Doctors call California’s probe of opioid deaths a ‘witch hunt’ – by Cheryl Clark – Jan 2019
The Medical Board of California has launched investigations into doctors who prescribed opioids to patients who suffered fatal overdoses, in some cases months or even years later.
The effort, dubbed “the Death Certificate Project,” has angered physicians in California and beyond, in part because the doctors being investigated did not necessarily write the prescriptions that led to a death.
That makes it the most comprehensive [and perverse] project of its kind in the country.
So far, the medical board has launched investigations of about 450 physicians and referred the names of 72 nurse practitioners, physician assistants and osteopathic physicians to their respective licensing boards.
Critics of the project call it a “witch hunt” and an “inquisition.”
Many doctors said it is causing them or their peers to refuse patients’ legitimate requests for prescription painkillers out of fear their practices will come under disciplinary review.
The project, first reported by MedPage Today, has struck a nerve among medical associations. Dr. Barbara McAneny, president of the American Medical Assn. and an Albuquerque, N.M., oncologist whose cancer patients sometimes need treatment for acute pain, called the project “terrifying.”
“It will only discourage doctors from taking care of patients with pain,” she said.
The influential California Health Care Foundation also has complained that the project could harm patients.
Nationally, a host of policy changes and educational efforts have driven down the rate of opioid prescriptions in recent years.
The goal of California’s program, quietly launched four years ago, is not necessarily to link a specific prescription to a specific death — although many of the cases do — but to find doctors whose prescribing patterns are so dangerous they put patients at risk of developing fatal addictions.
In some cases, a doctor was earmarked for investigation even though the cause of death included multiple drugs prescribed by many physicians, board documents indicate.
This really seems ridiculous.
With so many people dying from illicit street drugs, it makes little sense to trawl through prescription records from years ago to find a doctor who may have prescribed the person an opioid at some point – maybe even just for a few days of post-surgical pain.
All those that died also most likely used alcohol (by far the most common drug), but we are not pursuing the alcohol industry that has created many more addictions and deaths than opioids.
I have to wonder what kind of person devised such a selective retrospective implementation of opioid restrictions. This extreme measure is so absolutely perverse and senseless it’s no wonder medical organizations have pushed back.
In other cases, doctors were investigated when patients used prescription painkillers to commit suicide.
Kimberly Kirchmeyer, executive director of the Medical Board of California, defended the project. She said the effort has found patterns of “gross negligence,” incompetence and excessive prescribing among doctors.
She noted that part of the point of the project is to educate doctors and, through probation requirements, change the behavior of those who prescribe excessively.
This is absurd to call it “educating” when their policy “targets” doctors and doles out punishment that can ruin a career.
Some consumer groups fault the project for not being aggressive enough.
I wonder how these “consumer groups” will feel when they get cancer, have it treated, and then live the rest of their lives with the resulting chronic pain.
So far, the medical board has looked at opioid-related deaths only in 2012 and 2013. Investigators matched the names of the dead with the prescription drugs they had filled, which are listed in the state’s prescription database along with the names of the doctors who prescribed to them.
Physician experts reviewed those doctors’ prescribing history and targeted those who appeared to prescribe drugs heavily.
So often these days, “physician experts” are actually addiction specialists who believe that most opioid use is an addiction, a view that is not only heartless but extremely damaging to medical pain management practice.
Some doctors said they received letters concerning prescriptions they wrote as long as nine years ago.
McAneny, of the AMA, noted that prescribing practices now deemed unacceptable grew out of public policies years ago that “compelled doctors to treat pain more aggressively for the comfort of our patients.”
Also, payers have measured quality of care according to whether patients said their pain was well-controlled.
Many insurance plans and pharmacies have restricted the dosages and durations of certain painkillers, including limits on how many a physician may prescribe at one time
When pain specialists challenge these restrictions they may be heeded more than a bunch of miserable exhausted patients.
The CMA stops short of saying the medical board should stop the project.
They’ve said it was wrong to implement the restrictions and yet don’t stop those restrictions from going into effect.
This betrayal is the political part of the situation. They don’t want to anger their regulators.
But it has asked the board to hire an independent reviewer to assess the criteria it is using to decide which doctors to investigate, and whether physicians in certain specialties or regions of the state are being targeted more than others.
The doctors targeted are clearly the ones who prescribe the most opioids. And that would often would be pain specialists, so they’re the ones in the most danger.
Dr. Ako Jacintho, a San Francisco addiction medicine specialist, was notified by the board that he was in trouble more than a year ago.
I’m surprised they are even going after addiction treatments.
If doctors aren’t allowed to use opioids for MAT (medication-assisted treatment), these rules are counterproductive.
A patient for whom he had prescribed methadone fatally overdosed in 2012. The letter said “a complaint” had been filed against him, and asked him to respond to the allegations or, if he delayed, face a citation or fine of $1,000 per day.
The letter said the patient had died of “acute combined methadone and diphenhydramine [Benadryl] intoxication.”
Jacintho had refilled the patient’s prescription for methadone the day before but said a 10-milligram pill was not a toxic dose. And he said he never prescribed diphenhydramine, the antihistamine sold as Benadryl.
“The only way he would have died was if he had not taken it as directed, or had mixed it with a medication that was not prescribed,” Jacintho said.
As of early January, Jacintho was still waiting to hear if he would face a formal accusation of negligent prescribing.
Last year, the board rewrote its letters in a less accusatory tone — describing the “review” as routine — although it still threatens doctors with $1,000-a-day fines.
In a small subset of cases, it finds problems that result in formal accusations. These can result in public reprimands, restrictions on a physician’s ability to practice, or other disciplinary actions.
Despite its designation as a “Death Certificate Project,” the California effort has not been limited to doctors whose patients died.
In an unknown number of cases, the board has sent letters to living patients asking them to authorize their doctors to relinquish their medical records. If they don’t, the patients are told, the documents will be subpoenaed.
I’m stunned at this invasion of privacy and find it hard to believe that these tactics are legally sound.
Dr. Paul Speckart, a San Diego internist, said three of his patients received board letters last year that seemed to question his quality of care when all he did was try to relieve their well-documented pain. The board has not filed any accusations against him.