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 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.
To date, the regulators have formally accused at least 23 doctors of negligent prescribing, and more cases are expected. The one filed against Dr. Frank Gilman, for instance, describes a patient who received hundreds of opioid prescriptions over four years, most of them by Gilman. The San Diego internist did not respond to a request for comment.
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.
“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. (California Healthline is an editorially independent publication of the foundation.)
As the nation’s opioid crisis has gotten worse and worse, health officials have turned their attention to doctors who overprescribe the drugs.
Nationally, a host of policy changes and educational efforts have driven down the rate of opioid prescriptions in recent years. In California, the number of opioid prescriptions per 100 people dropped from 54.9 in 2013 to 47.9 in 2015, according to IMS Health in Danbury, Conn.
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. In other cases, doctors were investigated when patients used prescription painkillers to commit suicide.
“I understand their frustrations,” she said of the complaining doctors, “but we do have to continue our role with consumer protection.”
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.
“That’s education that could potentially save patients in the future,” said Kirchmeyer, whose agency licenses some 141,000 physicians.
Some consumer groups fault the project for not being aggressive enough.
“It’s long overdue,” said Carmen Balber, executive director of the nonprofit Consumer Watchdog.
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.
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.
“We’re [already] doing a lot of education to undo the damage” from those policies, she said.
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.
“What we’re finding is that more and more primary-care doctors are afraid to prescribe and more of those patients are showing up on our doorsteps,” he said.
The CMA stops short of saying the medical board should stop the project. 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.
Dr. Ako Jacintho, a San Francisco addiction medicine specialist, was notified by the board that he was in trouble more than a year ago. 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 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.
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.
“You can’t even begin to understand how disrupting and upsetting this is,” Speckart said. “It’s not just a threat on your license, it’s a threat that you’ve not been a good physician.”