Tennessee slashed opioid prescriptions, but deaths are still rising

• Opioid prescriptions fell to their lowest point in years in 2018.
• But fatal overdoses increased anyway, killing more than ever before.

For five years, the pattern has been the same.

Opioid prescriptions become weaker, less common and better regulated. And yet more and more people die from overdoses. The opioid crisis marches on, a little deadlier than it was the year before.

Tennessee suffered the worst-ever death toll for overdoses in 2018 despite continued progress on regulating prescription painkillers and doctor shopping. At least 1,818 people had fatal overdoses — 1,304 of which were tied to opioids — according to new data released by the Tennessee Department of Health. In total, more than 5,600 people have died of opioid overdoses in Tennessee since 2014.

SPECIAL REPORT:Pills, booze, family and justice: A Tennessee opioid crisis story

Rutherford County followed a similar trend as the rest of the state. Overall overdose deaths rose from 65 in 2017 to 89 in 2018, and opioid deaths jumped from 48 to 68. The county also recorded a significant increase in fatal overdoses specifically attributed to heroin — from 18 in 2017 to 26 in 2018.

Experts say the persistent rise in deaths statewide signals a continued shift of the opioid crisis toward black market drugs. Although the crisis was sparked by prescription painkillers, much of the epidemic is now fueled by street drugs and counterfeit pills that are less predictable, more dangerous and ultimately harder to stop.

Trevor Henderson, Nashville's opioid response coordinator, said this "second stage" of the opioid crisis is likely to plague the state for years to come. 

"Keeping an eye on prescriptions was one problem, but trying to figure out how many fake pills are coming into the neighborhood? That is a whole other thing," Henderson said. "Once people are buying off the streets, there is no prescribing, there are no records, and it’s hard to know who is doing what, when and where.”

Black market drugs tainted by fentanyl

The primary reason that black market opioids are deadlier than prescription drugs is the growing presence of fentanyl, a synthetic opioid that is 100 times as potent as morphine. Fentanyl was once rarely mentioned outside of a hospital but is now the most dangerous threat in the opioid crisis, commonly laced into heroin, cocaine and counterfeit pills. A fatal dose of fentanyl can be no larger than a few grains of sand.

In Nashville, fentanyl contributed to 53% of all fatal overdoses in 2018 and about 63% of all fatal overdoses this year, Henderson said.

Thank you for being a subscriber. Your support allows us keep you updated on the news that’s impacting our community.

People who use opioids from the black market are also far more likely to abuse multiple drugs at once — mixing painkillers or heroin with meth, cocaine or other pills — said Tommy Farmer, special agent in charge of the Tennessee Bureau of Investigation’s drug division. Generally, all of these drugs are more dangerous when combined, and any of them might be tainted with fentanyl, Farmer said.

“Now we aren’t dealing with a singular substance — an opioid abuser,” Farmer said. “Now we are dealing with a poly-substance abuser, mixing very powerful opioids with very powerful stimulants, which we believe is a very big contributor to this continued climb in overdoses.”

The Centers for Disease Control and Prevention estimates Tennessee's overdose death toll in 2018 is even higher than the tally released by the state. The CDC predicts that drug overdoses actually killed 1,940 people, but the causes of some of those deaths are unconfirmed.

OPIOID CRISIS:Narcan, an anti-overdose drug, is now sold online in Tennessee

Drug database stops doctor shopping

The reduction in opioid prescriptions appears to be largely the result of increased regulation and the Tennessee Controlled Substance Monitoring Database, which was created in 2012 to halt over-prescription and doctor shopping.

Doctors are required to check and update the database every time they write an opioid prescription, which prevents patients from getting overlapping prescriptions. Doctors can also be compared to their peers to identify pill mills or heavy-handed prescribers.

“The physicians now know that other doctors are looking at them,” Farmer said. “And sometimes, it’s amazing what that peer review can do.”

Prescription of opioid painkillers has declined since the database launched, and last year saw the largest drop in both number and strength in the past five years. The count of prescriptions fell 13%, and potency of those prescriptions — measured in morphine milligram equivalency, or MMEs —  fell more than 16%.  

In total, about 6 million opioid prescriptions were written in Tennessee in 2018. That means, for the first time in years, people outnumbered prescriptions in the state.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.