More About Tennessee’s Buprenorphine Guidelines

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Last week I was contacted by Dr. Tom Reach, one of the premier Addiction Medicine physicians in Tennessee, about last week’s blog entry. He supplied background information about the development of Tennessee’s office-based buprenorphine prescribing guidelines.

Dr. Reach contacted state Representative Matthew Hill about a proposed requirement for office-based buprenorphine providers that would have set treatment in that state back into the dark ages. The state legislation nearly approved legislation that would have required that all buprenorphine physicians apply for a certificate of need.

I know what you’re thinking. How could anyone in Tennessee, a state with one of the highest opioid overdose death rates in the whole U.S., even question the need for treatment? By now, surely even the slowest-witted people in the state know there’s a desperate need for opioid use disorder treatment.

This legislation wasn’t proposed because there were too many treatment facilities. It was proposed because bad treatment facilities were located in the areas of powerful legislators. It was also proposed because some areas of Tennessee have many office-based providers, while other areas have few. This legislation was proposed to control the quality and location of office-based buprenorphine prescribers.

Powerful legislators were sick of poorly run clinics, basically pill mills for buprenorphine, and these legislators believed a certificate of need process would weed out the bad providers. They hadn’t considered it would also limit the number of good providers, who probably couldn’t or wouldn’t want to go through an onerous certificate of need process.

Dr. Reach found out this bill was coming up for vote immediately. He flew into action immediately, educating Representative Hill about opioid addiction, its treatment with buprenorphine, and how treatment is best done. Then he quickly moved on to educated what sound like every member of the subcommittee voting on the certificate of need proposal.

It was a nail-biter.

Initially, only one out of the ten committee members opposed this idea to require certificate of need for OBOT treatment. After much conversation, half were still in favor of the requirement, but the other half had begun to believe it might not be good for the state. After more discussion, the committee eventually voted to table this discussion, and allow a panel of experts to gather more information and form a recommendation.

A coalition of stakeholders in the state was formed, but few members were physicians with experience treating opioid use disorder. Eventually, Dr. Reach was able to influence other members.

It turns out that the final document, about which I blogged last Sunday, was the result of a compromise between people with extremely different views about how medication-assisted treatment should be done.

While I think the guidelines are too restrictive…it could have been so much worse, had Dr. Reach not persisted in his efforts to educate other committee members. Also, the requirements initially ran to 78 pages, so the final 50 page document is comparatively brief.

Dr. Reach informed me that some buprenorphine providers in Tennessee have tainted public opinion about this medication and this form of treatment. He and other physicians, dedicated to providing quality care, are lumped together with prescribers running buprenorphine mills.

He says there are buprenorphine programs that get “patients” from West Virginia and Kentucky who drive to Tennessee, get prescriptions for the buprenorphine monoproduct, and sell them for $60 per 8mg tablet in their home states. These Tennessee programs have huge lines and run patients in and out, providing only prescriptions for medication and no counseling. No time is taken to get to know the patient and find out what’s going on with them, or how they are progressing in their recovery. Some programs don’t even do drug testing.

I commiserate with Dr. Reach. Bad programs damage the reputations of physicians dedicated to doing the right thing for their patients.

I still think there’s room in this conversation for harm reduction approach, which might say the more buprenorphine reaches the hands of people with opioid use disorder, the fewer people might die from opioid overdose. But Tennessee’s no Canada, and I doubt anyone could convince the law-and-order types that diverted buprenorphine could reduce heroin overdose deaths.

I am indebted to Dr. Reach, for his willingness to give background information about this whole issue in Tennessee. Thanks to his efforts, and the open-mindedness of committee members willing to be educated, patients with opioid use disorder in Tennessee have dodged a bullet. Yes, there are restrictions, but it could have been so much worse.

North Carolina legislators can learn from Tennessee’s experience. We can watch to see if these relatively restrictive Tennessee buprenorphine guidelines improve the quality of care in the state. And we also need to watch their numbers of opioid overdose deaths.

 

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3 responses to this post.

  1. Thanks for what you do for SUD patients! We obviously need more physicians such as yourself! 🙏👍

    Reply

  2. Posted by Matthew McClure, D.O. on February 18, 2018 at 7:08 pm

    I am somewhat befuddled how a buprenorphine ‘pill mill’ can work. I usually have between 92-95 patients. I like to keep a bit below the cap. I can meet their needs with 12-16 hours a week. That is with 90 minute evals and 30 minute med checks.
    I think if I had to jump through the hoops that Tennessee is setting up I would probably throw in the towel and completely retire.

    Reply

  3. Posted by Sean McKinnon on February 18, 2018 at 9:11 pm

    Cheers Dr. Reach!

    Reply

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