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