5.3 Tennessee Together Opioid Prescribing & Dispensing Restrictions

5.3 Tennessee Together Opioid Prescribing & Dispensing Restrictions

Quick Answer: Under the Tennessee Together legislation codified at T.C.A. § 63-1-164, outpatient opioid treatment for acute pain is restricted to tiered limits based on days' supply and total Morphine Milligram Equivalents (MME). The baseline under § 63-1-164(b) is a 3-day supply capped at 180 total MME, which requires no ICD-10 code, CSMD check, or informed consent. Exceeding 3 days or 180 MME triggers § 63-1-164(d)(1), requiring a thorough personal evaluation, documented consideration of non-opioid strategies, the ICD-10 code in the chart and on the prescription, and written informed consent — and then caps the course at 10 days / 500 MME under (d)(2), or at 30 days / 1,200 MME under (d)(3) for a more-than-minimally-invasive procedure or (d)(4) for documented "medical necessity." Prescriptions exceeding these limits cannot be lawfully dispensed unless a subsection (e) exemption applies (for example active cancer treatment, palliative or hospice care, sickle cell disease, or severe burns) and the prescription bears both the ICD-10 code and the word "exempt."

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1. Legislative Intent & Statutory Scope of Tennessee Together

Enacted by the Tennessee General Assembly under 2018 Public Chapter 1039 and amended repeatedly since (notably 2019 Public Chapter 124, which collapsed the former 20-day/850 MME surgical tier into a 30-day/1,200 MME tier and confirmed that 3-day/sub-180 MME prescriptions need no ICD-10 code; and 2023 Public Chapter 188 and 2024 Public Chapter 575), Tennessee Together (codified at T.C.A. § 63-1-164) represents one of the nation's most aggressive statutory responses to the opioid epidemic. The legislation directly targets opioid-naïve patients suffering from acute conditions to prevent physiological dependence and chronic addiction.

Acute Pain vs. Chronic Pain Definitions

• Acute Pain: Pain that is the normal, predicted physiological response to a noxious chemical, thermal, or mechanical stimulus associated with illness, disease, trauma, or surgery, and that is anticipated to last fewer than ninety (90) days. All acute pain prescriptions are governed by the Tennessee Together supply tiers.
• Chronic Pain: Pain that persists for ninety (90) days or longer from the initial onset or beyond the expected healing time of tissue injury. Chronic pain is not exempt as a general category; the closest statutory hook is § 63-1-164(e)(5), which exempts patients treated with an opioid daily for 90 days or more during the 365 days before April 15, 2018, or subsequently treated for 90 days or more under one of the other exceptions. Chronic pain management is otherwise governed by the Tennessee Chronic Pain Guidelines and the pain management clinic statutes at T.C.A. Title 63, Chapter 1, Part 3.

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2. Comprehensive Tiered Prescribing Limits Table

Tennessee Together organizes acute opioid therapy into a default tier plus three escalation pathways, each adding documentation as duration and dosage increase. Note carefully that the caps are stated in the statute as ceilings on treatment — § 63-1-164(a)(9) defines "treat" as prescribe, dispense, or administer:

┌─────────────────────────────────────────────────────────────────────────────┐
│                     TENNESSEE TOGETHER ACUTE OPIOID TIERS                   │
├─────────────────────────────────────────────────────────────────────────────┤
│  Tier 1:  3 Days   │  ≤ 180 Total MME   │ No CSMD query; No consent         │
├────────────────────┼────────────────────┼───────────────────────────────────┤
│  Tier 2: 10 Days   │  ≤ 500 Total MME   │ CSMD check + Consent + ICD-10     │
├────────────────────┼────────────────────┼───────────────────────────────────┤
│  Tier 3: 30 Days   │ ≤ 1,200 Total MME  │ CSMD check + Consent + ICD-10     │
│  (d)(3) procedure  │                    │ + more-than-minimally-invasive    │
├────────────────────┼────────────────────┼───────────────────────────────────┤
│  Tier 4: 30 Days   │ ≤ 1,200 Total MME  │ CSMD check + Consent + ICD-10     │
│  (d)(4) necessity  │                    │ + "medical necessity" ON THE Rx    │
└────────────────────┴────────────────────┴───────────────────────────────────┘

Two further statutory limits ride alongside the tiers:
  • § 63-1-164(c)(1): a patient must NOT be treated with an opioid more
    frequently than every ten (10) days, with a narrow adverse-reaction
    exception that requires the dispenser to cancel the earlier balance.
  • § 63-1-164(h): FDA-approved opioid cough/upper-respiratory products are
    outside the tiers entirely, but are capped at a FOURTEEN (14) day supply.

[!CRITICAL] Total MME vs. Daily MME: A widespread point of failure on the MPJE is confusing daily MME with total cumulative MME. Under Tennessee Together, the numbers 180, 500, and 1,200 represent the total cumulative MME across the ENTIRE prescription, NOT the daily dosage — § 63-1-164(a)(6) defines the "morphine milligram equivalent dose" as the MME calculation for the amount prescribed multiplied by the days of treatment! For example, a 10-day prescription capped at 500 total MME permits an average of at most $50\text{ MME/day}$ ($500 \div 10 = 50$), not 500 MME each day.

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3. Morphine Milligram Equivalent (MME) Conversion Mathematics

Candidates must be prepared to calculate total MMEs on the examination to determine whether an opioid prescription complies with Tennessee Together limits.

$\text{Total MME} = \text{Strength (mg/unit)} \times \text{Total Units Prescribed} \times \text{MME Conversion Factor}$

$\text{Alternative Formula: Total MME} = \text{Daily Dose (mg/day)} \times \text{Days' Supply} \times \text{MME Conversion Factor}$

Official CDC / Tennessee MME Conversion Factors

Step-by-Step Clinical Calculation Examples

Example 1: Hydrocodone/APAP 10/325 mg (Tier 2 Evaluation)

• Order: Hydrocodone/APAP 10/325 mg, 1 tablet PO q6h PRN severe acute back pain for 10 days. Total quantity = 40 tablets. Prescriber writes ICD-10 code M54.5 on the face.
• Calculation: $\text{Total mg of Hydrocodone} = 40 \text{ tablets} \times 10 \text{ mg} = 400 \text{ mg}$ $\text{Total MME} = 400 \text{ mg} \times 1.0 \text{ (Conversion Factor)} = 400 \text{ total MME}$
• Legal Assessment: The order is for a 10-day supply (≤10 days) and totals 400 MME (≤500 MME cap). It bears a valid ICD-10 code. COMPLIANT: Lawful to dispense under Tier 2.

Example 2: Oxycodone 5 mg (Exceeding Tier 2 Limits)

• Order: Oxycodone 5 mg, 1 tablet PO q4h PRN acute pain #60 tablets for 10 days. Prescription includes ICD-10 code S82.1.
• Calculation:
  • Scheduled dosing: 1 tablet $\times$ 6 times daily = 6 tablets/day $\times$ 10 days = 60 tablets.
  • Total oxycodone: 60 tablets $\times$ 5 mg = $300\text{ mg oxycodone}$. $\text{Total MME} = 300 \text{ mg} \times 1.5 \text{ (Oxycodone Factor)} = 450 \text{ total MME}$
• Legal Assessment: At 60 tablets of 5 mg, the total MME is 450 MME, which is $\le 500\text{ MME}$. COMPLIANT.
• Contrast Case: What if the prescriber wrote for Oxycodone 10 mg, 1 tab q4h PRN #60 tablets for 10 days? $\text{Total mg} = 60 \times 10 \text{ mg} = 600 \text{ mg}$ $\text{Total MME} = 600 \text{ mg} \times 1.5 = 900 \text{ total MME}$
  • ILLEGAL as an ordinary acute-pain order: Even with an ICD-10 code, 900 total MME exceeds the 500 MME cap that § 63-1-164(d)(2) places on a >3-day course. It could only stand if the prescriber documented a (d)(3) more-than-minimally-invasive procedure or a (d)(4) "medical necessity" course (30 days / 1,200 MME), or if a subsection (e) exemption applied and the prescription bore the ICD-10 code and the word "exempt."

Example 3: Hydromorphone 2 mg Post-Surgery (§ 63-1-164(d)(3) Evaluation)

• Order: Hydromorphone 2 mg, 1 tablet PO q4h PRN post-operative pain #90 tablets for 15 days following knee replacement. Annotated "Knee Arthroplasty - Surgery" with ICD-10 code.
• Calculation: $\text{Total mg} = 90 \text{ tablets} \times 2 \text{ mg} = 180 \text{ mg hydromorphone}$ $\text{Total MME} = 180 \text{ mg} \times 4.0 \text{ (Hydromorphone Factor)} = 720 \text{ total MME}$
• Legal Assessment: Days' supply is 15 days (within the 30-day ceiling of § 63-1-164(d)(3)). Total MME is 720 MME (within the 1,200 MME cap). A knee arthroplasty is more than minimally invasive, and the order bears an ICD-10 code with the prescriber's documentation. COMPLIANT. Note that this same order would have been non-compliant under the pre-2019 law, which capped the surgical tier at 20 days and 850 MME — a trap if you study from an outdated summary.

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4. Statutory Exemptions from Tennessee Together Limits (T.C.A. § 63-1-164(e))

The General Assembly recognized that rigid acute limits would inflict grave harm on patients facing malignant illness, end-of-life care, or hereditary blood disorders. Read the subsection letter carefully: subsection (d) contains the escalation tiers; subsection (e) contains the exemptions. Under T.C.A. § 63-1-164(e), the day and MME restrictions do NOT apply to:

┌─────────────────────────────────────────────────────────────────────────────┐
│            STATUTORY EXEMPTIONS FROM TENNESSEE TOGETHER LIMITS              │
├─────────────────────────────────────────────────────────────────────────────┤
│ 1. Active Cancer Treatment: Patients receiving active chemotherapy,         │
│    radiation, or surgical oncology treatment for malignant disease.         │
│ 2. Palliative Care: Specialized medical care for serious, life-limiting     │
│    illnesses focusing on relief from symptoms and stress.                   │
│ 3. Hospice Care: Patients certified as terminally ill receiving hospice care│
│    from a licensed hospice organization.                                    │
│ 4. Sickle Cell Disease: Patients with diagnosed sickle cell anemia.         │
│ 5. Long-Standing Opioid Therapy: Patients treated with an opioid daily for  │
│    90+ days during the 365 days before April 15, 2018, or subsequently      │
│    treated 90+ days under one of the other exceptions.                      │
│ 6. Inpatient Administration: Opioids administered directly to a patient     │
│    during treatment at a facility licensed under Title 68, ch. 11, or a     │
│    hospital licensed under Title 33, ch. 2, part 4.                         │
│ 7. Pain Management Specialists: Prescriptions issued by a pain management   │
│    specialist (or a collaborating APRN/PA who personally assessed the        │
│    patient), or in an exempt hospital outpatient pain clinic.               │
│ 8. Opioid Use Disorder Treatment: Methadone dispensed under 21 U.S.C.       │
│    § 823(g)(1), other FDA-approved OUD products, and opioid antagonists     │
│    that contain no opioid agonist.                                          │
│ 9. Severe Burns or Major Physical Trauma: Second- or third-degree burns, or │
│    blunt/penetrating trauma causing serious blood loss, fracture, or        │
│    significant impairment.                                                  │
└─────────────────────────────────────────────────────────────────────────────┘

Mandatory Exemption Notation on Prescription Face

Subsection (e) is conditional: where a prescription is issued under an exemption, the prescription must contain both the ICD-10 code for the primary disease documented in the chart and the word "exempt." Both elements are required — an ICD-10 code alone does not invoke the exemption, and neither does a narrative note such as "hospice patient" without the code and the word.

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5. Pharmacist Verification Duties & Partial Filling Rights

Corresponding Responsibility for ICD-10 Verification

T.C.A. § 63-1-164(d)(1)(B) draws an important line for dispensers: a pharmacist filling a prescription written by another practitioner for more than a three-day supply is not required to satisfy the prescriber-side duties in (d)(1)(A)(i)–(iv) — the personal evaluation, the non-opioid documentation, and the informed consent — provided the prescription contains an ICD-10 code. What the statute does require of the dispenser is that no more than one opioid prescription be dispensed to a patient per encounter.

• If an acute opioid prescription for more than a 3-day supply arrives without an ICD-10 code, the statutory precondition in (d)(1)(B) is unmet, so the pharmacist must resolve it before dispensing.
• The practical resolution is to contact the prescriber or the prescriber's agent, obtain the ICD-10 code for the primary disease, and record it on the prescription with the date and the pharmacist's initials — the same clarification a pharmacist may make to any other missing non-signature element.

Patient and Prescriber Rights to Partial Fill

To prevent surplus opioid tablets from lingering in household medicine cabinets, T.C.A. § 63-1-164(c)(2) expressly lets a prescriber authorize partial filling by writing "partial fill" or "PF" on the prescription, and federal CARA rules at 21 CFR § 1306.13(c) let the patient or prescriber request a partial fill of a Schedule II order:

• Patient-Requested Partial Fill: Any patient presenting an acute opioid prescription has the legal right to request that the pharmacist dispense less than the written quantity (e.g., "Please only give me 10 tablets instead of 30").
• Prescriber-Notated Partial Fill: Under T.C.A. § 63-1-164(c)(2), a prescriber may authorize partial filling by placing "partial fill" or "PF" on the prescription.
• Discharge of Remainder: If a Schedule II opioid prescription is partially filled at the patient's or prescriber's request, the pharmacy must document the partial fill, and the remaining portion may be dispensed under 21 CFR § 1306.13(c) within 30 days of the date the prescription was issued, provided the total quantity dispensed never exceeds the original authorization. (Partial fills for terminally ill patients and LTCF residents run on the separate 60-day clock in 21 CFR § 1306.13(b).)

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