In July 2018, as part of opioid crisis legislation dubbed TN Together, Tennessee enacted some of the country’s most stringent opioid prescribing policies. In July 2019, to address unintended consequences of the original legislation, the law was amended at the urging of patients and health care providers, though compliance for clinicians didn’t become much simpler.
According to close observers, the law has typically not been well understood by clinicians and this has led to needless disarray, particularly for patients with chronic pain.
Vanderbilt University Medical Center, through the offices of its Opioid Oversight Executive Committee, is offering its employees an online tutorial, Opioid Laws — Prescribing at VUMC, available at learningexchange.vumc.org (employee login required, type “opioid laws” into the search box). The brief tutorial is compulsory for VUMC clinicians who prescribe opioids.
“There are a few mandatory education components at Vanderbilt, like fire safety or fraud, waste and abuse compliance, to name a couple examples, and opioid prescribing compliance belongs on that list because it’s education about a recent piece of state legislation that, if clinicians are out of compliance, could jeopardize their ability to practice their profession,” said Warren Sandberg, MD, PhD, professor and chair of Anesthesiology and chief of staff for Perioperative and Critical Care Services at Vanderbilt University Adult Hospital.
The VUMC tutorial was written by David Edwards, MD, PhD, assistant professor of Anesthesiology, chief of the Division of Pain Medicine and co-chair of the Vanderbilt Opioid Safety and Stewardship Council. For those seeking information beyond what’s covered in the tutorial, in a longer online document Edwards uses a FAQ format to break down the law for clinicians.
“The state, wanting to reduce opioids and save lives, has created a law that’s very complicated. In struggling over the last year with that complexity, I’ve tried to make it as simple as I could for my own practice, and I’ve translated that understanding into these educational materials,” Edwards said.
For patients with 90 days or more of opioid therapy in the past 365 days, TN Together imposes no prescribing restrictions.
“This entire law, all this confusion, is strictly about the first 90 days of opioid therapy,” Edwards said.
Also exempt are opioid prescriptions for patients with sickle cell disease or active cancer, palliative care patients, major trauma patients, major burn patients and patients followed by chronic pain specialists.
A few highlights of TN Together as it applies to non-exempt opioid prescribing:
- No prescription refills are allowed. Before additional opioids may be prescribed, patients must be seen in person and the evaluation must be documented.
- Opioid prescriptions longer than three days require informed patient consent attested by patient signature on an opioid consent form.
- Limits on the amount of opioid that can be prescribed (for three, 10 or 30 days) are expressed in morphine milligram equivalents, or MMEs, calculated by comparing the prescribed drug’s potency to that of morphine.
- Prior to each new prescription, the clinical team must check the Tennessee Controlled Substance Monitoring Database.
- The law leaves unspecified any penalties for clinicians who are found in violation.
On a per-patient basis the prescribing of opioids at VUMC has over recent years been reduced. However, widespread confusion in the community about TN Together prescribing policies has led more patients to seek pain management at VUMC, such that total opioids prescribed have increased at the Medical Center. According to Edwards, each month around 10,000 opioid prescriptions are written by VUMC clinicians.
Edwards, on behalf of the Opioid Oversight Executive Committee, uses automated surveillance of prescribing practices to track aspects of VUMC clinician compliance and makes periodic opioid compliance reports available to clinical leadership.
VUMC’s clinical information system, eStar, has been adapted to assist documentation compliance.
Questions and concerns can be addressed to the Vanderbilt Opioid Oversight Executive Committee at opioidinfo@vumc.org.
