Opioid Plan, Part II — Coercion and Recovery (continued)

The House has now produced its own substance abuse bill. It takes a very sensitive approach to the issue of coercion of treatment by hospitals.  The Senate Chair of the Mental Health and Substance Abuse Committee has commented favorably on the proposal and was involved in its development, so, while there are more steps to the process, the legislature seems to headed in a good direction.

Many of the commenters on my post about the original proposal shared my concerns about making hospitals a place where persons with addiction could end up getting detained.  The House approach is sensitive to those concerns, while, at the same time, making it more likely that people with addictions will get treatment that they need.

  • It does not allow physicians to physically detain people with addictions and force them into treatment.
  • It does prohibit them from affirmatively discharging a person admitted for an opioid overdose without evaluating them and offering them treatment — patients would remain physically free to leave “against medical advice.”
  • If an evaluation doesn’t get done within the first 24 hours, perhaps because the patient does not wished to be evaluated, the hospital can discharge the patient.

I am much more comfortable with this approach.  I am profoundly sympathetic with people who are struggling with the destructive substance abuse disorder of a loved one, and I understand that some would like to see the system take over and force change, but I think we have to be realistic about what is possible.  Making hospitals into places that are scary for people with addictions will lead to more deaths, not less.   The new proposal does the right thing — it requires hospitals to offer more to people with addictions, without turning doctors into police.

The specific proposed language appears below.  Would very much appreciate your further comments.

SECTION 17. Chapter 111 of the General Laws, as so appearing, is hereby amended by inserting after section 51 the following new section:-

Section 51½: Substance Abuse Evaluations in Acute-Care Hospitals

(a) For the purposes of this section, the following words shall have the following meanings:-

“Acute-care hospital”, any hospital licensed under section 51 of chapter 111, and the teaching hospital of the University of Massachusetts Medical School, which contains a majority of medical-surgical, pediatric, obstetric, and maternity beds, as defined by the department.

“Licensed mental health professional” , a licensed physician who specializes in the practice of psychiatry or addiction medicine, a licensed psychologist, a licensed independent social worker, a licensed mental health counselor, a licensed nurse mental health clinical specialist or a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J.

“Substance abuse evaluation”, an evaluation ordered pursuant to subsection (b) that is conducted by a licensed mental health professional which shall include, but not be limited to, collecting the following information: history of the use of alcohol, tobacco and other drugs, including age of onset, duration, patterns and consequences of use; the use of alcohol, tobacco and other drugs by family members; types of and responses to previous treatment for substance use disorders or other psychological disorders; an assessment of the patient’s psychological status including co-occurring disorders, trauma history and history of compulsive behaviors; and an assessment of the patient’s Human Immunodeficiency Virus, Hepatitis C, and Tuberculosis risk status.

(b) Each person presenting in an acute-care hospital who is reasonably believed by the attending physician to be experiencing an opiate-related overdose shall receive within 24 hours of admission a substance abuse evaluation. A substance abuse evaluation shall conclude with a diagnosis of the status and nature of the client’s substance use disorder, using standardized definitions established by the American Psychiatric Association, or a mental or behavioral disorder due to the use of psychoactive substances, as defined by the World Health Organization. Each patient shall be presented with the findings of the evaluation in person and in writing, and such findings shall include recommendations for further treatment, if necessary, with an assessment of the appropriate level of care needed. Findings from the evaluation shall be entered into the patient’s medical record. No acute-care hospital licensed pursuant to section 51 of this chapter shall permit early discharge, defined as less than 24-hours after admission or before the conclusion of a substance abuse evaluation, whichever comes sooner. If a patient does not receive an evaluation within 24 hours, the attending physician must note in the medical record the reason the evaluation did not take place and authorize the discharge of the patient.

(c) After a substance abuse evaluation has been completed pursuant to subsection (b) a patient may consent to further treatment. Such treatment may occur within the acute-care hospital, if appropriate services are available; provided, however, that if the hospital is unable to provide such services the hospital shall refer the patient to treatment center outside of the hospital. Medical necessity for such treatment shall be determined by the treating clinician in consultation with the patient and noted in the medical record. If a patient refuses further treatment after the evaluation is complete, and is otherwise medically stable, the hospital may initiate discharge proceedings. All persons receiving an evaluation under subsection (b) shall receive, upon discharge, information on local and statewide treatment options, providers, and other relevant information as deemed appropriate by the attending physician.

(d) If a person has received a substance abuse evaluation within the past 3 months, further treatment and evaluation determinations shall be made by the attending physician according to best practices and procedures.

(e) If a person under 18 years of age is ordered to undergo a substance abuse evaluation, the parent or guardian shall be notified that such an evaluation has been ordered. The parent or guardian shall consent to the evaluation and may be present when the findings of the evaluation are presented and may authorize further treatment for the minor if such treatment is recommended by the evaluator.

Published by Will Brownsberger

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

26 replies on “Opioid Plan, Part II — Coercion and Recovery (continued)”

  1. This is a good approach. The last thing that we need to do is to discourage people from going to hospital for critical treatment. Now we need a budget to fund rehabilitation. An advertising and social media campaign and getting an organized program in place to encourage people to use the new drug treatment is necessary.

  2. Hello thank you Mr Brownsberger for allowing a venue to comment. Have received your emails for a few years now and appreciate your work in updating us on events.
    Im not a politically minded individual and not as engrossed with the political ins and outs . So my statemnt may be a bit naive for my thoughts/frustrations are an accumilation of my perception molded by the never ending RED/BLUE infighting , CEO’s and wall streets skating on their infractions, illegalalities, etc.
    My concern is that our elected officials votes are swayed willing / unwillingly, systematically in one fashion or another by big business lobbyist with promises of campaing funds, and/or loyalty toward party support, etc.
    All I ask from you Mr Brownsberger and your colleges is to vote towards helping the people in mind as the sole goal and not worry about the need to support businesses with a balanced policy.

    1. Thanks, Vincent.

      I understand the thought clearly. I think this proposal balances the need to help persons with addictions with the risk of helping them in ways that don’t work.

      It isn’t about balancing business interests.

  3. A desire to stop using drugs and alcohol has to be voluntary to succeed. Everyone knows that, but the providers don’t want you to know that because this is just a business model to them. Any “coercion” model is a BIG waste of money and effort. The Gloucester PD model is the one to look at…voluntary and without penalty.

  4. Yes, it’s an improvement not to lock up patients, but I question the value and propriety of the legislature mandating treatment protocols for doctors. Treatment should be determined by a doctor, not legislated. Under this legislation, doctors will be less likely to treat addicts and addicts will be less likely to enter a hospital for treatment. I guess the thinking is “I am an elected, important official who can make a law. Surely I know better than the doctor and a drug user how to deal with his problems.”

    1. Not sure how you get to that, Grant.

      I think this new proposal is respectful of physician expertise. All the decisions in this process will be made by physicians and patients with guidance from physician consensus standards.

      It is not about telling doctors how to care for substance use disorders. It only requires that they at least do so — the thought is that the opportunity is missed.

      Do you think the recommendations are too specific?

      1. I was lazy in writing my comment. Yes, the mandates (not “recommendations”) are too specific. The micromanagement is unjustified. Why not leave treatment to the professionals? The legislation treats them like incompetent or malign enablers. Let the professionals and the patient attempt to deal with the patient’s problems. The law reeks of hubris, suggesting that the legislature knows best. By requiring specific and onerous steps, the professionals will experiment and perhaps treat less. They will have little basis to establish a relationship with the patient. The implication seems to be that further regulation akin to the drug war is going to reduce the problem. I do not see what the legislation accomplishes other than increasing costs and hamstringing professionals. Legislature: FIRST, DO NO HARM!

  5. I’m not an attorney so I may be missing a bigger point, but it seems to boil down to if someone comes into a hospital because of an overdose as the only trigger, the hospital must hold them for 24 hours and it may perform a substance abuse evaluation in that time. The patient may act on the results of the evaluation ?

    Doesn’t seem very helpful to the patient.

    1. “Hold” is the wrong word. They can’t hold them, but, in effect, they are required to attempt the evaluation and referral.

      I know from your previous comments that you would favor a more aggressive approach. I just don’t think that will work.

      1. Thanks for providing a forum for people to express their views. My view is that this won’t work either but I gave my honest opinion based on a certain amount of experience. I guess little teeny weeny baby steps are better than nothing.

  6. Not clear if the substance abuse evaluation is mandatory. The proposal states a patient cannot be held against their will, so they would be free to leave before an evaluation and be discharged after 24 hrs whether they have agreed to an evaluation or not if it hasn’t been performed within 24 hrs.

    My first question is what is different from existing procedures?

    1. Correct that it is a modest change. Practice certainly varies, so it will be more of a change in some places and possibly no change in others. But it should overall adjust practice in the direction of attending to the possible behavioral health treatment needs of patients.

  7. What if the patient is not well enough to cooperate with evaluation, or to comprehend recommendations, within 24 hours of admission?

  8. This bill in un-American and unethical. Please read “Anatomy of an Epidemic” by Robert Whitaker.

      1. Will, thank you for not booting me off your e-mail list for my blunt comments!

        One part that’s missing is the fifty years of culpability of the APA. That organization, mentioned specifically in this bill, is scripted by Big Pharma and the healthcare industry. The medications being used for “treatment” have harmed thousands and thousands of people while the DSM, their “Bible”, is a manual for profit, not wellbeing.

  9. Thank you for taking a more level-headed approach than the Governor proposed. He wanted to shake up the process, and he has. Time for common sense to prevail.

    I think this is a big improvement. But all of us who work in the field or are connected to the problem in any way, know that making more and better treatment available, and encouraging people rather than trying to force them, will create the real change in the long run. We need more detox beds, and much more long-term treatment beds. We need public funding for good, clean, safe programs.

    (And we need nobody left for hours to die while in withdrawal in a van outside MASAC in Bridgewater, but that’s a separate problem.)

  10. Will, I agree with your approach to this. Regardless of the wishes of family members, adults should remain free to make their own medical choices, and should not be forced into treatment, and especially should not be forced to take drugs. I have a personal connection to mental illness in my family, and I strongly believe that my aunt’s mental illness was made worse by treatments that were pushed on her back in the day when ethics were not much of a concern. The state should not be forcing or coercing people to do anything to their bodies, except where an individual is a clear and present danger to others. Thanks for your work on this.

  11. Will,

    Thanks for keeping us up to speed on the progress of these two important components of the Governor’s and the Legislature’s efforts to address the opioid crisis. I like what I see and appreciate the compromises that where made.


  12. I am in favor of the three bullet points noted at top. I know several people who are in alcohol treatment programs and have continued weekly meetings for years. It was only after they initiated or agreed to treatment that they recovered (actually ‘recovery’ is probably inaccurate…have the urges under control with constant effort and support from family, friends, their own community is more accurate). I appreciate your ongoing efforts to keep us in the loop at the ground level.

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