Hard-Won Compromise Likely Means Limits for First-Time Opioid Prescriptions in Tennessee
The Haslam administration, lawmakers and health care providers may have finally reached a compromise that will put limits on the supply of opioids doctors can prescribe to first-time users or for temporary pain relief.
Although law enforcement and treatment play a role in the governor’s $30 million plan to combat the state's opioid crisis, a key focus has been prescriptions limits to patients deemed “opioid naïve.” The hope is to shut off the flow of new Tennesseans becoming addicted to the drugs.
The compromise moves the proposed legislation away from a strict, five-day limit to a policy that gives doctors more leeway — including the ability to prescribe up to a 10-day supply in some cases.
“We believe this compromise addresses concerns while still limiting the supply of opioids for opioid naïve patients and placing more checkpoints between healthcare practitioners and patients to prevent more Tennesseans from misusing or abusing prescription pain medicine,” said Jennifer Donnals, a spokeswoman for Gov. Bill Haslam.
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The Tennessee Department of Health and the Department of Mental Health and Substance Abuse Services have pointed to studies showing that patients who receive opioid prescriptions exceeding five days face a higher risk of addiction. Similarly, the departments have said the 7 million opioid prescriptions filled annually in Tennessee are indicative of a problem of over prescription.
Lawmakers, such as Senate Majority Leader Mark Norris, R-Collierville, and Rep. David Hawk, R-Greeneville, who are both carrying the governor’s bill to limit first-time prescriptions, have stressed that the governor's plan is not aimed at those suffering from chronic pain.
Still, doctors and organizations like the Tennessee Medical Association criticized portions of the governor's plan, known as TN Together, over concerns it limits a physician's discretion on when to prescribe opioids to patients in need.
A target in the legislation was strict language that limited first-time prescriptions to a five-day supply.
"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," the Tennessee Medical Association said in a statement after the bill was introduced earlier this year.
In addition to critics outside the legislature, two Republican lawmakers proposed a competing bill, supported by the TMA.
That measure, sponsored by Sen. Joey Hensley, R-Hohenwald, a physician, and Rep. Cameron Sexton, R-Crossville, chairman of the House Health Committee, focused instead on obtaining more feedback from insurance companies and healthcare providers.
These stakeholders would offer input on the implementation of the Tennessee Prescription Safety Act of 2016 and their recommendations would be presented to the Senate by Jan. 15, 2019.
But the Sexton-Hensley bill was deferred in the Senate while negotiations were ongoing with the administration.
The results of the negotiations is an amendment added to the governor’s signature bill during the Senate Health and Welfare Committee last week that gives doctors more leeway in their prescriptions.
What are the proposed new limits?
In the amendment, prescribers may offer patients a three-, five- or 10-day prescription with no more than a 10-day supply and with a dosage that does not exceed a total of 500 morphine milligram equivalent dose.
The bill also includes some other exceptions for serious ailments, such as a "more than minimally invasive procedure" or where the risk of intense pain exceed the risk of addiction.
The updated legislation also says doctors must enter information into a state database of opioid prescriptions for "a new episode of treatment."
Tennessee Medical Association Vice President Dave Chaney said his organization’s position on the bill has not changed, but he was glad his organization could be a part of the process and that he feels the bill is “in a much better place.”
“It’s much less confusing, but still somewhat complicated,” Chaney said. “There are a lot of unknowns of how it will affect patients and the practice of medicine."
Hensley expressed similar skepticism. But he said the governor's measure has “made progress.” The senator said he believes his proposal, which competes with the governor's bill, is unlikely to receive enough support to pass. He said he is still uncertain on whether he’ll vote for the governor's proposal.
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“I’m not saying I’m going to vote for the governor’s bill. I’m still not sure,” Hensley said. “I still believe in my heart it’s going to hurt a lot of innocent patients that are hurting. I’m afraid a lot of providers are just not going to give pain medicine to people because the bill is so complicated. It makes the process that they have to go through just to give a few days of pain medicine a very complicated procedure.”
Hensley also said he believes neither the governor's bill nor the governor’s plan as a whole addresses the issue he sees as the greatest source of the epidemic — long-term patients who are over prescribed.
Still, Norris said that although all sides are not completely happy, substantive progress has been made.
“The negotiation was to make a meaningful change in prescription practices without interfering with the discretion and the right to practice medicine,” Norris said after a Senate session Monday. “Not to be presumptuous, but I think the House is comfortable with it, and I think the prescribers are comfortable with it, so I think we’ve got a good compromise.”