Minnesota is notifying doctors if they prescribe disproportionate amounts of addictive opioid painkillers compared to their peers, and whether they need to change their practices or risk getting booted out of the state’s Medicaid program.

In a new tack against the state’s painkiller epidemic, letters were sent Friday to more than 16,000 doctors, dentists and others who prescribed at least one opioid in 2018 to a patient covered by the government-subsidized Medicaid and MinnesotaCare programs.

Those in the top quarter of prescribing rates will be put on notice this year and will be required next year to participate in state-monitored improvement programs. After that, poor performers could be barred from Medicaid, which covers one-fifth of the state’s patient population.

“This is one of the best tools for working with prescribers,” said Tony Lourey, commissioner of the Minnesota Department of Human Services, which oversees Medicaid and MinnesotaCare. “They really care how they stack up against their peers.”

Excessive prescribing has been linked to a sharp increase in Minnesota opioid overdose deaths, which rose from 54 in 2000 to 422 in 2017, according to state Department of Health data.

While many people died from overdoses of illicit heroin or potent synthetic opioids such as fentanyl, doctors have traced some of those cases back to initial prescriptions of common opioids such as oxycodone or hydrocodone that patients received after surgeries or other medical care. Those painkillers are still implicated in at least half of the overdose deaths, Lourey said.

Variations in prescribing rates by county or medical specialty underscore the problem. In one Minnesota county, doctors issued 27.4 opioid prescriptions per 100 residents. In another, the rate was 98.6.

“That’s pretty much one per every person in that county,” Lourey said in an interview Friday. “There’s something going on there in prescribing practices and we need to help prescribers better understand their role.”

Among emergency medicine doctors, the top quartile prescribed opioids at 2.8 times the rate of the state median.

Prescribing rates of individual doctors are not publicly available, per the 2015 state legislation that created the monitoring program.

Friday’s announcement came amid controversy over the ouster of Dr. Jeff Schiff, former medical director of the state’s Medicaid program and an architect of the state’s opioid prescribing guidelines. The chairman of the state’s Opioid Prescribing Work Group, Dr. Chris Johnson, wrote a newspaper op-ed criticizing the state for urging Schiff to retire at a time when his leadership is needed to convince doctors to accept the prescribing data they receive and to make changes.

“To proceed without the dedicated leadership of a medical director like Dr. Schiff is to take unnecessary risks with the outcome of our response to this deadly crisis,” said Johnson in the piece, which was signed by other members of the work group. “It is a disservice to providers and a danger to patients.”

Lourey said the change in leadership was due to a realignment of the state’s Medicaid program, which now is seeking separate medical directors for its mental and physical health programs. He acknowledged poor communication to the work group members about this transition and is meeting with them next month.

Aggressive marketing

Minnesota’s efforts to reduce opioid prescribing, and its consequences, have increased over the past five years. Other strategies include expanded access to naloxone, a rescue drug for overdoses, and additional disposal locations in pharmacies and law enforcement offices for unused prescription opioids that could otherwise be abused.

The Minnesota Board of Pharmacy has a similar monitoring program, but it checks for addicted patients who are “shopping” for opioid prescriptions among multiple doctors. The board sends letters to doctors when they have patients who fit this profile.

Many critics trace the national epidemic of opioid overdoses and deaths to unethical drug company marketing two decades ago, including the designation of pain as a “vital sign” that all doctors needed to measure and treat in patients. Minnesota and other states have sued drugmakers who engaged in these practices.

While opioids are recommended for short-term pain management, especially right after surgery, they have never been proven to manage long-term, chronic pain.

Johnson has been an outspoken critic of opioid prescribing, but he said the state needs to be sensitive to the fact that some patients have taken opioids for chronic pain for years and are now dependent.

Simply holding the line on the dosage level might be victory in those cases, he said. “For some patients, the best we’re ever going to be able to do is never increase their dosage again.”

Lourey said the state won’t automatically boot doctors from Medicaid if they don’t rein in opioid prescribing.

“Maybe a practitioner inherited a bunch of chronic pain clients” from a retiring doctor, he said. “There are things that can happen that are legitimate and we want to be sensitive to them.”