Harm Reduction

• Harm reduction is a policy philosophy aimed at minimizing negative health outcomes by embracing compassion and rejecting stigma. It is often described as “meeting people where they are.” • The core of harm reduction is acknowledging the lethality of modern drugs such as fentanyl. If you keep the person alive, you have a greater chance of getting them into long term recovery, even if that means tolerating their substance use for the moment. • Harm reduction does not mean condoning substance use, but it does mean withholding condemnation. • Tennessee already has a number of harm reduction policies in place, including increased naloxone availability, the Good Samaritan law, and syringe service programs (SSPs). These policies have already demonstrated a positive impact on overdose survivability, reduced transmission of infectious disease such as HIV, and increased entry into long term recovery. • Novel harm reduction strategies have been enacted in other parts of the United States, and are showing promising results for the fatal overdose rat

Naloxone Access

Key Points ● Naloxone is a life-saving opioid antagonist that can reverse an opioid overdose. Tennessee law makes it available to anyone with or without a prescription and protects from civil suit any physician who prescribes it, and any bystander who administers it to those who they believe are experiencing an overdose. ● The vast majority of all naloxone is distributed by the Regional Opioid Prevention Specialists (ROPS). ROPS provides naloxone to the public directly, as well as to first responders, anti-drug coalitions, and other points of contact with the substance use population. Syringe service programs (SSPs) are permitted to operate in the state of Tennessee as of 2018, with distribution of naloxone among their primary responsibilities. SSPs also obtain some of their naloxone from ROPS. ● Production delays, among other factors, have led to a nationwide shortage of naloxone. This has increased the urgency of improving naloxone distribution policies

MAT/MATE Acts

The DATA Waiver (or X waiver) requirement was removed in the Mainstreaming Addiction Treatment (MAT) Act, meaning providers no longer have to register with the DEA to prescribe buprenorphine as part of treatment for opioid use disorder (OUD). Federally, providers already authorized to prescribe controlled substances can now prescribe buprenorphine for OUD, but providers must still be aware of and follow any practicing state regulations. Whereas state law does not conflict with federal requirements for physicians, Tennessee state law still imposes limitations on buprenorphine prescribing for nurse practitioners (NPs) and physician assistants (PAs). With the X-waiver removal, the United States’ overdose rates could possibly decline, given the results seen in other countries

Prior Authorizations and Addiction Treatment

Key Points Concerns about prior authorizations have grown given research demonstrating inconsistent coverage and review policies across insurers, interruptions to care, high provider burden and higher healthcare costs. Tennessee policymakers and insurers have recently taken appropriate measures to ease the concerns and minizine unnecessary barriers. TennCare changed their policy on buprenorphine allowances in May 2023, essentially removing the prior authorization barrier for buprenorphine/naloxone preferred products. This is a significant step for Tennesseans given that the research shows that once the prior authorization process was removed for medications for opioid use disorder (MOUD), patients with opioid use disorder (OUD) were 47 percent less likely to relapse, hospital and emergency use decreased, and healthcare costs decreased

Opioid Overdose Deaths in Tennessee

Opioid overdose deaths (ODD) are best understood as three phases: first due to prescription opioid misuse, followed by a rise in heroin use, and currently due to contamination by synthetic opioids such as fentanyl. Each phase has posed unique policy challenges. ● Numerous policies and practices have successfully reduced prescription opioid and heroin ODD, but ODD due to fentanyl and other synthetic opioids continue to rise, especially since the COVID-19 pandemic began. ● Fentanyl test strips, syringe service programs, greater naloxone (Narcan, Kloxxado) availability and other harm reduction approaches have been implemented in recent years with positive results, but synthetic opioids continue to cause deaths due to their extreme potency and widespread availability. ● Expanding access to treatment is crucial to reducing ODD. Such policies include initiating medication for opioid use disorder (MOUD) within jails and emergency departments, reducing the behavioral health workforce pay gap, and expanding health insurance access. ● Additional harm reduction and prevention policies may have an even greater impact on reducing ODD

The Need for Point-of-Care Testing of All Illicit Substances

An estimated 107,477 overdose deaths occurred in the United States within the last year, with about 4,000 of those deaths being Tennesseans. Over 80 percent of these deaths are attributable to opioids such as fentanyl, for which there does not exist tests approved by the Food and Drug Administration (FDA) for point-of-care testing (POCT). POCT is intended to be used near or at the site of the patient and is performed outside of a physical clinical laboratory, usually at the bedside. A classic example of this is a bedside glucose test in the hospital. Tests for fentanyl and other illicit substances already exist but are limited to forensic use only. Without a point-of-care approved test, providers cannot legally use them to diagnose patients with a possible overdose and must rely on inference and guesswork. A Clinical Laboratory Improvement Amendments (CLIA) waiver would allow these tests to be used in healthcare settings. Meeting the requirements for a CLIA waiver would be fairly easy, given the opioid crisis has already been declared a national public health emergency. With polysubstance overdose as the new norm, the problem extends beyond fentanyl to other substances that also lack a point-of-care test, such as xylazine. A blanket CLIA waiver for all illicit substances that have a forensic use equivalent would significantly increase the diagnostic capacity of acute care providers treating individuals suffering from possible drug overdoses

The Need for Continuity of Care in the Criminal Justice System

People with mental health and substance use disorders who would benefit from treatment are overrepresented in the criminal justice system. It has been reported that 63% of individuals in jail and 58% of individuals in prison meet the criteria for having a substance use disorder, and 36% of the population serving a state prison sentence were being treated for a mental health disorder, which is 17% higher than the general population in Tennessee. Justice-involved individuals with mental health and substance use disorders have a higher risk of recidivism, especially when they lack access to medications and behavioral health treatments both during and after incarceration. However, despite this heightened prevalence and treatment need, criminal justice entities rarely have the resources needed to ensure at-risk individuals receive continuous evidence-based care. Given Tennessee’s incarceration rate has risen to 10% above the national average, and almost half of all incarcerated individuals are rearrested within three years of release, it is critical for individuals to have access to continuous care both during incarceration and at reentry into the community

Substance Misuse and Incarceration in Tennessee

Key Points Corrections in Tennessee cost over $1 billion annually due to a rising incarceration rate. The State’s increasing incarceration rate is related to the growth in substance misuse which on its own costs Tennessee$2 billion each year and leads to over $1 billion in lost income from a shrinking work force. Prioritizing evidence-based treatment that targets the underlying medical and behavioral issues driving addictive habits for justice-involved individuals could simultaneously address rising recidivism, reincarceration, and growing substance misuse. See report attached, and for additional information, visit https://smart.tennessee.edu/policy-briefs/substance-misuse-incarceration-tn/