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:
- 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.
- 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”.
- 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.
- 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
- 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.