The Tennessee Medical Association Board of Trustees has adopted the following position on Governor Haslam's TN Together plan for addressing the state's opioid abuse epidemic. Our position is based on a thorough review of the proposed legislation and feedback from member physicians in various medical specialties and practice environments across the state.
- The governor's proposal unfairly labels and segregates patients. Definitions for "acute" and "opioid naïve" patients in the draft bill are confusing, impractical and unfair. Every person is different, yet the legislation would put some patients into multiple categories, set broad-brush restrictions and take away doctors' medical discretion.
Our proposed solution: Remove the "acute care" definition to avoid conflicts with the "chronic non-malignant pain" definition already in state law, clarify "healthcare practitioners" instead as prescribers and dispensers, and give physicians some flexibility to determine reasonable exceptions to cookie-cutter labels.
- The governor's proposal interferes with the physician-patient relationship.TMA has been instrumental in the state's developing, implementing and improving the Controlled Substance Monitoring Database and was the first state medical society in the U.S. to support mandated lookups by prescribers. Data shows existing usage of the CSMD is already working - we have reduced doctor shopping by more than 70% since 2012. The number and frequency of mandated CSMD lookups in the governor's proposed legislation, however, will add unnecessary administrative burden on prescribers without really helping prevention or expanding the supply of staff to perform those lookups.
Our proposed solution: Remove the "acute care" definition and the associated CSMD checks from the bill, change existing state law to allow for more physician extenders to help perform worthwhile CSMD checks on abused medicines, and exempt doctors who prescribe and dispense in the same location from performing redundant CSMD checks at dispensing.
- The governor's proposal fails to protect patients who are suffering from legitimate chronic pain. A one-size-fits-all, five-day limit on opioid prescriptions could adversely impact some patients who do not respond to alternative pain treatments or other scenarios, such as those recovering from invasive surgery. Doctors should not be forced to refer patients to a pain management clinic when a five-day opioid supply is ineffective. There are not enough certified pain specialists in Tennessee to care for Tennesseans experiencing legitimate chronic pain.
Our proposed solution: Continue to limit dispensing instead of prescribing. Allow doctors to write the prescription they feel medically appropriate after checking the CSMD and restrict the initial fill to seven days at the pharmacy. Add a provision to the bill that requires insurance companies to pay for alternative (non-opioid) pain management treatments.
In addition to these and other specific changes, TMA advocates for a sunset date of 2021 on HB 1831 to allow all stakeholders to evaluate the law's effectiveness and determine specific areas worthy of long-term investment using valuable state resources.
TMA has worked with the General Assembly for years on solutions to address this public health crisis. It is encouraging that Governor Haslam is dedicating more funding for prevention, treatment and law enforcement. We have advocated annually for increased state funding for drug treatment programs, and we must give law enforcement resources to deal with the deadly rise in heroin and fentanyl.
TMA's primary focus in the ongoing opioid abuse epidemic remains educating healthcare providers and reducing initial supply, where physicians have direct influence on patient safety and quality of care.
- TMA was the catalyst to changing the prescribing educational requirements for Tennessee physicians and has delivered safety courses to more than 5,500 prescribers since 2012.
- Our members helped develop Tennessee's opioid prescribing guidelines and continually promote adherence to CDC chronic pain guidelines.
- We lobbied for passage of the Prescription Safety Act in 2012, and important changes to related legislation that passed in 2014, to help reduce Neonatal Abstinence Syndrome.
- TMA helped pass the original state law requiring pain clinic registration, supported the Addison Sharp Act requiring pain clinic guidelines and mandatory CME by prescribers of opioids, worked to pass legislation to require specialty training for pain clinic medical directors, and supported legislation to eliminate dispensing in pain clinics.
We applaud Tennessee's physicians for their leadership on this issue and look forward to working with state lawmakers to make sure doctors have input in important amendments to HB 1831.