BAD PRACTICE: A LETHAL MEDICAL LEARNING CURVE HAS FLATLINED
Accumulating evidence consistently links increasingly lethal public health crisis to medical professional noncompliance with measures, directives, and supports for safe prescribing
by Clark Miller
Published May 1, 2023
Recent posts have exposed disturbing trends and unreported deficits in America’s healthcare system that are driving persistent, increasingly lethal public health crises.
Those have included continuously accumulating consistent evidence of American Medicine’s opioid crisis interventions worsening rather than treating high-risk opioid use, distortion of research results in top medical journals to deceive about those outcomes by use of public health disinformation, and in multiple posts remarkable indications of failure of medical institutions and practitioners now decades into the lethal crisis to guide practice by or comply with research, professional guidance, measures, directives, and supports for changes in prescribing to reduce harms and deaths.
That problem – of continued unsafe prescribing of controlled opioid drugs, decades into an increasingly lethal crisis – was covered in this recent post, and is reinforced by research compiled for outcomes through 2022 –
Recent reports including from January of this year, 2023, provide the same picture, despite widespread media coverage that spin results by overly positive distortions.
The word “Might” saves this headline from constituting overt distortion and dangerous public health disinformation, and points toward the alternative of veracity if the wording would instead have simply announced, “Study on Effects of Letters to Doctors of Patient Overdose Death on Prescribing Inconclusive“.
The study appeared in JAMA in January of 2023.
Total weekly MMEs dispensed decreased 7.1% (95% CI, 0.37% to 13.79%; P = .04) more in the letter intervention group than in the control group 4 to 12 months after the intervention. The Table shows the absolute change in MMEs at 1 to 3 and 4 to 12 months after the intervention. New patients taking opioids decreased by 2.02 percentage points (95% CI, 0.79 to 3.25 percentage points; P = .001) more 4 to 12 months after intervention among intervention than control prescribers, respectively. There was no difference between effects at 1 to 3 and 4 to 12 months for total MME change (β = −0.02; 95% CI, −0.11 to 0.08; P = .71) or new patients (β = 0.01; 95% CI, −0.10 to 0.13; P = .83). The number of prescriptions that were at least 50 MME (β = −0.06; 95% CI, −0.14 to 0.02; P = .20) or 90 MME (β = 0.06; 95% CI, −0.05 to 0.16; P = .27) did not decrease at 4 to 12 months.
MMEs are morphine milligram equivalents, a means of standardizing measure of opioid potency across the variety of opioids prescribed.
Outcomes that appeared positive included the decrease by 2 percent of new patients given opioids and of 7.1 percent in total weekly MMEs dispensed.
Those are very small differences that don’t support strong or clinically (vs statistically) significant effects particularly on consideration of the study design, meaning, and limitations.
Confounding and qualifying the differences, there were no benefits found after 4 months of receipt of the letters in amount of opioids prescribed, new patients prescribed, or importantly, prescriptions of highest amouints of opioids.
As an independent reviewer noted here for a very similar study by the same research team, “the outcome measure of this study is prescription amounts, but Dineen says she’s curious to see if mortality rates fall after doctors get these letters”.
That’s a fair and diminishing point for a study aimed at evaluating the role of prescriber behaviors on high-risk opioid use and deaths.
Critically, the study could not measure the opioid use behaviors, risks, or potential outcomes for any of the patients themselves, leaving the possibility that reductions reflected reduced, short-term prescription of opioids for patients who would have had relatively low vulnerability to overuse and problem use in any case, without reductions for patients most at risk.
Speaking from clinical team experience with prescribers in such situations, it is much easier to tell a new patient that they can do without a week’s prescription of oxycodone for their sprain and get by as well with a non-opioid analgesic, than to attempt to reduce amount of opioids prescribed to a longstanding user with tolerance, psychological dependence, and verbally aggressive demands. Doctors can be inhibited in these situations by the confrontations, the risk of patient complaints, concerns about withdrawal, even threats of harm to self, and clinical setting in which the prescriber may not be supported in making those difficult changes. Those patients are also at higher risk of high-risk opioid use.
Results of this study are congruent with those scenarios. Total MMEs were reduced by a very small amount it appears by declining prescriptions to new patients, while patients using highest doses saw no reductions.
And more importantly, an illustrative example of how reliably – regardless of what a research study’s results do or do not support – medical, research, and major media will predictably distort and spin results to represent some gain against the opioid crisis.
Public health disinformation is not a gain.
Here’s another very recent study again published January of this year.
To facilitate safer prescribing of opioids and other drugs, nearly all states operate prescription monitoring programs (PMPs), which collect and share data on controlled substance dispensing. Policy makers have sought to raise clinicians’ engagement with these programs but lack evidence on effective interventions. Working with the Minnesota Prescription Monitoring Program, we conducted a randomized trial to assess whether letters to clinicians increased program use and decreased risky coprescribing of opioids with benzodiazepines or gabapentinoids. In March 2021 we randomly assigned 12,000 coprescribers to either a control arm or one of three study arms sent differing letters. The respective letters highlighted a new mandate to check the PMP before prescribing, provided information about coprescribing risks with a list of coprescribed patients, or contained both messages combined. Letters highlighting the mandate alone or along with coprescribing information increased PMP search rates by 4.5 and 4.0 percentage points, respectively, with no significant effect on coprescribing. These letters also increased PMP account-holding rates among clinicians. Effects persisted for at least eight months. The letter with only coprescribing information had no detected effects on key outcomes. Our results support the use of simple letter interventions as evidence-based tools to increase PMP engagement and potentially facilitate better-informed prescribing.
with no significant effect on coprescribing
The coprescribing of an opioid with benzodiazepine significantly increases risk of overdose and death by overdose.
Bottom line: as in other studies, consistently, letters to prescribers did not result in safer prescribing. Including these from pharmacists –
A decades long learning curve has flatlined, obviating a question posed 6 years ago.