Overdose Death Notices Plus Guidance Sink Opioid Prescribing

Physicians who received a letter from a medical examiner about a patient’s fatal overdose — along with suggested guidance for future visits for pain — prescribed fewer opioids, according to a cluster randomized controlled trial.

Doctors who received the death notice plus guidance had a drop in weekly morphine milligram equivalents (MMEs) pre- to post-intervention (157.81 to 77.05), according to Jason Doctor, PhD, of the University of Southern California in Los Angeles, and colleagues.

While physicians who only got a death notice also saw a decline in weekly MMEs (157.70 to 103.16), those with the death notice plus guidance letter had a 12.85% greater decline in opioid prescribing (PNature Communications.

“Providing physicians a simple plan that will guide them at a patient visit appears to help temper their use of these drugs,” Doctor said in a press release. “This represents a promising approach to reducing fatal drug overdoses, one that is both affordable and scalable.”

Doctor and colleagues noted that previous work showed that notifying physicians by mail when a patient died of an opioid overdose helped diminish opioid prescribing. But they wanted to know whether adding “planning prompts” — concrete actions that can be triggered by a specific set of circumstances — could reduce this prescribing even further.

“For example, a physician might better use the information in the letter, if the letter guidance urges them to implement steps at the visit, such as discussing alternative pain management strategies or consulting with a pain management or addiction specialist for evaluation and care,” the researchers wrote.

To conduct the trial, Doctor and colleagues randomized 541 clinicians in Los Angeles County to receive either a standard letter about the patient’s death (n=284) or the letter with guidance (n=257).

Participants were included because they prescribed schedule II-IV drugs within the prior year to a patient who died of an overdose where opioids were a primary or contributing cause. Overall, 316 deaths from late October 2018 to late May 2020 were included.

Both physician groups received a letter signed by the examiner-coroner informing them of their patient’s opioid-related overdose death and information about judicious prescription practices. The intervention group additionally received an “if/when-then” plan that explained alternative ways to handle patients who needed pain treatment. The letters were sent monthly between April 4, 2019, and July 8, 2020.

In addition to greater declines in opioid prescribing, doctors who received the additional “if/when-then” plan also had greater declines in benzodiazepine prescribing, with an 8.32% reduction in weekly diazepam milligram equivalents (P

The study was limited because it may not be generalizable outside of Los Angeles County, the largest county in the U.S., and by its small sample size. It examined a short-term effect and did not follow up to determine any effects on patient outcomes.

Also, the intervention reached only prescribers with a death in their practice, though the researchers emphasized those clinicians were likely most in need of the intervention.

They called for further research “to confirm the results, examine the long-term effects of the intervention, and explore its potential effects on patient outcomes.”

Doctor added that the study “is part of an evolution toward better understanding how to enact behavior change among physicians whose patients have suffered negative consequences from care by the medical community.”