Holly Fletcher

hfletcher@tennessean.com

Health care professionals in Tennessee last year wrote more than 7.8 million opioid prescriptions — or 1.18 for every man, woman and child — even as the state grapples with a scourge of painkiller addiction and abuse.

The total places Tennessee second in the nation, behind only Alabama in prescriptions of the drugs, according to IMS Health data. Even though the number of scripts has fallen by 724,070 since 2013 when there were over 8.5 million total prescriptions, the state remains ensconced as a leader in prescribing oxycodone, hydrocodone and Percocet.

The state, along with the nation, is in an opioid epidemic. In 2014, still the latest year available, 1,263 Tennesseans died from opioid overdose — be it painkillers or heroin — a figure that outpaces those who died in car accidents or from firearms.

But what does 7,800,947 prescriptions mean? Why are there so many prescriptions? And why won’t prescribers just stop writing them?

There are 6.5 million people living in Tennessee and there are 38.8 million people living in California, where there was 0.48 prescriptions in 2015 for every person.

"I truly do not believe that we are skewed toward a higher level of pain or a lower level of pain tolerance than the rest of the country," said Dr. Richard Soper of the Center for Behavioral Wellness in Nashville.

The answer, to the chagrin of policymakers in all corners of health care, is a combination of several factors, including accepted medical practice and education, successful pharmaceutical advertising campaigns, insurance benefit coverage structure, and patient lifestyle. There are also several layers of economic dependence.

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It’s hard to pinpoint one bad actor or even a single group of bad actors when every part of the system and society needs to be examined, said Soper, noting how he's bombarded with drug ads when he watches TV.

There are "consistently positive signs" that prescribing habits are changing and that the state is making in-roads into the epidemic, said Dr. David Reagan, chief medical officer of the Tennessee Department of Health.

Tennessee was one of four states to receive the "making progress" designation in a recent report from the National Safety Council on efforts to curb opioid abuse and misuse. It met five of six criteria; no state met all six.

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The health department has asked physicians to write prescriptions with fewer doses so there are fewer leftover pills. It’s important to balance the legitimate uses of the painkillers against the crackdown on prescriptions, said Reagan.

The state monitors the morphine milligram equivalent, or MME, a unit that compares the strength of opioids into the potency of morphine, more than it watches the number of prescriptions.

Over the last four years, the number of prescribed MMEs have dropped by two billion from 9.16 billion MMEs in 2012 to 7.83 MMEs in 2015. There’s been a decrease in every county, according to health department data.

"We believe we are lowering the amount that ends up in people’s medicine cabinets," Reagan said.

Physician and prescriber education is essential in curbing the rate of prescription. Medical schools are beginning to focus more on pain treatment – it’s historically been a tiny component in the curriculum unless the student opts to become a pain specialist.

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Schools are beginning to incorporate more into programs and there are efforts to boost pain education offerings in the continuing education options for physicians, said Reagan, who described the existing offerings as “very modest.” Dr. David Edwards, a pain specialist at Vanderbilt University Medical Center, said the medical school is rethinking its pain curriculum; there are other efforts taking shape around the state.

Opioid prescriptions are here to stay.

Pain treatment has to be individualized for each patient and opioids are often the best choice for getting people through surgery recovery, experts said.

But there need to be more alternative treatments, such as physical therapy, easily accessed and have reasonable coverage in insurance plans, Reagan and Edwards said. Generic opioids are cheaper than newer drugs or alternative therapies that may have limited coverage under someone’s insurance benefits.

Edwards is working with a patient who after being on opioids for about 10 years and being in her 80s to wean her off the prescription using first aquatherapy then regular physical in conjunction with other types of pain medications. He was concerned other side effects would negatively impact her health as she ages. She’s made good progress over the course of the year but is in limbo until 2017 when her physical therapy allotments reset, he said.

Doctors also have to grapple with the expectations of the people sitting in the exam rooms, which influence what they want out of a visit and what they accept as satisfactory treatment.

Patients have come to equate a successful visit with a page from the doctor's prescription pad, whether it's an antibiotic to help a winter cold or a painkiller for a weekend injury, said Natalie Tate, vice president of pharmacy management at BlueCross BlueShield of Tennessee.

People have expectations about living without pain, which became known as the "fifth vital sign" in the 1990s.

Reagan said there is not enough talk about functionality and what it takes to ensure people can do what they need and want to in life.

“There is the expectation, or the hope, that the pain will be gone, so you don’t have to think about that. Part of that is just human nature. Part of it is American society (looking to) medicine for a quick fix,” said Edwards. "Pain doctors, we don’t necessarily cure any kind of pain. We think of it like diabetes. You have a problem or a disease that needs to be managed. If people don’t want to harm their kidneys they manage their diabetes really closely. If you have chronic pain, it may be there the rest of your life."

Reach Holly Fletcher at 615-259-8287 or on Twitter @hollyfletcher.

States with the most prescriptions per capita

Alabama - 1.2 Tennessee - 1.18 West Virginia - 1.13 Arkansas - 1.11 Mississippi - 1.07

States with the fewest prescriptions per capita

Hawaii - 0.45 California - 0.48 New York - 0.51 Minnesota - 0.54 New Jersey - 0.55

Number of Opioid Prescriptions in Tennessee, 2013-2015

2013: 8,525,017

2014: 8,239,110

2015: 7,800,947

Number of Tennessee pain clinics

2015: 309

Current: 196

How experts would change the fight against opioid pervasiveness

Dr. David Edwards, a pain specialist at Vanderbilt University Medical Center

I would say that, take a little less pressure off the patients and put a little more onus on the prescribers. I would require the creation of educational tools for the alternatives to opioids. Every prescriber should be educated or re-educated on what the alternatives are in addition to safe prescribing guidelines and having the controlled substance monitoring database link to other states.

Dr. David Reagan, chief medical officer of the Tennessee Department of Health

I honestly think the most important things are being able to destigmatize substance abuse disorders so we can talk about them openly and we don’t ostracize people who are impacted by them. If we thought about it fundamentally like diabetes or cancer we wouldn’t spend time moralizing over whether actions put people at risk.

Dr. Richard Soper, an addiction specialist with Center for Behavioral Wellness in Nashville.

Having a regular forum for health care, law enforcement, media and community leaders every quarter or so would help increase an open dialogue and move toward an environment that doesn’t punish people for coming to medical professionals for help. The state needs more in-patient beds to treat addiction.

Natalie Tate, vice president of pharmacy management at BlueCross BlueShield of Tennessee

It can‘t just be from a prescription management change, for example, that we may do here or it can’t be us only talking with physicians. There needs to be an acute awareness that this is a public health crisis for us across the state and the long-term consequences — even though I don’t know if we fully recognize the extent at this point. It’s not really a policy but a public awareness that it’s critical for us to be successful.