We continue to have to engage in the political arena to maintain the privilege of practicing addiction medicine in accordance with established standards of care. In a page 12 article featured in the September TMA journal, Tennessee Medicine, it was stated, “Suboxone will be included in the type of prescriptions considered as part of determining whether a location meets the definition and should be registered with the state as a pain management clinic”. This statement was precisely the opposite of all previous pronouncements on the topic, but it turns out to be true regarding a fundamental change in the legislation enacted, Senate Bill No 676, unbeknownst to me or anyone else in the addiction community, on the advice of the TMA’s prescription guidelines committee. Please continue to read.The intent is to prevent pill mills from avoiding registering as pain clinics by using buprenorphine off label for pain for a number of their “pain patients”. An office must register as a pain clinic, with very burdensome paperwork, regulatory oversight, and expenses, if half of the patients are on long tern opiates or benzodiazepines. The unintended consequences of the bill are that many board-certified specialists in addiction medicine all over Tennessee would have to close the doors of their small practices, because if Suboxone were to be included in the type of prescriptions considered as part of determining whether a location meets the definition and should be registered with the state as a pain management clinic, then many addiction medicine practices will fit the definition by offering medication-assisted therapy (MAT) for their patients.
No one wants to let this happen. Addiction medicine is not the victim of a witch hunt. Addiction medicine was simply not being considered at all; not part of the thinking at all; out of sight, out of mind; ignored again. On September 5, 2013, I sent a letter. We got a nice reply. Nothing can be changed legislatively until the state assembly comes back into session in January, 2014. Meanwhile there is an effort to have the Commissioner of Health issue a position paper clarifying that the use of buprenorphine for addiction treatment in patients working an addiction program will meet the criteria for those types of prescriptions considered as part of determining whether a location should be registered with the state as a pain management clinic. I drafted a policy clarification and sent it to Nashville. The wording was adopted and included into a letter from the TMA’s legal department to the Commissioner at the Department of Health. So far, we have received the following reply (I kid you not):
The mission of the Tennessee Department of Health is to protect, promote and improve the health and prosperity of people in Tennessee. http://health.state.tn.us/
We have received reassurances repeatedly and as recently as today (September 30,2013) that “Things look positive but as of this weekend, nothing yet official from the DOH”. Dr. Gary M. Zelizer, Director of Government Affairs of the Tennessee Medical Association, is working with us on this and has been a great and courteous ally. Yarnell Beatty, JD, Vice President, Advocacy, of the Tennessee Medical Association has also been very helpful. Last week she recontacted the chief medical officer for the Tennessee Department of Health, Dr. David Reagan, at “‘[email protected]‘” <[email protected]>: “Good morning. I was just following up on our conversation of 9/17 whereby you indicated that the Department planned to adopt the proposed policy on PC 430 as outlined in my letter of September 11. Given the deadline is October 1 (Tuesday) I was wondering if the Department has a final resolution of the matter.”
So. Yes. This law — Senate Bill No 676 — goes into effect tomorrow. But don’t panic, yet. Perhaps it is time, however, to let our collective voices be heard in Nashville. The email appears to be a lame firewall: [email protected]. Commissioner of Health John Dreyzehner, MD, MPH at (615) 741-3111 might be a better option. David R. Reagan, MD, PhD, is chief medical officer for the Tennessee Department of Health, and serves as an advisor to the commissioner on matters of health policy and assists in setting priorities for the department. His email is listed above as [email protected]‘” <[email protected]
Let’s give it a day or 2 but we may need to speak out en masse.
John Standridge, MD, FAAFP, FASAM