Tennessee’s Prescription Pill Addiction is Getting Better, but Fentanyl Looms Large

It’s a little hard to tell, but Tennessee may be turning a corner on prescription pill abuse.

Although fatal opioid overdoses continue to rise throughout the state, deaths attributed specifically to prescription painkillers dropped for the first time in five years. The 12 percent decrease in 2017 is a rare sign of progress in a state ravaged by addiction.

The shrinking painkiller death toll likely is the result of opioid prescriptions gradually becoming weaker and less common throughout Tennessee over the past five years.

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“I think that this is where it begins,” said Dr. Manny Sethi, co-founder of Healthy Tennessee. “If you have less prescriptions and less of this stuff out there, then less of it can be stolen and less of it can be sold on the illegal market. But I also worry about the scourge of fentanyl and how that market has changed.”

Decreasing prescription overdoses but growing fentanyl deaths illustrates the evolution of Tennessee opioid crisis, as doctors and lawmakers crack down on prescriptions and addicts transition to more dangerous illegal drugs.

Opioid overdoses killed 1,268 people in Tennessee in 2017, according to new state overdose statistics. The mix of drugs that caused those deaths changed in a way that increases risk for current addicts, but may prevent future addictions altogether.

For this story, The Tennessean interviewed opioid epidemic experts from the state and Davidson County government, the nonprofit Healthy Tennessee and the Sycamore Institute, a Nashville health care think tank.

All agreed that new statistics showed Tennessee was gaining ground on prescription pill abuse, but the experts were tepid in their celebration because of skyrocketing deaths attributed to fentanyl. Fentanyl deaths rose 74 percent in 2016, killing 294, then another 70 percent in 2017, killing 500.

Still, the experts said it was likely that progress on prescription pill abuse will prevent future addicts from being snared by the epidemic in the first place. Most opioid addictions begin with prescription opioids, then addicts switch to heroin when they either lose access to pills or need stronger drugs. Therefore, as prescription opioids become less common in Tennessee, fewer people will have the opportunity to become addicted to pills and then later transition to heroin, which could be laced with fentanyl.

“Hopefully, this will stop a whole new stream of addiction from coming into play,” said Trevor Henderson, an opioid expert with the Nashville Metro Public Health Department. “But, for those who are already on these opioids, the big question is what happens with them?”

So far, nobody has found that answer, said Mandy Pellegrin, policy director of the Sycamore Institute.

Fentanyl is a synthetic, cheap-to-produce, incredibly potent opioid that was once barely known outside of hospitals. Now it is on the front line of the opioid epidemic. Drug dealers often smuggle fentanyl across the border from Mexico or through the mail from China, then mix it into weak heroin to maximize profits.

Nationwide, law enforcement have struggled to stop the influx in part because fentanyl quantities are so small. A lethal dose is no larger than two grains of sand.

“I think that if there were a magic answer, it would have been adopted by some other state, or Congress or our own state at this point,” Pellegrin said. “Congress is looking at literally dozens of bills right now, which gives you an idea of how complex this problem is.”

Opioid prescriptions: Fewer, weaker and less deadly

The progress on prescription pill abuse can be measured by three statistics – number of prescriptions, prescription strength and overdose deaths:

• The number of opioid prescriptions in Tennessee has fallen steadily the past five years, and the speed of the descent is increasing. Prescriptions fell from 7.5 million in 2016 to 6.8 million to 2017, the single largest drop since the state began to count. If the trends continues, 2018 will be the first since the opioid crisis began that people outnumber opioid prescriptions in the state of Tennessee.

• The strength of the prescriptions also is decreasing at an accelerating rate. The total strength of Tennessee prescriptions, measured in morphine milligram equivalents (MMEs), fell from 6.9 billion MMEs in 2016 to 6 billion MMEs in 2017, according to statistics from the Tennessee Department of Health.

• Finally, the number of overdose deaths attributed to prescription opioids fell in 2017 for the first time in five years. Pain relievers killed 644 people in Tennessee last year – still the most of any drug – but decreased from a 2016 total of 739.

A similar trend has been seen within the membership of BlueCross BlueShield of Tennessee, the largest health insurer in Tennessee. Total prescriptions and prescription strength among members have dropped by 15 and 19 percent respectively since 2015, according to the company.

BlueCross announced recently it would stop covering OxyContin, one of the most prescribed painkillers in the country, at least in part because of decreasing demand for opioid prescriptions.

Opioid database stopping 'doctor shopping'

Generally, the opioid experts said the single largest contribution to preventing prescription abuse came from Tennessee Controlled Substance Monitoring Database Program, which was created in 2012 to curb over-prescription and doctor shopping. Since then, the database has dramatically reduced redundant prescriptions, which stymied abuse and likely contributed to decreasing prescription overdoses.

Sethi, a Vanderbilt trauma surgeon, said the database has become a “very powerful” tool for keeping both doctors and patients “honest.”

“Just from my own experience, I have started to write less prescriptions based on the utilization of the (database), and I’m sure others have too,” Sethi told The Tennessean. “It’s also stopped doctor shopping – it’s killed doctor shopping.”

Doctor shopping is a practice where patients go to multiple doctors simultaneously so they can receive redundant opioid prescriptions, providing them with enough pills to abuse or re-sell to addicts. The practice ran rampant in Tennessee for years – leading prescriptions to outnumber people – and fueled the opioid crisis in its early stages.

But the database prevents this tactic by creating a watchdog for both patients and doctors. Doctors are now required to log all patients who receive opioid prescriptions in the database, and other doctors can then cross reference the database if the same patient attempts to get another prescription.

Pharmacists also check the database whenever an opioid prescription is filled, which means they can spot patients with redundant medication or flag doctors who do not appear to be using the database as required.

Tennessee Health Commissioner John Dreyzehner credited the success of the database to foundational support from the medical community, which acknowledged early that it had “some responsibility” for the state’s opioid epidemic.

Instead of opposing this new form of oversight, doctors generally supported lawmakers’ efforts to create one of the first opioid databases in the country, Dreyzehner said

“Kentucky made that law a few days ahead of us, but what we had in Tennessee was agreement and buy-in by our health care partners, and I think that’s made all the difference,” Dreyzehner said.

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