by Flora Y. Bessey, Pharm.D., BCGP

As many members may recall, since 2013 the Medical Board of California (MBC) and the California Department of Public Health have been working with various state legislature subcommittees to try and address the issue of opioid “overprescribing.” One initiative of this project is now known as the “Death Certificate Project.” 

This Project is a good faith effort to address the crisis of accidental deaths due to prescription opioid overdoses. To very briefly recap: the MBC has obtained data from the CDPH for 2012 and 2013 related to opioid prescriptions. These data used codes that the CDPH uses to identify underlying AND “contributing” causes of death in order to identify opioid-“related” deaths. The MBC began to examine these data in 2015, cross-referencing them with the California Controlled Substance Utilization Review and Evaluation System (CURES) database to determine who was prescribing to these individuals, and also looked at the prescribing habits of the attending physician, or the physician who certified death. These data were then sent to “experts” to evaluate whether there might have been inappropriate prescribing.

What does that mean to clinicians in our setting? Well, those above-referenced “experts” have finished analyzing the data, and have begun to issue ominous letters to prescribers (some of you may have already received one). They say, somewhat misleadingly, that the CDPH has received a “complaint filed against you” regarding a patient death (keep in mind, the deaths referenced will be from 2012 and 2013).

Based on the above investigations, letters are also being sent to living patients stating MBC "is reviewing the quality of care provided to you by Dr. X,” and asking the patient to authorize the doctor to promptly turn over that patient’s medical records to the Board.

It is obvious the problems this may cause, and the questions that we must answer: 

• Does your setting employ pain specialists? If your facilities have a pain specialist, consider yourself lucky; there is a severe shortage of pain specialists in our setting. How willing might these doctors be to continue to treat our very complex chronic pain patients knowing that ANY death that occurs while the patient has an opioid prescription will be scrutinized so minutely?

• Do you as a LTC practitioner know the particulars of this “Project?” It is very important that we educate ourselves, as many/most of us (pharmacists included) are part of the CURES database.

• How apprehensive may we all be about treating pain, and how you and the IDT go about addressing pain in your residents? We have all been subject to the inconvenience of “triplicate” documentation; how much more of a challenge are we going to face now?

Not surprisingly, prescribers who have received these letters have immediately contacted lawyers (and the various medical associations are recommending just that). So, we are further down the road of “defensive medicine.” An increasing number of prescribers are saying “Forget it, I just won’t treat these patients!” Since there are millions of people who are presently being treated with opioids, it is obvious the crisis this will cause if enough doctors go this route. And it is unfortunate that many patients with legitimate indications for opioid use and severe pain will probably not be treated adequately.  

For now, it is even more important to keep scrupulous records on your patients; several of the doctors who have received the MBC letters have been “cleared” due to the fact that they had sufficient documentation of how they were treating these patients.

More in-depth information on the “Death Certificate Project” can be found below:

https://www.medpagetoday.com/ painmanagement/painmanagement/ 74856

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