MARY LOUISE KELLY, HOST:
California is taking an aggressive approach to combating the opioid epidemic. It's called the Death Certificate Project. The state medical board is combing through the death certificates of patients who died from opioid overdoses. Then the board is investigating the doctors who prescribed the drugs. From member station KQED in San Francisco, April Dembosky reports some doctors are so afraid of being sanctioned they have stopped treating patients with chronic pain.
AKO JACINTHO: Dear Doctor, pursuant to...
APRIL DEMBOSKY, BYLINE: About a year ago, San Francisco doctor Ako Jacintho got home from traveling to find a letter from the state medical board.
JACINTHO: The complaint alleges the following.
DEMBOSKY: It said a patient of his had died in 2012 from taking a toxic cocktail of methadone and Benadryl, and he was the doctor who wrote the last prescription for methadone. He had two weeks to respond.
JACINTHO: Written summary of the care, expert testimony, a certified copy of the patient's medical record.
DEMBOSKY: And if he refused?
JACINTHO: Citation penalties of $1,000 per day.
DEMBOSKY: The letter seemed to presume he did something wrong. But when Jacintho reviewed the patient's medical charts, he was convinced he didn't.
JACINTHO: This person had intractable pain.
DEMBOSKY: At the time, Jacintho says, methadone was common for treating the kind of back pain his patient had. And he takes issue with the board's choice of words here, overprescribing and toxic levels.
JACINTHO: What's a toxic level for someone may not be a toxic level for someone else.
DEMBOSKY: It wasn't until 2016 that the CDC issued guidelines for prescribing opioids, telling doctors to start low and go slow. But back in 2012 and '13, doctors like Jacintho were being admonished to never leave a patient in pain. The California Medical Board's own guidelines said, for certain types of pain, opioids were the cornerstone of treatment and should be pursued vigorously.
JACINTHO: It actually says that no physician will be punished or receive disciplinary action for prescribing opioids to patients with intractable pain.
DEMBOSKY: But now the medical board is using death certificates from 2012 and '13 to discipline doctors. The punishments include public reprimands, probation and even revoking a doctor's medical license. The timing of the investigation really bothers Jacintho because in the six years since his patient died, he's totally revamped his practice. As a family doctor, he saw the opioid crisis coming, so he got more training to become an addiction specialist.
JACINTHO: If they're looking for clinicians who are overprescribing, I'm the wrong doctor.
DEMBOSKY: The head of the medical board, Kim Kirchmeyer, says the board takes things like this into account. And it's only punishing doctors with a clear and repeated pattern of inappropriate prescribing.
KIM KIRCHMEYER: Individuals were prescribing drugs without even performing a history and physical exam. They don't have a treatment plan with...
DEMBOSKY: Investigators sent letters to about 500 doctors who seem to deviate from the standard of care.
KIRCHMEYER: ...Any type of testing....
DEMBOSKY: So far, they've filed formal accusations against 25 of them.
KIRCHMEYER: ...Just not paying attention to drug-seeking behavior.
DEMBOSKY: The majority of doctors who've been investigated up to this point have been cleared of any wrongdoing. Hundreds more, like Jacintho, are still waiting more than a year later to learn their fate. But ultimately, Kirchmeyer says, this is about patient safety, not doctors' comfort.
KIRCHMEYER: If we save one life through this project, that is meeting the mission of the board. And that makes this project so worth it.
DEMBOSKY: But some fear the project could ultimately harm patients. Some doctors have been so frightened by the letters they've lowered their patients' opioid doses or cut them off completely. Public health researcher Phillip Coffin has done preliminary research suggesting some of these patients are twice as likely to turn to street drugs, increasing their risk of overdose.
PHILLIP COFFIN: Scaring providers into not prescribing opioids is not the ethically appropriate way to go forward.
DEMBOSKY: Kirchmeyer says the board doesn't want doctors to simply stop prescribing. She says they're trying to wrap up investigations faster. And they've rewritten the letter so they sound less accusatory. But the board is committed. After it finishes reviewing the 2013 deaths, it's going to start on 2014. For NPR News, I'm April Dembosky in San Francisco.
KELLY: And that story is part of a reporting partnership with NPR, KQED and Kaiser Health News.
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