Of all the hare-brained ideas states have implemented to clamp down on legal and medically appropriate opioids, California has come up with the worst:
Comb through the state’s PDMP for the last three years to find a link from someone who recently died from an overdose of illegal drugs to a doctor who prescribed them opioids up to three years ago, and threaten them with prosecution if the CA medical board doesn’t agree with some aspect of this long-ago prescription.
About a year ago, Dr. Ako Jacintho of San Francisco returned home from traveling to find a letter from the state medical board waiting for him.
The letter explained that a patient he had treated died in 2012 from taking a toxic cocktail of methadone and Benadryl — and Jacintho was the doctor who wrote the patient’s last prescription for methadone.
He had two weeks to respond with a written summary of the care he had provided, and a certified copy of the patient’s medical record. He faced fines of $1,000 per day if he didn’t comply.
This certainly makes me better understand why doctors are so afraid to prescribe us opioids. I can’t imagine how I’d have felt to receive such a career-threatening, legally intimidating letter while I was still working.
The letter was one of more than 500 sent to doctors in recent years throughout the state, all part of the California medical board’s Death Certificate Project.
The board typically investigates doctors in response to patient complaints, but with this project, it proactively collected almost 3,000 death certificates of people who died of opioid overdoses, then cross-referenced those with the state’s drug prescription database.
Investigators are going back three years to identify any doctors who may have prescribed the drugs inappropriately, even if it was not the fatal dose, and send them letters.
Doctors who are found to have violated state law face public reprimands, probation, or even revocation of their medical licenses.
When Jacintho received his letter, his first reaction was grief. But then he grew afraid, then indignant. The letter seemed to presume he did something wrong — it used words like “complaint” and “allegation.”
But when Jacintho reviewed the patient’s medical charts, he was convinced he didn’t.
“This person had intractable pain,” Jacintho says, and at the time, methadone was a preferred treatment.
Thank you so much Dr. Jacintho, for standing up for us patients with very real chronic pain that get very real benefit from years of opioid therapy.
Methadone is long-acting, and was considered to have less potential for addiction than other opioids. In particular, Jacintho says he takes issue with the board’s choice of words in the letter: “over-prescribing,” and “toxic levels.”
“Toxicity is a very subjective word,” he says. “What’s a toxic level for someone may not be a toxic level for someone else.”
How refreshing to hear such simple clarity about the intricate complexity of medical opioid dosing.
The California medical board’s own guidelines from 2013 advised doctors that for certain types of pain, opioids were the cornerstone of treatment and should be pursued vigorously.
This is, of course, still the truth, at least as long as health insurance doesn’t cover the necessarily life-long intense therapies of most of the “alternative” pain therapies.
However, like I’ve heard from everyone else, opioid therapy is started only after many non-opioid treatments were tried and failed to achieve sufficient pain relief, and only for patients for whose pain these medications are effective. (yes, there are a few kinds of pain that don’t respond to opioids – I know this because I sometimes have one)
“[The California medical board’s own guidelines from 2013] actually says that no physician will receive disciplinary action for prescribing opioids to patients with intractable pain,” Jacintho says.
But now the medical board is using death certificates from 2012 and 2013 to discipline doctors.
The executive director of the medical board, Kim Kirchmeyer says they review medical records according to the standard of care that was in place at the time.
The board is only punishing doctors who actually broke the law, she says — those with a clear and repeated pattern of inappropriate prescribing.
“Individuals were prescribing drugs without even performing a history and physical exam,” she says. These doctors never did any kind of testing, they didn’t provide informed consent. “They don’t have a treatment plan or objectives. They just continue to prescribe and prescribe.”
This sounds no different than how many drugs are prescribed these days, like for high blood pressure or high cholesterol or depression.
I hope my doctor isn’t wasting her time to itemize the diagnosis each time she refills my antidepressants or thyroid and there hasn’t been a change in my condition. For anyone else but the bureaucrats trolling through long-ago prescription records, the reasons for our prescriptions are obvious.
Especially with chronic pain when we’ve been seeing our same doctor for years, such extra documentation of the obvious and unchanging is a waste of time.
Investigators have so far completed investigations for about half of the 500 doctors originally identified as possibly deviating from the standard of care.
The majority were cleared of any wrongdoing, and the board filed formal accusations against 25 doctors.
But there are hundreds of doctors who are still waiting, more than a year later, to learn their fate.
Ultimately, the medical board is a consumer protection agency, Kirchmeyer says, and this is about patient safety, not doctors’ comfort. “If we save one life through this project, that is meeting the mission of the board, and that makes this project so worth it,” she says.
But it’s unclear if the overall effect of the project will be good for patients.
No, it’s not unclear at all. Reducing the dose of opioids a patient is prescribed without a medical reason is always bad for patients.
Some doctors, including Jacintho, have been so frightened by the letters that they’ve lowered their patients’ opioid doses or cut them off completely. Some doctors are telling their chronic pain patients to find another doctor, according to the California Medical Association. This carries a whole new set of risks.
The CDC’s 2016 guidelines on how to prescribe opioids are for patients who have never taken them before.
I believe the reason everyone is jumping on these numbers, even if they aren’t applicable to chronic pain patients, simply because this document provided what all the anti-opioid folks had desperately needed: numbers.
I do not believe it was either unforeseeable or unintended that the CDC guideline chose to quantify that which is not quantifiable: namely, the amount of pain relief achieved by a specific opioid at a specific dose, at a specific time, for a specific patient.
But they include virtually no guidance on how to taper down doses for chronic pain patients who have already been taking high doses of opioids for many years.
“Scaring providers into not prescribing opioids, I think that is not the ethically appropriate way to go forward,” Coffin says of the California Death Certificate Project.
It was never the California medical board’s intention for doctors to simply stop prescribing opioids, Kirchmeyer explains, and it doesn’t want that outcome.
She says board members have already learned some lessons on how to improve their approach:
They’ve rewritten the letters so they’re less accusatory. And, they know they have to move faster with the investigations.
I think it’s outrageous that this is their idea of an improvement when their actions remain exactly the same. Just “being nice” about prosecution changes nothing about this horrific process.
But the board is committed to the project. Kirchmeyer says after the board finishes examining the 2013 death certificates, it will start working on 2014.