STATE'S TOP PRESCRIBERAn April 2012 report to the Tennessee General Assembly by the Tennessee Department of Health included information on the top prescriber of pain medication in Tennessee. The prescriber's name was not released.Total doses: 5,053,473Total prescriptions: 37,266Total patients: 3,611DRUGS / DOSES / STREET VALUE • Hydrocodone bitartrate and acetaminophen): 10 mg/500 mg tablet / 947, 891 / $3.8 million-$8.5 million• Oxycodone hydrochloride: 30 mg tablet / 854,561 / $25.6 million• Methadone hydrochloride: 10 mg tablet / 539,560 / $3.8 million• Oxycodone hydrochloride: 15 mg tablet / 367,097 / $2.2 million-$9.2 million• Clonazepam: 0.5 mg tablet / 345,864• Hydrocodone bitartrate and acetaminophen: 5 mg/325 mg tablet / 280,252• Carisprodol: 350 mg tablet / 190,454• Oxycodone and acetaminophen: 7.5/325 mg tablet / 100,643• Clonazepam: 1 mg tablet / 85,343• Hydrocodone bitartrate and acetaminophen: 10mg/650 mg tablet / 73,532• Alprazolam: 1 mg tablet / 72,270• Oxycontin: 80 mg tablet, film coated, extended release / 66,420 / $5.3 million• Diazepam: 10 mg tablet / 48,808• Endocet: 325 mg; 10 mg / 41,174(Street value information from the Tennessee Drug Diversion Task Force website.)
Last year, the top 10 medical prescribers in Tennessee wrote prescriptions for more than 20 million doses of restricted pain medication, with the top prescriber in the state doling out more than one-quarter of those.
That is more than three pills for each of the state's 6 million-plus residents, but it's only a small fraction of the doses handed out by more than 30,000 medical prescribers statewide.
Together, all prescribers in the state wrote nearly 18 million prescriptions for controlled substances such as Oxycontin and hydrocodone, according to an April report to the Tennessee General Assembly. Excluding certain drugs that were added in 2011, the number of prescriptions written increased about 23 percent from 2010 to 2011.
The numbers put Tennessee among the top states in the nation for so many things -- prescriptions written, oxycodone and hydrocodone sales and drug overdose deaths.
But officials say a new law puts Tennessee in the top spot for something else -- being one of the first states to require doctors to check a drug monitoring database before they prescribe pain medication as part of a new treatment.
Tennessee's drug monitoring database has been up and running since 2007, but only about a third of the state's doctors are registered to use it, and even fewer regularly check patient information, officials say.
The new law also requires pharmacists to upload prescription information every seven days rather than every 30 days, and allows state officials to determine which doctors are prescribing the most painkillers.
"This is landmark legislation that can be a model for the nation -- it puts Tennessee in the forefront of addressing this issue," said Bill Gibbons, commissioner of the state Department of Safety and Homeland Security, who helped craft the bill. "As we talked to people across the state, this was the number one issue for almost everyone."
Gibbons and other officials said they hope the changes will make doctors more aware of the number of prescriptions they write and allow them to spot patients who are "doctor-shopping" to buy pain medication for an addiction or to resell.
But some critics, including doctors, say the law puts a burden on all doctors rather than targeting the few who are careless or overprescribe. Others don't think the law goes far enough, pointing out there are no clear rules for enforcement or penalties.
"It's a step in the right direction -- I think it's another good step -- but I don't think it goes far enough," said Dr. John Blake, a Chattanooga pain management doctor who said he already does everything the law requires. "It may be a bit of a hassle for doctors, but it's a small price to pay," he said of the mandatory use of the drug database.
National epidemic
BY THE NUMBERS• Prescription opioid overdose is now the second leading cause of accidental death in the United States, killing more people than heroin and cocaine combined.• In 2009, Tennessee ranked second in the nation, with 17.3 retail prescriptions written per capita, compared with a national average of 12.• Nationwide, prescription drugs account for the second most commonly abused category of drugs, second only to marijuana.• 7 million Americans report current nonmedical use of prescription drugs, more than the number using cocaine, heroin, hallucinogens and inhalants combined.• 1,059 Tennesseeans died from drug overdoses in 2010, more than doubling over a decade.• The top prescriber in Tennessee wrote prescriptions for more than 5 million doses of painkillers in 2011.Sources: The Centers for Disease Control and Prevention, Tennessee Department of Health, White House Office of National Drug Control Policy
Tennessee's law goes into effect as the nation faces an epidemic of prescription painkiller abuse. Overdose deaths have soared in the last decade -- more people die from prescription drug overdoses than car crashes.
Tennessee counted 1,059 fatal overdoses in 2010 -- more than twice as many as in 2000 -- and a large percentage came from prescription drugs, officials said.
The numbers have left health care providers, state governments and law officials grappling for solutions, from cracking down on pill mills and doctor-shoppers to providing more treatment programs for addicts.
Across the country, 43 states now have operational prescription monitoring databases and five more have enacted legislation.
States also are looking to link their databases or share information on patients who cross state lines to buy pills that can sell for as much as $80 each on the street.
Georgia lawmakers voted to approve a database in 2011, and officials say they hope to have it operational by January. Alabama has had an operational database since 2006.
Laws vary from state to state, but in most, checking patient profiles on the database is optional for doctors, according to Sherry Green, who heads up the nonprofit National Alliance for Model State Drug Laws.
Kentucky passed a law this year requiring prescribers to check the database before prescribing for new patients. A handful of other states require doctors to check the database under certain conditions, Green said.
But Tennessee's law will be one of the most comprehensive when it takes effect in April 2013. Doctors will need to check the database every time they begin a new episode of treatment and at least once a year after that.
"We will certainly be watching to see what happens," Green said. "This is something that is being hotly debated at both the national and state levels -- what is the best way to approach the issue?"
'A sea change'
Tennessee's law goes into uncharted territory, officials say. On the one hand, they hope to clamp down on rampant prescription drug abuse. On the other hand, they aren't sure if the database will be able to handle the increased traffic or whether doctors will actually change prescribing habits.
Gibbons, who also is chairman of a public safety working group for Gov. Bill Haslam, calls the law a "sea change" but said the state knows the battle against prescription drugs will take years and must include much more than the drug monitoring database.
Officials considered two approaches, Gibbons said.
The first was to emphasize law enforcement by giving agencies unfettered access to the database to pursue investigations.
The second, the one the state chose, was to have a doctor-driven system, with additional requirements placed on doctors.
"This law really puts doctors in the driver's seat," Gibbons said. "It relies on doctors to really be gatekeepers, because we felt this would be more acceptable to the medical community."
The Tennessee Medical Association initially expressed reservations about the new law and asked for amendments, including exceptions for checking the database for hospice care and surgical patients.
Rae Bond, who heads the Chattanooga-Hamilton County Medical Society, said most doctors still are learning about the new law. A request sent out to doctors affiliated with the medical society to discuss the law brought only one response.
Bond said most doctors she has talked with realize prescription drug abuse is a problem, but they also are concerned about the additional time it will take to check the database before they write prescriptions.
"It is a significant work-flow issue," Bond said. "Some physicians feel there are more ways to go after a handful of people who are truly overprescribers."
A prescribing question
Even doctors who support the legislation point out that prescribing pain medication is a complex issue that cannot be boiled down to a few simple numbers.
With an aging population, more patients truly need pain control. The problem is when doctors overprescribe or fail to weed out bogus pain patients.
Tracking the top prescribers in the state is a start, but just tracking numbers is not enough, said Tennessee Health Commissioner Dr. John Dreyzehner.
The state has money to hire an epidemiologist to evaluate doctors based on the prescribers' numbers and what they do.
For example, a pain management doctor will be expected to prescribe more pain medication than a general practitioner. The state plans to give that information to doctors.
"Just looking at the top prescribers is not enough because buried down in the data may be a nonspecialist who is prescribing much higher amounts of medication than their similarly matched peers," Dreyzehner said.
The state does not release the names of top prescribers, providing only a profile of the number of prescriptions, doses and patients for the top 10 prescribers.
Blake, the pain management doctor, agrees that determining who is prescribing too much medication can be complex.
Many patients are badly undertreated for pain, he said. But Blake also worries that unethical doctors will ignore letters from the state or simply check the database to jump through the hoops but keep writing prescriptions.
"You can just throw that piece of paper from the state into the trash can," he said. "There is no punishment."
But the law allows state and federal agents to pull information from the database without a warrant, if they are already working on an investigation.
Tommy Farmer, assistant special agent in charge of the Tennessee Bureau of Investigation drug investigation division, said the law sends a message to doctors -- if you are prescribing outside the scope of practice, the state is watching.
"We are looking for you and we will be coming after you," Farmer said.
A Chattanooga doctor was indicted last week on more than 100 federal charges related to an operation officials are calling a pill mill.
Looking ahead
There is no magic bullet to fight prescription drug abuse, and the changes to the monitoring database are only a step in the right direction, Dreyzehner said.
The state is increasing education for doctors about patterns of addiction.
And the law tells the state to find ways to share information with its neighbors. Having access to other states' databases will be key for doctors, said Dr. Gregory Ball, who owns Consultants in Pain Management in Chattanooga.
Many of his patients come from neighboring states, which means he cannot check their medication history, Ball said.
The key in the new legislation and in the state's other steps is that everyone is working together, including health care providers and law enforcement, officials said.
It will take everyone if the state can even hope to make a dent in the problem, Farmer said, a problem that he says is larger than cocaine or meth ever was.
"I don't even know if I can quantify it; in sheer numbers it is so far ahead of anything we've ever seen," he said. "We are in danger of losing a whole generation if we don't act now."