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Tennessee establishes guidelines that apply to all buprenorphine prescribers

Zach Vance • Jan 6, 2018 at 12:27 AM

Tennessee now has guidelines for all buprenorphine prescribers to follow, regardless of how many patients are being treated.

The Tennessee Nonresidential Buprenorphine Treatment Guidelines went into effect Jan. 1, establishing a protocol in Tennessee for treating opioid addiction with buprenorphine, otherwise known as Suboxone or Subutex.

Although the guidelines will not be directly enforced through licensing, the state’s Board of Medical Examiners and other medical licensing boards will expect all buprenorphine prescribers in the state to follow them.

“The Board of Medicine and (Board of) Osteopathic Examination are going to adopt them as a standard of care,” Dr. Wes Geminn, chief pharmacist for the Tennessee Department of Mental Health and Substance Abuse, said.

“Although it is allowable to stay outside the guidelines, the boards will want to look for documentation on why they went outside the guidelines.”

At 50 pages long, the guidelines cover everything from how a doctor should assess an opioid-dependent patient to how a doctor should approach tapering a patient off buprenorphine. The guidelines also set requirements for when benzodiazepines, such as Xanax, should be co-prescribed with buprenorphine.

Last January, a rule took effect requiring doctors who prescribed buprenorphine to more than 150 patients or 50 percent of their patient base to get a license through the Department of Mental Health and Substance Abuse.

According to the state’s website, 15 prescribers or clinics in Washington County fell under that criteria and now have a license from the Department of Mental Health and Substance Abuse.

However, more than 60 physicians in Washington County have a federal waiver to prescribe buprenorphine, according to the Substance Abuse and Mental Health Services Administration.

Geminn said the state found many prescribers intentionally kept their patient counts under the state-mandated threshold to evade obtaining a license.

“We found there were several individuals who opted to stay under that threshold or (they) rented out an additional office space and split the patients. Instead of having 200 patients, then all of a sudden they have 100 here, 100 there, and they don’t have to get a license. The additional benefit of (these) guidelines is it closes that loophole,” Geminn said.

“If we have bad actors out there who are not providing those tools to the patients, who thought they could get away from any kind of scrutiny or oversight by staying under that patient count, with these guidelines now in effect, they will be expected to follow very similar requirements to those we require for our licensees, but instead it will be enforced by their respective boards.”

In April 2017, the Tennessee General Assembly passed a bill directing the Department of Mental Health and Substance Abuse commissioner to create the Nonresidential Buprenorphine Treatment Guidelines and review them each year beginning in 2019.

“(When the bill was passed,) there was widespread acknowledgement of the need for these treatment guidelines due to the growing prevalence of individuals who have an opioid use disorder, an increased number of individuals using medication-assisted treatment with buprenorphine, and diversion issues associated with buprenorphine,” Commissioner Marie Williams wrote about the guidelines.

Between May and November, about 40 health professionals, addiction specialists, pharmacists, doctors, counselors and law enforcement personnel from all across the state met several times to draft the guidelines.

Paul Trivette with the Tennessee Recovery Coalition, Dr. Timothy Smyth with the Tennessee Society of Addiction Medicine and Dr. Tom Reach with Watauga Recovery Centers were among those from the Tri-Cities who traveled to Nashville and contributed.

“We were honored to be a part of it and to have a voice and a vote there. That meant a lot to us and we’re grateful for that,” Trivette said.

Smyth, who also served on the Buprenorphine Guidelines Workgroup, said he was satisfied with the end result.

“There was nothing (in the guidelines) I disagree with. I’m just happy we were able to come together and create these guidelines so everybody in the practice has a standard of care they can look to,” Smyth said.

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