Letters to Doctors Reduced Their Opioid Prescribing for a Year

By Pat Anson, PNN Editor

Many doctors in the U.S. have scaled back or stopped prescribing opioid pain medication because they fear scrutiny or even imprisonment by the DEA and other law enforcement agencies.

A team of USC researchers believes there’s a better way to address risky opioid prescribing: have coroners and medical examiners notify all doctors by letter when a patient dies from an overdose.  

“This is not meant to be a law enforcement exercise but a simple nudge. The point is not to scare, blame or shame doctors, but to make them aware of real risks in their patient cohorts, risks they may not be aware of otherwise,” says Jason Doctor, PhD, Professor and Chair of Health Policy and Management at USC’s Sol Price School of Public Policy.

Doctor and his colleagues found that when 809 prescribers received a letter from San Diego county’s medical examiner notifying them about the overdose death of a patient, they reduced the doses of opioid prescriptions they wrote for up to a year afterward. Their findings, published in JAMA Network Open, builds upon a previous study that found the same clinicians reduced their prescribing for three months after receiving such a letter.

"Clinicians don't necessarily know a patient they prescribed opioids to has suffered a fatal overdose," said Doctor. “We knew closing this information loop immediately reduced opioid prescriptions. Our latest study shows that change in prescribing behavior seems to stick."

Nationwide, opioid prescribing has fallen dramatically over the past decade. But USC researchers found the reduction was faster and more extensive among clinicians who received the letter. After one year, their prescriptions were 7.1% lower in morphine milligram equivalent units (MME) than clinicians who hadn't received the letter. The number of new patients they prescribed opioids to also fell by two percent.

"The new study shows this change is not just a temporary blip and then clinicians went back to their previous prescribing," said Doctor. "This low-cost intervention has a long-lasting impact."

Other Drugs Often Involved

There are three major caveats to the USC study. The first is that other substances besides prescription opioids – such as illicit drugs -- were involved in many of the overdose deaths. That’s because the criteria for the study were broad and subjective, including any patient who died when "prescription drug overdose was the primary cause or contributed to the cause of death."

Second, clinicians were included in the study if they had written any opioid prescription within 12 months of the patient’s death. That would explain why 809 prescribers received letters about the overdoses of 166 patients. Doctors received a letter even if a patient was no longer under their care and without conclusive evidence that the prescription they wrote was involved in the death.

Third, the study does not address the growing number of deaths caused by illicit fentanyl, which is now responsible for the vast majority of U.S. overdoses. Letters to doctors are unlikely to have any major effect on overdoses involving street drugs. A 2022 study confirmed there is very little correlation between overdoses, prescription opioids and MME dosage levels.

There have been several previous efforts to rein in opioid prescribing by sending warning letters to doctors. Federal prosecutors in Wisconsin and other states have done it, telling high-dose prescribers they could face prosecution, even when they have not been charged with a crime or linked to an overdose.

The Medical Board of California’s “Death Certificate Project” sent threatening letters to doctors about overdoses that occurred months or years after an opioid prescription was written -- an effort that some likened to a “witch hunt.” Some doctors were targeted even when multiple drugs were involved or the cause of death was suicide.

USC’s Doctor says a gentler “nudge” is needed, not threats. And he wishes the letters sent to San Diego doctors were mandatory statewide.

“That was a terrible approach to delivering letters that the medical board carried out,” Doctor wrote in an email. “We had none of the outcry or problems the (board) did because we were supportive and met clinicians on a professional level.”

The Fentanyl Exposure Myth Must End

By Roger Chriss, PNN Columnist

There is a pervasive belief that exposure to even a speck of illicit fentanyl can be immediately life-threatening. The most recent example is a story from USA Today.

“Dramatic body camera footage shows that a sheriff’s deputy in California nearly died after being exposed to fentanyl at an arrest last month,” the story begins, explaining that Deputy David Faiivae collapsed after finding a “white substance” in the trunk of a suspect’s car on July 3.

Faiivae appears to be revived by his training officer with a nasal spray of naloxone, an anti-overdose medication. The body camera video of the incident was so dramatic, the San Diego County Sheriff’s Department turned it into a training video:

There are reasons to be cautious with stories like this. Fentanyl is a potent synthetic opioid responsible for tens of thousands of overdose deaths, but experts say it’s not nearly as dangerous as it is often portrayed.

"You can't just touch fentanyl and overdose," Ryan Marino, medical director for toxicology and addiction at University Hospitals in Cleveland told NBC News. "It doesn't just get into the air and make people overdose.

"We have a lot of scientific evidence and a good knowledge of chemical laws and the way that these drugs work that says this is impossible."

Casual contact with fentanyl is not generally life-threatening. As Marino explains in a guide for first responders, fentanyl powder is not absorbed through the skin and powdered opioids do not aerosolize.

This is a well-founded view. Drs. Lewis Nelson and Jeanmarie Perrone wrote in STAT News that “there is clear evidence that passive exposure to fentanyl does not result in clinical toxicity.”

But stories of passive exposure to fentanyl being life-threatening are becoming more common. Google Trends shows a rapid uptick from 2017 onward after media coverage of an Ohio patrol officer supposedly overdosing on fentanyl after brushing a bit of powder from his shirt.

According to a 2020 study in the International Journal of Drug Policy, there were 551 news articles in 48 states about casual contact with fentanyl from 2015 to 2019. The reports received about 450,000 Facebook shares, potentially reaching nearly 70 million people.

“Fueled by misinformation, fentanyl panic has harmed public health through complicating overdose rescue while rationalizing hyper-punitive criminal laws, wasteful expenditures, and proposals to curtail vital access to pain pharmacotherapy,” the study found.

If passive exposure to fentanyl were as risky as media and law enforcement suggest, wouldn’t there be a flood of bodies from illicit drug operations? Drug labs do not operate with robust safety measures and street dealers handle drugs in ways that would make passive exposure inevitable. Deaths result when fentanyl is ingested, not from casual contact.

The misperceptions of passive exposure risks are impacting law enforcement, emergency services and medical care. As a result, pharmacy professor Lucas Hill joined with Marino and others to write an open letter this week to media outlets called “Retraction Request for Dangerous Drug Misinformation.”

“We are issuing this letter to request a retraction and correction of your recent article which perpetuates a myth: that casual contact with potent synthetic opioids such as fentanyl poses a health risk to first responders. This is dangerous misinformation that can cause harm both to people who use opioids and to members of the law enforcement community. We greatly appreciate your cooperation in addressing this error.”

The letter is the latest attempt to reduce the harms of media misinformation about drugs. But as with so many things involving drugs, mythology drives too much of the media and law enforcement narrative.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.   

Medical Examiner: ‘I Can’t Remember Last Death From Prescribed Fentanyl’

By Pat Anson, PNN Editor

A recent statement from the San Diego County Medical Examiner’s Office caught our eye – because it offered a rare distinction between prescription fentanyl and counterfeit painkillers made with illicit fentanyl.

It’s an important point for millions of pain patients who use fentanyl responsibly.

“In the last decade when someone overdosed on fentanyl, it was often when someone was prescribed it, and perhaps put on too many fentanyl patches or altered the patches,” said Chief Deputy Medical Examiner Dr. Steven Campman. “I can’t even remember the last time I saw a death from misused prescribed fentanyl.”

Campman was talking about a 68% increase in fentanyl overdose deaths in San Diego. During the first six months of this year, 69 people overdosed on fentanyl -- compared to 41 the year before – and every one of those deaths was attributed to illicit fentanyl.

“Now, in the deaths we see, the fentanyl is illegally obtained as counterfeit oxycodone or alprazolam (Xanax). Illegal drug makers and dealers make pills to look like oxycodone or alprazolam, but the pills have fentanyl in them, and they are deadly,” Campman is quoted in a press release.

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine that’s been used for decades in palliative care and as an anesthetic during surgery. More recently, fentanyl has been used in transdermal skin patches, oral sprays and lozenges to treat severe pain.

COUNTERFEIT OXYCODONE

“Each of these new uses of fentanyl exposed millions of Americans to the drug without evidence of an inordinate degree of harm if it was used as directed,” Dr. Lynn Webster explained in a recent column.

Only in recent years has illicit fentanyl become a scourge on the black market and given a bad name to a medication that alleviates a lot of suffering. “Mexican Oxy” and other counterfeit pills made with illicit fentanyl have been linked to thousands of overdose deaths around the country. According to a recent analysis by the DEA, one in every four counterfeit pills have a potentially lethal dose of fentanyl.

“The drug isn’t designed to be put in a pill like that, and it takes very little of it to kill someone. And the illicit drug makers don’t have the kind of quality control measures that pharmaceutical companies have either,” Campman added.

Federal prosecutors have called San Diego the “fentanyl gateway” to the U.S. because the city is near ports of entry in southern California that are major transit points for Mexican drug cartels. In July, a drug courier was pulled over by an alert Texas trooper in Amarillo and found to be transporting 73 pounds of illicit fentanyl powder -- enough to kill 10 million people.

The underground fentanyl trade has also given rise to “Breaking Bad” style pill press operations.

In September, DEA agents found five pounds of pure fentanyl in the San Diego apartment of Gregory Bodemer, a former chemistry instructor at the U.S. Naval Academy, who died from an apparent overdose. Also found in the apartment was a pill press, powders, liquids and dyes used in the manufacture of counterfeit drugs.

Bodemer’s death is yet another example of how the opioid crisis has evolved from a prescription drug problem into a fentanyl crisis.

“This is how we are seeing the opioid epidemic here, mostly in the rise in fentanyl deaths,” Campman said.

Fentanyl Overdoses Spike in Seattle

By Pat Anson, PNN Editor

Public health officials in the Seattle area are warning about a spike in fentanyl-related overdoses that have killed at least 141 people in King County since June. As in other parts of the country, many of the deaths involve counterfeit oxycodone pills laced with illicit fentanyl.

Three of the recent overdose victims in King County are high school students who took blue counterfeit pills stamped with an “M” and a “30” – distinctive markings for 30mg oxycodone tablets that are known on the street as “Mexican Oxy” or “M30.”

“Teenagers who are not heroin users are overdosing and dying,” said Brad Finegood of Public Health – Seattle & King County. “Do not consume any pill that you do not directly receive from a pharmacy or your prescriber. Pills purchased online are not safe.”

Gabriel Lilienthal, a 17-year-old student at Ballard High School in Seattle, died Sept. 29 from a fentanyl overdose.

“Gabe died from a fake OxyContin called an M30,” the teen’s stepfather, Dr. Jedediah Kaufman, a surgeon, told The Seattle Times. “With fentanyl, it takes almost nothing to overdose. That’s really why fentanyl is a death drug.”

Fentanyl is 50 to 100 times more potent than morphine. It is prescribed legally to treat severe pain, but in recent years illicit fentanyl has become a scourge on the black market, where it is often mixed with heroin and cocaine or used in the production of counterfeit pills. Illicit drug users often have no idea what they’re buying.

As PNN has reported, counterfeit oxycodone pills laced with fentanyl are appearing across the country and have been linked to hundreds of deaths. Yet this emerging public health problem gets scant attention from federal health officials, who are currently focused on an outbreak of lung illnesses associated with vaping that has resulted in 18 deaths.

‘Enough to Kill San Diego’

In San Diego last month, DEA agents found five pounds of pure fentanyl in the apartment of Gregory Bodemer, a former chemistry professor who died of a fentanyl overdose. Prosecutors say that amount of fentanyl was “enough to kill the city of San Diego” or about 1.5 million people.

Also found in Bodemer’s apartment was carfentanil, an even more powerful derivative of fentanyl, along with a pill press, powders, liquids and dyes used in the manufacture of counterfeit medication.  

Bodemer’s body was found in his apartment Sept. 27. Rose Griffin, a woman who also overdosed at the apartment and recovered, has been charged with drug possession and distribution.

Bodemer was an adjunct chemistry professor at Cuyamaca College in 2016. He had previously worked as a chemistry instructor at the U.S. Naval Academy in Annapolis, Maryland.

Feds Warn of Counterfeit Oxycodone Deaths

By Pat Anson, PNN Editor

In the wake of four fentanyl overdoses in southern California, federal authorities have issued a public safety alert warning drug users about a lethal strain of counterfeit medication designed to look like 30mg oxycodone tablets.

The blue bills have the letter “M” in a box on one side and the number “30” with a line down the center on the other. On the street they are referred to as blues, M-30s or Mexican Oxy.

The pills were found at the scene of four fatal overdoses in San Diego County last week. The deaths in Poway, Santee, Lakeside and Valley Center were all reported within 24 hours.

Although tests on the pills are ongoing, authorities suspect they are laced with illicit fentanyl or carfentanil, which can be fatal in tiny doses.

SAN DIEGO SHERIFF’S DEPT. IMAGE

“That heroin, that meth, that coke, that oxy you think you are taking? Well, it just might have fentanyl in it, and it just might be the last thing you ever do,” U.S. Attorney Robert Brewer said in a statement. “I cannot be more clear than this: Fentanyl may be the costliest drug you ever do, because you may pay with your life, and you won’t even know you took it.”

Brewer said border seizures, prosecutions and overdoses are on pace to hit all-time highs in San Diego County by the end of 2019. The Medical Examiner’s Office has confirmed 50 fentanyl-related overdose deaths so far this year, plus another 28 suspected but yet-to-be confirmed cases.

If the trend continues, the death toll could potentially reach 130, which would amount to a 47 percent increase over last year’s total of 90 deaths. The victims are overwhelmingly male, with the average age about 36.

“Just when we think it can’t get any worse, the latest numbers prove us wrong,” Brewer said.  “I am alarmed by the dramatic surge in trafficking activity and deaths, particularly of young people. San Diego is the fentanyl gateway to the rest of the country, and we are working hard to close that gate with interdiction, prosecution and education.”

Federal authorities have confiscated 1,175 pounds of illicit fentanyl – more than half a ton -- at or near the international border so far this year. In addition, there has been a record number of seizures involving counterfeit blue pills labeled M-30 that contain fentanyl. The pills sell on the street for $9 to $30 each and are appearing around the country.

Ports of entry near San Diego are major transit points for illicit fentanyl smuggled in from Mexico. The fentanyl is usually transported in vehicles, often by legal U.S. residents acting as couriers.

A recent report from the Wilson Center found that Mexican cartels are playing an increased role in the fentanyl trade.

“San Diego is the fentanyl gateway to the rest of the country.”

— U.S. Attorney Robert Brewer

“Chinese companies produce the vast majority of fentanyl, fentanyl analogues, and fentanyl precursors, but Mexico is becoming a major transit and production point for the drug and its analogues as well, and Mexican traffickers appear to be playing a role in its distribution in the United States,” the report found.

“Both large and small organizations appear to be taking advantage of the surge in popularity of the drug, which is increasingly laced into other substances such as cocaine, methamphetamine, and marijuana—very often without the end-user knowing it. To be sure, rising seizures of counterfeit oxycodone pills laced with fentanyl illustrate that the market is maturing in other ways as well.”

Last week a former Mexican police officer was indicted for fentanyl trafficking by a federal grand jury in Texas. Assmir Contreras-Martinez, 30, was pulled over by a Texas trooper on Interstate 40 in Amarillo in May. About 73 pounds of illicit fentanyl powder was found inside his 2007 Ford Explorer, enough to kill 10 million people, according to DEA experts. 

Contreras-Martinez admitted he was paid $6,000 to transport the fentanyl from California to Florida and that it was his second such trip. Before his unlawful immigration to the United States nine months ago, Contreras-Martinez had been employed for eight years as a municipal police officer in Cananea, Sonora, Mexico.