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. 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.

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

  3. 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.

  4. 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.

  5. 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.

  6. 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

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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!

  15. 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?

  16. 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

  17. 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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