Next Up: Opioid Control Legislation

A committee of Senators has been working to develop legislation in response to the current wave of opioid drug use.  The Senate will take up the legislation next week.

Perhaps the most innovative and possibly controversial concept in the legislation is to verbally screen middle-school and high school students for substance abuse.

Section 5 of the bill requires the school committee (or local department of public health):

to screen pupils for substance use disorders through a verbal screening tool approved by the department of public health.

The word verbal is important — there is no mandate for drug testing and what the legislation contemplates is the use of very brief conversations asking questions that are designed to elicit evidence of possible substance abuse and suggest the possibility of seeking treatment.

The most famous brief screen is the CAGE instrument. The questionnaire used in a Northampton school system pilot is known as CRAFFT and includes the following:

  1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
  2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
  4. Do you ever FORGET things you did while using alcohol or drugs?
  5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
  6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

If a person answers several of these questions positively, they are likely to be abusing substances or dependent and the interviewer would follow with a “brief intervention” — a conversation designed to generate some internal motivation to seek treatment.

The key result from the research is that if a person is comfortable enough to answer a few well-designed questions candidly, one can very quickly and accurately ascertain their possible need for treatment.  And with some supportive dialog, one can, in a percentage of cases get them interested in voluntarily seeking treatment.

Section 6 provides that:

Verbal substance use disorder screenings shall be performed by nurses, physicians or other personnel approved by the department of public health and shall be conducted at least once annually in grades 7 and 10.

Section 7 provides for an opt-out:

A child or the child’s parent or guardian may opt out of the verbal substance use disorder screening at any point prior to or during the screening.

The legislation provides that the anonymous results will be reported to the Department of Public Health, but otherwise protects the results of screening as confidential.

Except as required under state and federal law and as provided in this paragraph, a school employee shall not disclose confidential information provided during a verbal substance use disorder screening under section 57. Confidential information shall not be subject to discovery or subpoena in any civil, criminal, legislative or administrative proceeding without the prior written consent of the child or the child’s parent or guardian.

There is a lot of consensus that Screening, Brief Intervention and Referral to Treatment (SBIRT) is a cost-effective process.  I’m eager to see its use expanded in many settings.

One concern I have is that SBIRT has to be entirely voluntary — if a person doesn’t feel safe in the conversation it just won’t work and that safety may be difficult to create in the context of a mass screening program in schools.  I did an experimental study trying to use SBIRT in Dorchester Court about 10 years ago and it didn’t work well — people just weren’t comfortable enough to be candid in the court house.

However, pilot experience over the last year has been positive.  The key idea about SBIRT is that it is so inexpensive that  even if it only is helpful a small percentage of the time, it can be cost-effective.  Funding for the program may be included in a supplemental budget that is currently working its way through the legislature — Senator Flanagan, the lead sponsor believes they can fund 440 sites for approximately $1 million.

Your thoughts on the SBIRT mandate or any aspect of the legislation would be very welcome.

Thanks to all who supplied comments on the screening issue. Based on these comments I did some additional research on the issue. The view I formed was that:

  1. SBIRT in schools is a promising approach, but the jury is still out in its effectiveness. There is a very solid base of research on SBIRT for adults and “school-based SBIRT appears to be promising approach“. However, “existing literature sheds only dim light on screening and brief intervention for adolescents”.
  2. The success of any screening approach is very likely to depend heavily on exactly how it is done; the research base on method in school settings is far too thin to guide decisions.
  3. The success of a program of screening depends on school leadership that really wants to make it work and is willing to give it a lot of attention to adjust it and assure its success
  4. Accordingly, I reached the conclusion that while we should continue to work on expanding SBIRT it was unwise to mandate it for all school systems at this stage.

During the debate on the bill on October 1, I wrote one amendment to leave it up to the Department of Public Health as to how frequently to screen adolescents and argued for another amendment to make the screening a local option. The local option amendment was addressed first and went down on an 11-27 roll call. I let my own amendment go down on a voice vote as it was clear how my colleagues felt. I also let go of my amendment to broaden and so soften the screening mandate in a way that would allow DPH and school systems to tailor their screening programs to the mental and behavioral health issues most salient among their students.

The emotion driving the vote for a strong and focused drug screening mandate was that even if it saves only one life, we should be doing it. Of course, every life is important, and we should act. At our level, however, I think we have to recognize that we are making choices about how to spend money and the time and energy of public employees and we have to judge each opportunity to save lives against alternative ways to save lives. I support SBIRT but only in places that want it and are ready to make it actually work and only if done in a way that respects the privacy of students — the students who most need help will not be honest if they don’t feel that they can speak safely.

To the point of privacy, I was pleased to get an amendment passed adding language that strongly protects the confidentiality of the screening process — with the language in my amendment, only the student being screened can consent to the sharing of his/her statements, their consent must be written, and no written record will be made of their statements that could identify them. If this language survives into the final legislation, it will do a lot to assure that all school-based SBIRT programs adhere to a highly voluntary approach to screening that is focused on truly helping students.

Any statement, response or disclosure provided by a pupil during a verbal substance abuse screening shall be considered confidential information and shall not be disclosed by a person receiving the statement, response or disclosure to any other person without the prior written consent of the pupil on a form to be approved by the Department of Public Health or in cases of immediate medical emergency and shall not be subject to discovery or subpoena in any civil, criminal, legislative or administrative proceeding. No record of any such statement, response or disclosure shall be made in any form, written, electronic, or otherwise, which includes information identifying the pupil.

The issue that got the most attention in the debate was how to give patients the ability to say no to over-prescription by doctors — it is very common now for doctors to write prescriptions for a large quantity of pain medication to people recovering from procedures; the result is the waste of a large quantity of narcotics and the availability of extra narcotics in a lot of households. It was contested because the first solution that Senator Keenan proposed seemed to conflict with federal law. After a lot of negotiation, an approach was developed that seemed both effective and legal — the kind of good outcome that comes when everyone hangs tough on their position, but everyone stays at the table.

Overall, it’s a good bill and passed the Senate with strong support (October 1, 2015). The issue now moves to the House.

Below is an outline of the other major ideas in the legislation. They mostly involve tightening of decision-making around prescription drug dispensation — new rules and oversight for patients, physicians, pharmacists and insurers — with the goal of making sure that people are not getting abusable drugs if not necessary.

  • Training and information dissemination
    • For police officers responding to overdoses. §1.
    • For physicians and pharmacists on best practices to lower   abuse of pain medications. §2, 12.
    • General prescription drug awareness. §17.
  • Option for patients to not fill a full prescription of abusable drugs
    • Notice to patients that they do not need to fill full prescription of an abusable drug. §14
    • Directive to the Attorney General to consult DEA to determine that it is not a federal legal violation to for a pharmacist to underfill a prescription). §35.
  • Precautions in prescription of abusable opioid drugs
    • For practitioners.  §§10, 11, 13.
    • By patients — new concept of a voluntary non-opiate directive by which patients can express a binding preference to avoid use of opiates. §§4,13.
    • Oversight — confidential notifications to providers who are prescribing more than others. §§15, 32.
    • Addition of gabapentin to prescription drug monitoring program. §31.
    • Oversight by insurers of volumes of drugs prescribed to individual patients; patient access to alternatives to narcotics for pain management.  §§21-26.
  • Manufacturer take back of unused drugs.  §16.
    • “Drug Stewardship” program by manufacturers — outreach and collection of excess drugs.
    • Department of Public Health supervision.
    • Option for manufacturer to opt-out and instead pay assessments to the Prescription Drug Awareness Trust Fund (which may make grants for take back programs — §17).
  • Good samaritan protections for any person administering Narcan to people who appear to be overdosing.  §19. [This section is designed to protect first responders.]
  • Disciplinary diversion and rehabilitation program for health care professionals with addictions.
    • Pilot pharmacists with addictions.  §20.
    • Study of expansion to other professions. §30.
  • Strengthening of rules providing access to substance abuse treatment.
    • New reporting by insurers on denials of mental health or substance abuse treatment claims.  §27, 28.
    • New disclosures to patients of reasons for denial.  §29.
    • Create universal intake form to streamline administration of entry in to substance abuse programs. §34.
  •  Reorganization
    • Dissolve Public Health advisory council on alcoholism. §3.
    • Dissolve Public Health drug rehabilitation advisory board. §18.
    • Create commission to study a pain management access program. §33.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

89 replies on “Next Up: Opioid Control Legislation”

  1. I guess I’m just a little confused. Help me understand. We have an epidemic of opioid abuse. Therefore, we are going to ask kids whether they drink too much alcohol? Why not ask them if they are taking pills or shooting up? Is that really too far a leap?

      1. So many people love to throw their weight around in small administrative positions, this idea is very dangerous and an awful waste in my opinion. None of these things you can supposedly opt out of is really opt out friendly. Is it going to be a videotaped interrogation? If my kid is potentially on drugs, I want a drug test, plain and simple. Why fool around with so-and-so said such-and-such? And who on earth is better trained to talk to kids and make an accurate assessment than a drug sniffing dog? A dog can tell you who is on drugs a thousand times faster and more reliably than this kind of waste of time. When I think of a bully we have as an admin and imagine him interrogating my kids, I am horrified at what he’d do or say. I prefer dogs and lab testing a zillion times over.

  2. I think your concerns are well founded.
    School staff is all ready stretched to its limits. Most schools do not have social workers or full time nurses. If this was to be implemented it would need staff that was trained and this would need to be funded. Giving it to a variety of untrained people would undoubtedly lead to unintedended consequences. It would also need a pilot program to develop an effective means of implementing a verbal screening process. Again this would take funding. Please don’t just throw it in the schools and expect that they’ll figure it out. If handled improperly it could be viewed as an interrogation of criminal activity resulting in distrust by students and parents. It’s hard enough to build rapport between the schools and students. A verbal screening that wasn’t properly developed or mishandled could be very damaging for everyone involved.

    1. Actually, it has been successfully piloted in several schools already, so we are not starting cold. And there is funding moving in another bill. This information wasn’t originally in the post. I’ve added it as I learned it.

      1. I had to chuckle at that. I had a high risk pregnancy. You should see the implementation of the verbal drug and alcohol screening on that. I was waiting for them to pull out the light bulb and say, “Vee have vays,…” when they pulled out a light bulb.

        1. Second to chuckling was the gulp it took to consider how we have the cart before the horse, asking kids social worker questions when we do not have a functional DSS to handle the answers.

  3. Hey, why stop there with the personal questions?
    Let’s go further with questions from BIG BROTHER, shall we? How about these?

    1. Do your parents or guardians ever talk about LGBT people?

    2. Do your parents or guardians ever say anything negative about LGBT people?

    3. If #2 is Yes, does this upset you?

    4. Do YOU have any such negative feelings about LGBT people?

    5. If #2 or # 4 is Yes, would you like a school counselor to straighten you out, or would you like to have the school counselor talk to your parents about their homophobia?

    6. Anything else you’d like to reveal to BIG BROTHER about your personal life, your sex life, or your homophobic parents?

    BIG BROTHER wants to hear.

    All totally confidential of course.

  4. I am totally against the SBIRT in the school context. It looks to be ineffective, would make both student and school personnel uncomfortable, and would pile on yet another unfunded mandate. There are better ways to address these social issues. The state could fund more effective social and emotional learning programs in schools and provide better mental health treatment for children. See Dr. Ross Greene’s Collaborative Problem Solving approach.

  5. SBIRT has no teeth. The use of heroin is rampant, and destructive beyond current controls. Alcohol is more addictive and destructive, parents should be educated to this fact and given a voluntary screening test at pta mtgs. Just a thought.

  6. Well intentioned, but not worth the legislation. Rather than trying to legislate this throughout the state, why can’t this be encouraged through local policies in the most high risk areas? While this is a real problem, there are many areas of the state that don’t have this problem, where this will be just another burden on the schools and an eye-rolling state mandate.

  7. I don’t think this will be effective, and creates undo intrusion and stress, especially on middleschoolers. I’m not sure the solution, other than knowing our kids. I feel like this is akin to the overreach we’ve done after 911 – seemingly for a justified cause, but we lost too much in the process.

    Drug users are liers and so I don’t think would get tripped up here — maybe the extremely casual or first-time one.

    If we really are serious about not trusting our schools or kids, then let’s go all-in and mandate testing for all middle and high schoolers. That would be the only way, but is beyond too far for most of us, including myself.

  8. This is a bad idea and it won’t work. Kids are going to give the “right” answers and it will be a big waste of time for everyone. And it will become a big joke with the kids.

    A good idea would be to train the parents on how to talk to their kids, train them on how to prevent all kinds of drug abuse, and how to pay better attention and notice what’s happening with their own kids.

    As tempting as it is to get the schools involved in every problem under the sun, they have enough to do already. The parents are responsible for solving this problem so if you want to help, help the parents.

  9. I would much rather an annual screening for substance come via my children’s pediatrician (primary care Dr.) rather than school staff. In a school, many children are going to feel persecuted and may not have any motivation for disclosing. Children may be more trusting of their MD, see that person as a health authority, and be more willing to disclose when separated from the school structure. I’m a psychologist and screening for mental health and substance use concerns makes a lot of sense but the devil is in the details.

  10. This is a ridiculous proposal and possibly a violation of the US constitutional right to privacy. It is taking the Nanny State to a whole new level. Scrap it. I will personally take this one to the ACLU for action.

  11. WTF? Asking middle schoolers if they had witnessed drug use? This is over the top and as others have noted intrusive, ineffectual, and an underfunded and ultimately inconsequential piece of feel-good legislation. Let the state deal with root causes and not encourage school systems to be useless busybodies.

    My kid’s high school had a student dance tonight. In order to attend, parents and students had to sign a “contract” stating that they understood that breathalyzer tests would be conducted on any student some chaperon suspected of intoxication. This policing attitude is taking us in the wrong direction. For one thing, it will simply shift use of intoxicants away from alcohol and to other substances, some worse, some better.

    Best to focus on educating young minds about what they can expect if they go that way, with graphic examples and first-person testimonies.

    Forget survey results. The proposed legislation is just bogus grandstanding.

  12. I have no child currently in school, but as an attorney I just don’t feel comfortable with questioning a young person about behaviors which carry criminal penalties, without a lawyer present, and with the proposal limiting the conversations to private ones between a doctor or nurse and the student. I think pediatricians currently do some sort of drug screening – they certainly ask kids about their behaviors. I would rather see this approached by underage kids’ physicians in yearly physicals where a relationship of trust often already exists and where there are confidentiality provisions, than entrust this to school personnel. I understand the seriousness of the problem. I just don’t think it protects children enough the way it is formed. It is too intrusive and gives too much power to school personnel to make these judgments.

    1. Our children’s pediatricians asks the kids about this; for my teenager, without me present so that she might be more comfortable talking without a parent there. I am fine with this approach, but not in schools for the very reasons that you point out.

  13. I would want to know what the follow up procedures are, what people or agencies are involved, whether parents are in the loop if a student is eligible for treatment, what the treatment consists of, who provides it, how is it evaluated to determine when the intervention has succeeded or not.
    It may be well intentioned and an attempt to get arms around the problem. There seem to be a number of links where the process can go awry.

  14. Frightening thought to see such a legislature proposal. Verbally screening children in Middle school for possible drug use? I felt nervous while reading the questions, and I am a full grown adult and parent…. I cannot imagine a child feeling comfortable answering these type of question. I can see abuse from the interrogator… Yes the interrogator …. Looks like we are turning into a Nazi state! This makes me rethink the concept of homeschooling and seriously consider this option for my child if such a legislation were to pass!

  15. One of my main concerns here is unintended consequences. Given the growth of the “school-to-prison pipeline” in recent years and the increased police presence in schools, I feel that such legislation could inadvertently worsen that problem.

    As an anonymous and voluntary questionnaire, it could have value to get a general read on a student population. (The senior health class in y high school in suburban Philadelphia had an annual survey covering sex, drugs, alcohol, etc., etc.) But it seems to me that students might either (a) not feel comfortable sharing or (b) feel pressured into doing so–neither of which is good.

  16. I don’t support the verbal screening. I think it’s invasive and if I were a h.s. student, I would just lie.

  17. I see that you people have it covered. Your trail and error will prove to be a success with your proposals in place in my way of thinking. What is necessary will cost, but, it will be what keeps us safe. Great proposals! Thank you.

  18. Will,

    I think using such a questionnaire routinely, for all students, particularly in grades as early as the 7th grade is a very bad idea. In the first place it normalizes drug use in that it implies that drug use is common and that such questions are not far fetched. I realize that is not the intention, but I believe it will nevertheless be the effect in many cases. Also if it is administered across the whole student body, it will quickly become a ritualized procedure and thus make it easy for those who are drug users or have friends who are to easily evade the questions.

    Finally it a massive intrusion into schools and childhood by the drug treatment community and perhaps even by law enforcement. At the very least, such questionnaires should be at the discretion of school principals or superintendents and not mandated statewide by an inflexible state law.

    I certainly hope that you will oppose the bill.


  19. Can you post links to where this has been successfully piloted? I am terribly,terribly skeptical, but would read them with interest and with an open mind.
    Can the claim be made that these “successful” efforts are generalizable?

  20. I am against. It’s invasive and will require more bureaucracy, e.g., procedure for opt out, procedure for test. Kids will quickly learn the drill and those that use drugs will lie. Do not divert school resources to this.

  21. Has anyone done a study to determine if middle and high school students are the largest users of opiates? I would suspect not.

    We continually target students because they are a captive audience (they are already forced to go to school) with the idea that we can add yet another mandate and procedure to an already dense school day. This appears to be a facile solution to a societal problem that, in my estimation, will have little effect on the overall problem.

  22. Morning Senator,
    “just wondering”
    Reading the responses you have to this inquiry makes me think it is possible that the youngster answering these questions could lie.
    Perhaps one question would be sufficient, ask them if they have a nice photo of themselves?
    That way if they overdose, or ride in a car with a driver who is high or experiment with a little bit of drug their families will have a nice photo of them to put into their obituary!

  23. It may be inexpensive in terms of money but the time and scheduling to do it by school nurses would be overwhelming. You can’t expect to send a whole class down for a screening at one time…that would defeat its purpose.
    With up to 300 students in a large middle school 7th grade…how would you do it? It sounds nice but it is another task imposed on the public schools.

  24. I think it would be good to support the verbal screening program (i.e., I believe you when you say it works), but your caveat about voluntary is huge. I wouldn’t make it mandatory for schools to have such a program because I suspect quite a few administrators would take it too far, creating only cost and cynicism.

    On the partial prescription option — if I change my mind, can I go back later to get the rest of the prescription? What are the cost options on that? (This would work well for me; last time I had surgery I ended up discarding over half the prescribed pain reliever).

    I strongly suggest that we look at results from other countries (e.g. Switzerland) where obtaining heroin from the government is an option. For obvious reasons that reduces overdoses and disease transmission, but it also disrupts the illegal market. I realize that this makes some people uncomfortable, but they’ve gotten good results from this.

  25. Dear Will,
    This is a responsible attempt to address a deadly problem. While I may quibble with parts, as it goes beyond the conversation with kids, the HUGE benefit is the start of a community conversation.
    Would it work to have a recovering addict talk to school groups, starting with the faculty? Best, John

  26. Will: thanks for summarizing and discussing. I read about the bill in the Globe and had mixed feelings. It seems like a good idea – I know several youth who have engaged in risky behavior and would likely benefit from some intervention. The key to me is to listen closely to teens about what is likely to help – and use sound data. Is there an age when it is more likely to yield results? In some cases, a nurse makes sense – some students may tell a stranger since it feels more anonymous and confidential . Yet in other cases a teacher or trusted adult in the school would be more likely to elicit a truthful response.

    And, like most legislation, the details of implementation matter. Funding is one thing – but how it is implemented, what additional paperwork is required is really important. I hope you all pass legislation (which has been proposed) to examine all mandates and their burden – in cost and time – on school districts. The more reports in some ways the less individual attention to students…

    This effort seems to be in one with the student centered/whole child approach. It is not just about cognitive learning – if students don’t feel safe, are hungry or anxious, they can’t learn.

    good luck,


  27. Okay, If you screen and you find that there is a problem or issue that needs attention, what then. Are you going to fund the needed additional services. Are the “official screeners” going to be subject to mandatory reporting to law enforcement like child abuse reporting? That has not been explained.

    The problem with this is that a systematic solution is needed, likely with a start by decriminalizing of the substance abuse. Then education like smoking and then support services. We will not get anywhere without ending the cache of the risky behavior, its illegal, adults just do not want us to have fun thinking that kids have.

    Better to spend money on after school activities that kids would want to do rather than allowing them to be bored and left with little to do in the burbs. Which is a problem all over the state.

  28. The bill is very invasive to our children and with virtually no guarantees against prosecution and becomes a threat to reputation which could and would follow into adult life.I feel it echoes Patriot Act sentiments and is a slippery slope. This is not what we do in the Commonwealth of Massachusetts. The portions of the bill dealing with tracking patients’ history of pain relief medication is also a violation of privacy with negative impact on treatment for legitimate use.

  29. My concern is with mandating. One should have an already established relationship with students so that informal conversation would be possible. I know this is idealistic, and that those who work in public schools are overworked. I don’t like mandated tests either. We should be encouraging positive and creative actions among our students.

  30. The legislation sounds reasonable so long as it is adequately funded and can reasonably be fit into the school day/year. I agree that the idea of a mandate is rather off-putting. Could this just be recommended or disseminated to towns for adoption as they choose?

  31. No to this type of screening.
    To invasive, too expensive for cities & towns.
    Teachers can see & report students who are having problems now. No need for state intervention.

  32. Will,
    To put it politely, I don’t think interviewing the kids who score positive on the CAGE screen is a good idea. As your own experience in Dorchester suggests – it does not get much participation. To have “trained” nurses and physicians do the intervention is expensive and I doubt that it would have much effect on the “drug crisis.” Using the CAGE incorporated into a series of group discussions about drug use with the option for kids who want to talk to someone about their concerns might be useful – but I also think it will turn up a number of depressed kids rather than your eventual problem drug users.

  33. As a mother of 19 and 21 year old sons, i wish that this had been in place when they were going through the system. I won’t elaborate on the specifics of our experience but intervention is needed early. From experience i can say that kids will feel more comfortable being honest in a medical setting with no school officials nearby. I’m Not sure all the area schools have private medical rooms that are set up for this but they should. A positive example is Boston Latin Academy. I am for this proposal. Thanks, as always, for asking!

  34. Will,

    I reviewed the PowerPoint presentation linked above to the words “pilot experience over the last year has been positive.” With all due respect, if the information in that PPT is the best evidence you’ve got that the pilot program was successful, then it is by no means sufficient evidence to justify mandating SBIRT.

    The statistics about referrals and interventions generated by the pilot program tell us nothing about whether those referrals and interventions actually prevented or stopped even one teen from using drugs or alcohol.

    The statistics about teens’ state of mind immediately after the SBIRT interview tell us nothing about whether there is any long-term impact on their thinking or behavior.

    There was no long-term followup.

    This was not a controlled study.

    There was no controlling for population type (even if this program was effective in these specific school populations, who’s to say that it would be effective or appropriate in school populations with drastically different demographics?).

    There was no attempt to establish any sort of control group.

    In short, there should be an extremely high bar for evidence of benefit before a legal mandate is called for, and the evidence of benefit here is far too weak to justify such a mandate.

    Aside from my concerns about insufficient evidence of benefit to justify a legal mandate, I have other concerns as well.

    I have five children. All five of them have attended a K-8 private school; three of them are still there, while two (a senior and a sophomore) are now in high schools in the Boston Public Schools system. I’ve experienced more than 37 child-years of parenting kids in primary and secondary schools, during which time, my wife and I have been active participants in our kids’ education, including volunteering and participating in school governance. In short, I have more than a passing acquaintance with how schools work.

    And one thing I can tell you with conviction, something that I’ve seen over and over and every school I’ve been involved with, is that every faculty and staff member, from the principal down to the janitor, is overworked. The primary effect of this mandate, if enacted, will be to give more work to people who are already overworked. Which brings me back to the evidence issue — without ample evidence of efficacy, putting more work on these people’s plates is not justified.

    Another doubt I have with this program is whether it would be effectively administered. I know part of the pitch is that the proposed screening mechanisms are easy and straightforward, but I’ve seen plenty of “foolproof” systems destroyed by incompetence, and there’s incompetence in our schools just like anywhere else (some would say more so, but the argument I’m making is not dependent on whether that’s true). I am sure that the pilot programs were carefully designed and executed under close supervision by trained, competent staff. We cannot assume that the same would be true if this were mandated to occur at every school state-wide; in fact, it would be more realistic to assume that it most certainly would not.

    Which brings us to the question of privacy, confidentiality, and overzealous disciplining of children. One need only look at the case of Ahmed Mohamed to see what happens when school officials’ conscious and subconscious biases intersect with their duty to supervise children. Frankly, I simply do not believe that a program like SBIRT can be run in such a way as to completely prevent abuse, and we must weigh the cost of the abuse — i.e., the harm to some children — that will inevitably occur against the potential benefit the program might have to some other children. That brings us back, yet again, to the question of efficacy, i.e., there is insufficient evidence that the benefit would outweigh the cost.

    In summary, while it may be true that SBIRT is a great program which a lot of benefit, and it may be true that putting such a program in place in every single school in the country would benefit students greatly with little cost, there is not yet anywhere near enough evidence to justify legal mandates.


    Jonathan Kamens

    1. Agreed that study is a thin reed. I’m trying to get a better handle on the evidence base for this — there is a lot of good general literature, but I’m not clear on the results of school experiments. All your other points also well taken.

  35. While well intended, this proposal puts too great of an administrative and practical burden on the schools. It is much too complex to add to the general screening for vision, scoliosis, etc., and adds an additional layer to the nursing and guidance positions that are already stretched thin. Like many other requirements/mandates, I have little reason to be optimistic about adequate additional funding for this purpose.

    1. I agree!!! Administering this program would not be as easy as it sounds, and for what might be a negligible benefit. I am not convinced. I also imagine that teens would see this as a waste of time and intrusive.

  36. No, I don’t think it is appropriate to put students in a position to report about their lives nor do I think it will be effective. The questions the bill should concentrate are: 1) why are students turning to drugs? 2) where do drugs come from. We should not ask our children to do the dirty work for the things that we have messed up.

    Thank you.

  37. Concretely, how effective was the Northampton program?

    Have the other programs been evaluated scientifically or just through anecdotes?

    What’s the cost of implementing the legislation?

    1. Will,

      Thanks for seeking input.

      I too am quite interested in measurable results from the North Hampton program (or any similar pilto program elsewhere).

      In general I support this legislation.


  38. Kids see through hyprocrisy and hyperbole, and some of these things smack of that. Having a drink to help relax is an indicator of abuse? That broadens the definition of “abuse” to the point of absurdity.

    It didn’t take me long to figure out that DARE was overblown, and we all laugh at the Reefer Madness PSAs of yesteryear. Why add to the list?

    I suspect that the main effect of programs like this is that kids will (rightfully) see the authorities crying wolf, and will be less likely to trust them on *real* addiction issues.

    I’d be more inclined to support something like this if it acknowledged the difference between non-dangerous social use and real abuse.

  39. Thanks Will for facilitating this discussion.

    When I saw the Globe article on the proposal my gut reaction was negative and everything I have seen since reinforces that reaction. But maybe my reaction reflects my personal ignorance of a complex matter?!

    Are 7th & 10th graders prime opioid abusers? If not, why bother questioning them? I particularly am concerned about questioning 7th graders.

    Opt-out – is this a parental or student decision? If a student opts out, will that be because they are drug/alcohol users? So is the screening then really useful/effective?

    I think we need to be looking at more fundamental change in how we deal with drugs and alcohol rather than tinkering at the edges. Essential to any change/reform is moving drug abuse from the criminal system to the medical system where treatment not punishment is the primary goal. We all need to move away from the “War on Drugs” mentality; this has been an approach that has simply been a miserable and expensive failure.

    Thanks for the opportunity to comment.

  40. It sounds innocuous enough in wealthy communities such as Arlington and Belmont, but I worry about Dorchester and Fall River. It sounds much more complicated to implement fairly there.

  41. “And with some supportive dialog, one can, in a percentage of cases get them interested in voluntarily seeking treatment.” A “percentage of cases”?
    That is a low standard. .001% meets it. And if kids now are like they were back then I can guess why proponents are not being more specific.

  42. I do not support this proposal.As terrible as the drug epidemic is in this country, drug screening is trampling the student’s rights.

  43. Dear Will,

    After reading the comments of others below, I’m still unsure if this is a good plan. I think it might be a step in the right direction, but perhaps as others have pointed out, it might be better in a medical or therapeutic setting, rather than in school.

    But I can’t help thinking about the bigger picture. I know this is not that easy in a legislative context – one is often sentenced to burying one’s nose in a lot of detailed language, motions, and counter motions, right?

    What occurs to me are all the other things that it would help to verbally screen for in general. What about potential suicides? They are just as much a problem as heroin overdoses, right? Or almost as much of a problem, perhaps (I don’t have the statistics handy). What about domestic violence? Can’t we screen for that from whatever source we can get our hands on (including young people living in the house)? What about sexual or other abuse going on? Yes there is a great risk that the “police” will come and break up the family, so we need much better alternatives to “treat” domestic violence, and other abuse situations than we have now (i.e., beyond just throwing someone in jail before they really injure or kill someone).

    What I’m trying to say is we are operating a culture right now without enough good quality human contact where young people (or people of any age for that matter) have someone trusted to turn to, to open up about what’s got them down, is bothering them, stressing them out, making their life miserable, etc. No, the state can’t get directly into the business of therapy. But clearly social services are already failing under the load these days. I think that’s where the resources we have really need to go.

    This is where I think the source of drug use really lies. People who are not that stupid, who just feel like they have run out of other options for what’s going on inside them. This is what I hope we end up discussing.

    I’m not one of those “liberals” who hates capitalism, per se. It’s just that the ‘free market’ in all its wisdom, can’t really address any of this well. Community is not a “service” that can be sold for a price, or even created directly by government programs. But it is something that definitely needs our attention and support! In a way, aggressive commerce is destroying community by teaching us relentlessly that you can buy your way to happiness (so that somebody can make a profit from that), when in fact, it’s the things that money can’t buy that really count.

  44. No! terrible idea — use the resources it would involve to add more services for families in need.

  45. I am strongly opposed to legislation mandating verbal drug screening in schools.
    a. Each school has different problems and approaches to solutions. Legislation mandating verbal drug screening in schools would focus and provide funding for one approach. It could inadvertently eliminate more effective approaches in different schools.
    b. Once an effective screening system has been used a period of time, it becomes known, learned, and ceases to be effective. For example, there is a website named ”How to pass a drug test?”
    c. Legislating programs into our schools that had impressive pilot programs have a history of disastrous results. Pilot programs are tested by dedicated people well trained in a program. Legislation implements programs on a mass scale. Therefore, they are often put into practice by people who are untrained and just saddled with the program. One example is removing phonetics in the 1950’s in favor of sight-reading that left a generation with spelling and reading challenges. New math was so badly implemented that we are still untangling its repercussion on the study and mastery of mathematics.
    d. Just because our schools provide a captive audience, does not mean they should be used for medical or therapeutic experiments.
    e. Children mirror society. If there bad habits we wish to remove from our children, we should remove them from society first. Perhaps removing the overwhelming number commercials to use a plethora of legal drugs for a sundry of medical symptoms would make self-medicating with illegal drugs less of a first thought. Perhaps making drug rehabilitation centers readily available for all ages would make getting help less traumatic.
    I am opposed to legislation in response to the current wave of opioid drug use because it is reactive. Reaction leads to doing something visible that feels good rather than being effective. I would much rather see legislation that addresses the current wave of opioid drug use.

  46. Hi Senator Brownsberger,

    This sounds like a reasonable and uninvasive approach to helping kids. I believe that prevention and information is best started early. I would wonder how it can be applied though, so that kids can take it seriously enough, but not be intimidated. It is worth a try.

  47. The pilot may have been successful (define?, but I would suggest having the questions/conversation with older peers. Train students 3 or more years older to ask these questions, perhaps within the context of a conversation.

  48. I am in favor – as long as confidentiality is observed. Parents often don’t notice or don’t know what to ask. Would not want mandatory testing.
    Liz Seelman

  49. I can not imagine this being effective. As a high school student I would not have believed that my answers would be confidential or that they would not result in punitive measures. I don’t think kids are any more trusting now.

    On the other hand, a kid who has a problem and willingly answers affirmatively to any of the questions is probably a pretty good candidate for intervention.

    In the end I would oppose this proposal on the grounds that it is not likely to be effective and I do not trust that every school system would take sufficient measures to ensure confidentiality.

  50. I have several comments. As the mother of a son with serious addiction issues and mental illness, I’ve spent years in family programs in rehab, AA and AlAnon. While the SBIRT program may be attractive because it’s relatively cheap, it troubles me that there’s no back end plan for treatment of the affected students. And believe me, effective treatment is not cheap, nor is it quick, especially if individuals are self-medicating for underlying mental and emotional disorders, which is often the case. Also, considering the criminalization of drug use in this country, it seems unrealistic to expect a statistically significant number of teens to respond candidly to the SBIRT survey. Assurances that their answers will be held confidential may not be persuasive. I myself am not persuaded that red-flagging the surveys that answer questions in the affirmative creates a “paper trail” that is hard to contain.
    Second, the legislative efforts to curb prescription opiates has thrown up steep barriers for patients with long term chronic pain issues who are not abusing, but taking the drugs as prescribed to make normal daily function possible. The medical establishment still has little to offer people with serious, on-going pain issues other than opiates. Alternative treatments such as acupuncture and chiropractic medicine are rarely covered by Medicare or private insurance, so may not be an option for many patients. Any discussion of anti-drug policies in MA should include a mention of the many thousands of patients who are NOT abusing the pain medications they are taking, and whose suffering may increase if their doctors find it too much of a bureaucratic hassle to authorize refills of their prescriptions.

  51. A psychiatrist I once worked with said that in the face of saving a person’s life he would unearth every treatment modality and all personal/collateral information he could. The breadth and grip of the drug use crisis absolutely demands this. Parents, teachers, friends and guides are not up to the task of doing this alone. Many cannot seek and face the truth that behavior is molded starting in prenatal life and continuing every minute after birth. Isn’t the most fortunate child one whose thoughts are respected, solicited and challenged? Drug screening and the required transparency, based on evidence based medicine, is a reasonable continuation of that truth seeking and opportunity to manage future life.

    The overwhelming challenge is having resources for those who do share their experiences and need support and treatment. It is immoral to solicit truth and be unable to address expressed needs. In my own job as a nurse, the impetus to screen is booming while facilities, money, and treaters are not expanding.

    I’m hoping the pressure of need for treatment will circle back to the pivotal moment of choice to embrace or reject drug use and the life of loss.

  52. We share an objective, I think, that we want schools to be comfortable environments where students feel able to learn and thrive.

    I understand completely the desire to do this, and to handle it in a voluntary and non-confrontational way. My concern is with the redisclosure of the information, either outside the school, or to the school resources officer in the school if there is one. We cannot hope for students to be candid if there is any chance of such information getting into the wrong hands.

    Therefore, I would be more comfortable with language that said, “Notwithstanding other provisions of state law [can’t do anything about federal, of course], the school employee to whom this information is first disclosed shall not disclose to any other school employee or to a non-school employee confidential information provided during a verbal substance use disorder screening under section 57”, or better language to that effect.

  53. Based on the information here, I support the legislation as described above. The brevity of the list of questions and the provision for who asks them, as well as the ability to opt out, make me believe this could be a worthwhile approach. This might be especially effective with young people who know something is wrong, or who are uncomfortable with their drug use, but who don’t know how to go about stopping or getting help.
    There is always the possibility that people will give false answers, but I think it’s worth that risk in order to reach others who could use the help. Also, even those who answer falsely will get the message that people care and want to help.
    I think it is important that the list of questions be asked by individuals who are not aggressive, but, rather, who feel empathy and concern.
    Thank you for asking.

  54. What will you be replacing the 2 advisory groups with?
    If Neurontin is not an opioid, why would it be monitored? Thanks.

    1. Not sure the intention is to replace the groups. Some groups do not actually function.

      Regarding Neurontin (gabapentin), apparently, their is a level of abuse. Some non-opioid drugs with legitimate uses also have potential for abuse.

  55. I was not aware that any adolescent could legally sign away his privacy. Shouldn’t a parent be involved in this??

    I have five children and eight grandchildren. When they were still very young, all of them were helped to understand that their bodies and minds were their greatest gifts and that all through their lives they would be responsible for their care.

    As far as SBIRT is concerned, if you wait until they are in their teens, you will be too late!!

    1. The idea is that kids should be able to talk to the screeners/counselors without fearing that the counselor will run to their parents with whatever they say.

      I do agree that it might make sense to start earlier. In the final version of the bill, we left that up to DPH as to when to do the screening — requiring only that it happen annually in two grades.

  56. Back in the day, I knew students who started using alcohol and/or drugs starting in middle school. Young people have the “411” on other students. What do they think could help their peers?

    I believe drop-in guidance services (yes, more expensive than an oral test) could serve as a resource to those who aren’t getting what they need at home.

    A trusted adult could make all the difference!

  57. Too bad your amendments went down. If screening is to be done, I believe it should be made a local option. But then, the state would need a carrot to make it harder to turn down, and I don’t think the government is in a financial position to do that without siphoning monies away from education or other important public responsibilities.

    And a stewardship program would help, I believe, but it needs a carrot too, such as reimbursement from drug companies of the cost of the drug to a patient, and a convenient drop-off plan (at pharmacies, perhaps).

    What do you expect the House to do with the bill?

  58. Hi Senator:

    I like that the DPH will regulate as needed the drug testing according to local needs on an individual basis.

    The Behavioral population seems to be the target for such testing upon recognition that prescription drugs are needed and accepted at a moderate level.

    As needed, being the operative word followed by the counselors recommendation in accordance with a state mandate seems fair.

    Thanks for your input. It appears that any regulation will be better than no regulation with measures to check progress in place on an individual school/system basis, again.

    Best regards,
    Lori Ajamian, M.Ed

  59. Will,

    Sorry I did not respond in time, but I appreciate your amendments to the bill. Even though I am involved in this issue and even though I know the value of screening for medical disease, I have reservations about this screening. I recently read an article about SBIRT and I agree that the jury is still out on its effectiveness.

    Thank you for your thoughtful amendments.


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