Aim Is to Lower Supply, Limit Prescriptions
Tennesseans alarmed over the state's staggering opioid statistics are hopeful a new law that went into effect this month will have a positive impact on an epidemic that continues to intensify.
Tennessee has the second-highest rate of opioid prescriptions in the nation, with more prescriptions than residents, according to local reports. But lawmakers and healthcare officials are optimistic about the new law that requires extra steps by physicians and patients before a prescription for opioid treatment can be filled.
Dave Chaney, Vice President of the Tennessee Medical Association (TMA), worked with Gov. Bill Haslam's office on SB 2257/HB 1831 to reach its current form. Earlier this year, TMA and physicians were concerned about the restrictions placed on dosing of opioids and worked with the governor's office to create necessary exemptions.
Mark Swanson, MD, is Vice President, Baptist Physician Enterprise and President and CEO of Baptist Medical Group - Baptist Memorial Health Care Corporation. He said Baptist is "supportive of the actions being taken within Tennessee to deal with the opioid crisis. We have tried to be as proactive as possible and communicated to our physicians and nurse practitioners information about the new law as it was being developed."
Although the law is a significant change for prescribers, it's a small piece in the large, multi-faceted puzzle of the epidemic.
The new law aims to lower the supply of opioids, with proponents of the bill counting on a reduced supply preventing patients from becoming addicted while at the same time making the drugs more difficult for addicts to abuse. This is the "medicine cabinet phenomenon" or "pass along" rate that targets the supply of prescribed opioids to the public.
The law defines prescription limits (three-day prescriptions, followed by 10-day supply for acute pain and up to 30 days with medical exemption) for opioid naïve and acute pain patients.
Additionally, the prescribing practitioner must obtain patient consent before dispensing the opioids, and check the controlled substance database to ensure a prescription has not been prescribed in the previous six months and that the patient has not been treated with an opioid 30 days prior (or 90 days for an "acute care patient").
There are four restrictions and six patient exceptions to the above restrictions, which makes the new law slightly complicated for prescribers. TMA has created a flow chart for members to help navigate the restrictions, such as limiting opioid naïve patients to a five-day supply, to trials of appropriate non-opioid treatment, and potential patient exceptions, such as palliative cancer or hospice care.
Clint Cummins, Memphis Medical Society executive vice president, says this bill is administratively more challenging for physicians but agrees it was imperative to take action to help combat the crisis.
In Memphis, however, Cummins worries about the shortage of pain management specialists who are equipped to help patients. Jeff Harris, MD, Medical Director at the Methodist University Hospital Emergency Department, agrees that the key is long-term pain management, not a quick fix.
"This law itself represents common guidelines for ED practice, it won't really change our practice that much from what we've been implementing because we try to use the full range of therapy available and try to solve the pain," Dr. Harris said. "Some departments have talked about going to opioid-free departments, or put a ban on certain types of medications, and we have not taken that route.
"We just try to tailor . . . often it's [the treatment] not an opioid or not a medicine. There's a full range of therapies, and that takes longer as a provider, but we try to sit down and make a connection to see what drives a person's pain."
Patient education can go a long way toward preventing the spread of opioid abuse and addiction, but it requires a continuous care plan. Dr. Harris points to the available treatments for pain management that patients are often unaware of.
"We [the medical society] have not done enough to date to provide the resources to people to use non-pharmacological agents for their pain. ... We try to connect people with a pain clinic and here's what our emergency plan is for treating your specific pain, but that has to be a warm hand-off to follow-up."
Not finding the diagnosis and taking the time to educate the patient on lifestyle and other changes for pain management can be a pitfall, Dr. Harris said.
Jillian Foster administers the pharmacy service line at Baptist Memorial and says the hospital has "championed an 'opioid light' order set for our emergency departments. It outlines some non-opioid options for treating pain not related to trauma. We have metrics showing significant reduction in opioid administrations in our emergency departments."
Medicare evaluates hospital and physician performance on pain management, so working with patients to help them understand their pain management options is critical for satisfaction. The July 1 start was a challenge for quickly communicating the intricacies to physicians and nurses, but Foster said Baptist has entered the ICD10 codes for automatic adding during prescribing, which will hopefully alleviate any learning curve for prescribers.
The governor's TN Together plan includes funding and other programming to address the opioid epidemic. Shelby County has a disposal program, Count It! Lock It! Drop It!, and the joint city-county Opioid Task Force has unveiled their multi-faceted plan. All are efforts to attack the problem from multiple angles.
Still, Dr. Harris points to the shortage of primary care physicians as one piece of the issue, preventing patients from having a point of contact for regular care and building trust. Cummins agrees, adding there is a shortage in Memphis of pain specialists and pain clinics.
The University of Tennessee Health Science Center's Center for Addiction Science was recognized in 2016 as the first addiction medicine center of excellence in the country, but there is concern that patients will turn to illicit drugs like heroin if their pain is not managed. Often, it takes several rounds of rehab for patients to stay opioid-free.
Autry Parker Jr., MD, President of the Memphis Medical Society, addressed the issue in a Memphis Medical News article last month, saying the rapid-release nature of opioids is what makes them so addictive, and the illicit opiates like fentanyl so deadly.
What's next in the fight against opioid addiction? Starting January 1, 2019, a partial fill requirement for pharmacies will begin. This requires the pharmacist to fill only half of the first opioid prescription, and if patients require the second half of the dose, they must come back.