low-cost intervention that can help modify clinician behavior.

“This study is an interesting follow-up to an important trial by the same authors published in Science in 2018 that made a big splash, said Dr. Michael Lawrence Barnett, an associate professor of health policy and management at the Harvard T. H. Chan School of Public Health in Massachusetts.

“They sent letters to prescribers who had a patient die from an opioid overdose and, in the original study, observed a decrease in opioid prescribing three months after prescribers got the letter,” he told Medical News Today. “This study shows that the effects were still persistent up to 12 months out from the initial letter, though the difference between the treatment and control groups diminished.”

“The study shows that one letter has effects that last an entire year. Clinicians likely internalized the notification and made lasting changes to their practice. The intervention is scalable; every county in the U.S. has a medical examiner,” added Jason Doctor, PhD, a study author and a professor at the University of Southern California’s Price School of Public Policy.

The United States has been battling the opioid crisis since the late 1990s.

The crisis has been characterized by a surge in overdose deaths, initially predominantly due to prescription opioids and non-medical opioids.

Opioid analgesics were originally developed to alleviate pain in people with cancer.

However, during the mid-and late-1990s, clinicians started to increasingly use prescription opioids for the treatment of non-cancer pain. Moreover, the development of extended-release and long-acting formulations of opioids in the 1990s made it possible to use high doses of opioids for prolonged periods.

The use of opioids over a prolonged duration, especially in high doses, is associated with an increased risk of addiction, overdose, and mortality.

Individuals who develop a dependence on prescription opioids are also at risk for using heroin, an illicit opioid drug.

The overprescription of opioids involving the prescription of high doses of opioids for common conditions where the risks outweigh the benefits has also been a major driver of the opioid epidemic.

Researchers say healthcare providers may underestimate the potential risks of prescribing high doses of opioids due to limited personal experiences of opioid misuse or overdose among their patients. This is because clinicians are more likely to encounter patients who have not been misusing or abusing opioids. A lack of oversight from the authorities may also contribute to the excessive prescription of opioids.

In the recent study, the researchers examined whether a notification letter from the county medical examiner informing the clinicians about the fatal overdose of a patient to whom they had prescribed an opioid analgesic in the previous 12 months could change their prescribing behavior.

The researchers’ rationale for using the letter was that memories of impactful, personal experiences tend to have a stronger influence on decision-making.

They said receiving a letter detailing such an incident of a fatal overdose in a patient would elicit a memory of the adverse effects of opioids in clinicians and influence the prescription of opioids. Such a letter would also indicate to the clinicians that their prescription patterns are being monitored by the authorities.

The letter included details about the patient and informed the clinicians about the number and type of prescription drug-related overdose deaths during the previous year. The letter also contained information about safely prescribing opioids and accessing the state prescription drug monitoring program to ascertain the opioids or other prescription medications used by the patient.

The study’s authors had previously shown that receiving a letter from the medical examiner resulted in a reduction in the overall dose of prescribed opioids during the three-month period after receiving the letter.

In the present study, the researchers examined whether such a letter could result in a sustained decrease in the prescription of opioids by clinicians up to 1 year after receiving the letter.

The study included 826 clinicians who had prescribed opioids to their patients during the 12 months period before their subsequent fatal overdose between July 2015 and June 2016.

The clinicians were randomized to either receive a letter or no notification. The researchers then examined the prescription patterns of opioids 12 months before and after the intervention.

The researchers calculated the total dosage of opioids prescribed weekly by each group of clinicians between 1 and 3 months and 4 and 12 months after the intervention.

The dose of the prescribed opioids was calculated in terms of morphine milligram equivalents (MMEs), which is the dose of the prescribed opioids converted into a dose of morphine that would produce an equivalent effect. The measurements provide clinicians and researchers with a standardized measure of the potency of opioids, thus allowing comparisons between different types and amounts of opioids.

In the study, the researchers reported that about 56% of overdose deaths occurred primarily due to prescription opioids. A majority of the remaining deaths were caused by a combination of prescription opioids with either alcohol or illicit drugs.

During the period between 4 to 12 months after the letters were mailed, the clinicians in the group that received the letter showed a 7% greater decline in total weekly MMEs dispensed than those in the control group. In addition, the clinicians in the letter recipient group started 2% fewer new patients on opioids than their peers in the control group.

The letter recipients showed no difference in the total MMEs prescribed, new patients initiated on opioid therapy, or the number of high-dose prescriptions between 1 to 3 months and 4 to 12 months after receiving the letter.

Researchers said their findings suggest that this low-cost intervention can change clinician prescription patterns.

The study authors, however, noted that addressing the opioid crisis requires not only minimizing the overprescription of opioids but also the treatment of opioid dependence using medications, counseling, and behavioral therapies.

In addition, there is a need to improve access to naloxone for treating overdoses.

The authors also noted that the cause of opioid overdoses has shifted from prescription opioids to synthetic illicit opioids such as heroin and fentanyl.

However, such letters could still be useful for changing the behavior of healthcare providers. Doctor said.

“Future letters should include an encouragement to evaluate patients for substance use disorder given the rise of an illicit market for fentanyl,” he told Medical News Today.

“This study implies that low-cost interventions that inform prescribers of potential negative consequences that their patients’ experience could make a difference in improving opioid prescribing,” added Barnett. “An important question not addressed in the study is how the letter recipients felt about the message. Another paper suggests that letters like this might contribute to physician burnout.”