As the 110th General Assembly of the Tennessee State Legislature drew to a close at the end of April, new legislation (SB 2257 / HB 1831) was approved to address a significant part of Gov. Bill Haslam's TN Together Plan to combat the opioid crisis in the state.
As passed by the House and Senate, prescribers will now have additional rules regarding checking the state's controlled substance database and new limits on opioid prescriptions for opioid naïve patients and for acute care patients. Although a strong proponent of proper prescribing, the Tennessee Medical Association had previously opposed several points of the plan based on concerns that setting hard limits on dosing sidestepped clinical judgment and didn't allow physicians to write prescriptions they deemed medically appropriate on a case-by-case basis.
Despite that objection, the new law restricts treatment of an opioid naïve patient to no more than a five-day supply of an opioid and no more than a 30-day supply for an acute care patient. Furthermore, the dosage of a prescribed opioid cannot exceed a daily 40-morphine milligram equivalent (40 MME). However, as part of a compromise with TMA, the law does allow that in "exceptional cases" where the prescriber deems an additional supply of the opioid might be warranted and circumstances exist that would make it difficult for the patient to acquire a second prescription, the provider could issue an opioid naïve patient a second prescription simultaneous to the initial prescription. Written documentation of why the second prescription was written must be included in the patient record, and the provider must counsel the patient or patient representative on the circumstances under which the second prescription could be filled (no sooner than five days or later than 10 days from issuance).
Additional rules for prescribing to acute care patients were also codified including the mandate that a provider must personally assess the patient and obtain informed consent before prescribing an opioid, and other "reasonable, appropriate, and available non-opioid treatments for the pain condition" have been tried first or a contraindication or intolerance of those other options have been documented.
There are a number of exceptions to the rules including inpatient treatment, treatment by certified pain management specialists, and treatment of those in hospice care or who are undergoing active or palliative cancer treatment.
On April 25, Nita W. Shumaker, MD, 2017-18 president of the Tennessee Medical Association issued the following statement on Tennessee's new opioid law:
"It was clear when Governor Haslam announced his TN Together plan in January that lawmakers were going to do something to try to address the state's opioid abuse epidemic. With the passage of SB 2257 / HB 1831, Tennessee now has one of the most comprehensive and restrictive laws of any state.
"The Tennessee Medical Association was actively engaged in the process and appreciates legislators' willingness to consider input from physician stakeholders. From the beginning and during the past several weeks of negotiations, TMA advocated for a mindful, yet practical, approach to initial opioid supply and dosage. Most importantly, we wanted to make sure it did not unreasonably obstruct patients in legitimate pain from getting the care they need.
"The final bill is substantially improved from the initial version. New restrictions on prescribing and dispensing will no doubt achieve the governor's stated goal of reducing overall initial supply. TMA will educate doctors on the new law as part of our ongoing efforts to promote safe and proper prescribing.
"Tennessee's doctors remain concerned, however, about unintended consequences for patients who because of the new law may have more difficulty accessing effective pain management. There are not enough certified pain specialists in Tennessee to care for Tennesseans experiencing legitimate chronic pain. Meanwhile, exploding use of fentanyl, heroin and other illicit drugs are causing more accidental overdose deaths even as opioid prescriptions decline. We still need a multi-faceted and well-funded strategy including treatment and law enforcement to turn back this epidemic."
New Data Shows Decrease in Opioid Prescribing
A new report published by the IQVIA Institute for Human Data Science ("Medicine Use and Spending in the U.S.," April 2018) shows that Tennesseans filled 6,709,154 opioid prescriptions at retail pharmacies in 2017, a nearly 9 percent decrease from the previous year and a 21.3 percent drop from 2013.
Tennessee outperformed most of its contiguous states and is on par with the national average for year-over-year improvements and five-year trends.
The Tennessee Medical Association pointed to the data as validation of the medical community's ongoing efforts to self-regulate prescribing and reduce initial opioid dosage and supply. "This report shows that Tennessee's medical community is driving real change in the initial supply of opioids in our state, despite the fact that clear data to help us identify who is writing excessive amounts for patients is available only to government regulators," said 2017-18 TMA President Nita W. Shumaker, MD. "Physicians, for decades, were told these medications were completely safe and faced potential litigation if we did not treat pain aggressively. As a result, patients developed unrealistic expectations about pain management. Once we recognized the addictive dangers of these medications, we worked hard to change the culture and improve supervision. The report confirms that we are making progress."
National trends show 22.2 percent fewer opioid prescriptions were filled in 2017 than had been filled in 2013, with every state in the nation showing some reduction in the past year. In 2017, a total of 196 million opioid prescriptions were filled in the United States, representing an 8.9 percent decrease from the prior year - the sharpest single-year decrease reported by IQVIA.
Prescription opioid volumes in the U.S. peaked in 2011 at 240 billion milligrams of morphine milligram equivalents and have declined by 29 percent to 171 billion MMEs.
More Money to Fight Opioid Crisis
In April, Senate Health Committee Chairman Lamar Alexander announced Tennessee will receive a nearly $14 million grant from the Department of Health and Human Services in the state's fight against the opioid crisis. The state received nearly $14 million last year, as well - both grants were funded by the 21st Century Cures Act that Alexander authored and President Obama signed into law in 2016.
"The devastation of the opioid crisis has touched nearly every community in our state, and today's announcement - that Tennessee is set to receive another nearly $14 million to fight its ongoing opioid epidemic - will provide a major boost to Tennesseans on the front lines of a battle that is being waged county by county and doctor's office by doctor's office," Alexander said at the April 18 announcement.