Convincing Heavy Prescribers Of Opioids to Change Their Ways: A Tough Sell

A new study investigated whether informational letters to physicians would be sufficient to alter inappropriate prescribing of opioids and other addictive medications. A variety of evidence suggests that physicians generally do not want to be outliers when it comes to their medical prescription habits. Most want to have prescribing behavior that is similar to their physician peers.

There is evidence in several medical systems across the United States that a small proportion of physicians prescribe the lion's share of opioids for chronic pain. And that is true in the US Medicare program for retirees and other beneficiaries.

What about just informing these physicians they are way out of step with their fellow physicians in their opioid prescription behavior? Would that be enough to get them to change their prescription habits? To explore this question, Adam Sacarny, MD, and colleagues at the Columbia University Mailman School of Public Health used Medicare prescribing data to identify heavy prescribers of opioids, amphetamines, and other addictive drugs within the Medicare Part D prescription drug program.

There is a substantial overprescription of addictive medications within the Medicare program, just as there is in nonretirement health care programs. For instance, about one third of all Medicare Part D enrollees fill a prescription for an opioid every year.

The researchers identified 1525 physicians who, on average, prescribed 400% more controlled substances than their peers in 2012. Although these doctors represented just 0.2% of prescribers of controlled drugs within the Medicare program, they collectively accounted for 10% of prescriptions.

"CMS [Centers for Medicare & Medicaid Services] crafted a letter for these prescribers that incorporated insights from behavioral science research. Of the 1,525 prescribers who were identified as potentially risky and enrolled in the study, a randomly selected half were sent the letter. The researchers then used CMS's data repository to track the effect of the letter on prescribing behavior during the following ninety days," noted Sacarny et al.

"To our knowledge, these informative letters to outlier prescribers have not previously been evaluated," they explained.

However, they have been proven to be effective in other medical settings.1

Unfortunately, the letter-writing campaign had no apparent effect on prescribing behavior. "We were unable to detect a statistically significant effect of this intervention," according to Sacarny et al. In fact, the intervention was followed by a slight rise in the prescription of addictive medications.

The researchers are currently studying potential reasons for the failure of this intervention. It is possible, given the bureaucracies involved, that the letters never actually reached the desks of the doctors involved. Another possibility is that the letters were not adequately crafted to convince the recipients. The research team is working with experts on behavioral science to craft new letters that might be more effective.

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