In the war against opioid overdose deaths, Tennessee is winning one battle — doctors are prescribing pain pills at much lower rates — but still losing other battles.
Tennessee doctors prescribed 43% fewer prescription opiates in 2018 (.82 prescriptions per person) than they did in 2010 (1.4 per person), following a national pattern.
The state still sees some of the country’s highest rates of pain pill prescriptions, particularly in Appalachian counties, but tougher rules have reduced the number of people who can access them and the number of pills they can get at a time.
“We have made considerable progress over these last five years, and we will always strive to balance safe and effective pain management with ending the cycle of addiction for Tennesseans by cracking down on overprescribing and pill mills,” Tennessee House Speaker Cameron Sexton (R-Crossville) said in a statement.
But the state is losing other battles. Tennesseans keep dying of overdoses, and the death rate isn’t improving.
With no signs that fewer people will become addicted or die of overdoses anytime soon, Tennessee’s leaders have largely stuck to the approach of former Gov. Bill Haslam, who signed a number of opioid-related laws in 2018.
In fact, the General Assembly hasn’t passed a single bill related to opioids this spring.
Leaders have celebrated the reduced number of pain pills being prescribed and used, and they have advocated for tougher law enforcement.
But advocates say the state needs to invest much more in harm reduction, prevention and treatment. The total amount of opioids is at its highest level ever, and the number of overdose deaths has increased each year since 1999, according to the National Institute on Drug Abuse. There were 1,818 overdose deaths in Tennessee in 2018, according to the Tennessee Department of Health.
“Any increases in opioid-related deaths are not the result of prescription opioids,” Sexton’s spokesman, Doug Kufner, stated in an email. “Any increase is because of the illicit sale of heroin and fentanyl . . . by drug cartels.”
A culture takes hold
Haslam signed a package of laws in 2018 known as “TN Together,” which sought to prevent addiction through tighter prescription rules, increased investment in recovery services, targeted drug traffickers, and equipped police officers with naloxone.
While prescriptions are down, the use of fentanyl and heroin is increasing, and law enforcement is only able to catch a fraction of the fentanyl shipped to the United States. The pandemic has made in-person addiction treatment services difficult or impossible.
The isolation, uncertainty and job loss related to COVID have made it harder for many to stay away from drugs. According to the Tennessee Bureau of Investigation, about 70,000 people in the state are addicted to opioids.
The lower number of pills “limits that gateway to the first use that often starts the cycle,” said Mary Linden Salter, executive director of the Tennessee Association of Alcohol, Drug and other Addiction Services (TAADAS). “We’re certainly grateful for that.”
But, she said, “the culture of opioid use has taken hold.”
Heroin, fentanyl and methamphetamines “have become a way of coping, especially during COVID. We’re certainly not seeing any declines. If they had any inclination to use, this pandemic has done nothing but made it seem any more attractive, unfortunately.”
Lawmakers and Gov. Bill Lee haven’t made waves since the TN Together initiative started.
TAADAS advocated for a bill in the General Assembly that would have made it easier to distribute naloxone, an overdose-reversing drug, but it was withdrawn earlier this month.
Nothing has come of another opioid-related bill, sponsored by Sexton, which would require the state health commissioner to report on the impact of recent legislation and recommend any other changes to the law.
Heroin and fentanyl in Memphis
Tennessee and Appalachia have been hit hard by the opioid epidemic because of exploitative labor practices and intergenerational trauma, according to Salter, whose organization advocates for addiction-related legislation, runs a referral hotline and maintains a virtual library.
Salter said in isolated mining towns, company doctors were incentivized to get injured patients back to work quickly rather than safely.
“There’s a history of being prescribed whatever it takes to get back in the mine or whatever (workplace),” Salter said. “That culture really set the stage for overuse and abuse.”
Josh Weil, a Shelby County-based addiction prevention worker for the state, echoed that thought. He said pills have been the primary way East Tennesseans have consumed opioids, whereas street drugs are more widespread in Memphis. About half of addicts become addicted through prescriptions, he said.
Weil, a Regional Overdose Prevention Specialist (ROPS) in Memphis, said most fentanyl is shipped to the U.S. from China, and he estimated law enforcement only catches a tenth of it.
“There’s just not enough manpower to go through all the international packages,” he said.
Weil’s job is to distribute naloxone and provide education and training. The Tennessee Department of Mental Health and Substance Abuse Services estimates ROPS distributed more than 134,000 doses of naloxone from October 2017 to December 2019.
Weil said about one in 10 overdoses results in death. Many overdoses happen when users don’t realize their supply is laced with fentanyl, a synthetic opioid much more powerful than heroin. Others knowingly seek out fentanyl, Weil said.
The Regional Overdose Prevention Specialist program isn’t perfect, says Daniel Garrett, an independent “harm reductionist” in Jackson.
Garrett is an active opioid user who is nonetheless trying to help other users. He runs the Tennessee Harm Reduction blog and promotes the principle of harm reduction, a strategy popular in some parts of the country that seeks to help users be as safe as possible with their addiction.
Garrett said ROPS can’t reach addicts in rural West Tennessee as well as they do in Memphis, and it’s much harder to access naloxone. He said a lot of users don’t trust social services for fear of getting tangled in the criminal justice system.
“The bad thing about ROPS is this: they struggle, really, really hard to reach people who are actually using opioids,” he said. “Maybe they’ll hit some old grannies who get opioid (prescriptions). Maybe they’ll hit some family members of people who’re in active addiction. But in terms of people who’re at the most risk . . . ROPS suck at reaching those people.”
Garrett estimates he’s given out 7,000 syringes, 1,100-1,750 doses of naloxone and an unknown number of fentanyl test strips in the past two years.
“I actually break the law to distribute these supplies, unfortunately, namely with syringes,” said Garrett, a copywriter in addition to running the blog.
He said it’s so tedious to access naloxone and other supplies that he gets them for free from a supplier in New York City.
“Harm reduction is non-existent here,” he said.
‘They don’t die. Now what?’
What needs to change in order to keep people from dying?
“The impact of COVID, social isolation, setbacks in school performance, loss of income and social status resulting from lost jobs — and on and on — will not likely dissipate in five years,” said Salter, of TAADAS.
“We can make inroads in resulting mental health and substance abuse issues by starting prevention programs now that focus on resiliency and coping skills that help people focus on long-term personal goals that are practical and attainable,” she said.
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