Last week, the legislature reached agreement on legislation to control opioid drug abuse. The Governor is expected to sign it this morning.
As the official press release further below explains, the bill does a lot. I feel it is a good bill and I was pleased to support it.
There were three big issues that I focused on during the debates and in previous discussions with my constituents. Here is a how they each came out:
Screening in Schools
I felt that the Senate’s original draft went too far in specifically ordering schools to start screening students for substance abuse. I do strongly support voluntary screening in as many venues as possible — essentially it means offering people help and it doesn’t take long. But, for it to be effective, it has to be done very sensitively. If people are uncomfortable talking, the process just won’t work. Screening in schools, where students are in a disciplinary environment, is very likely not to work well and the research base on screening in schools is still thin – not an idea ready to be rolled out as a statutory mandate.
The conference bill does include a screening mandate, but it appears to have been finessed with a key phrase: The mandate is made “subject to appropriation”:
Subject to appropriation, each city, town, regional school district, charter school or vocational school district shall utilize a verbal screening tool to screen pupils for substance use disorders. Screenings shall occur on an annual basis and occur at 2 different grade levels as recommended by the department of elementary and secondary education, in consultation with the department of public health. Parents or guardians of a pupil to be screened pursuant to this section shall be notified prior to the start of the school year. Verbal screening tools shall be approved by the department of elementary and secondary education, in conjunction with the department of public health. De-identified screening results shall be reported to the department of public health, in a manner to be determined by the department of public health, not later than 90 days after completion of the screening.
How that will be interepreted and rolled out remains to be seen. The bill does require that screening begin in the 2017-2018 school year.
I was pleased that the bill preserved confidentiality language which I had fought for:
Any statement, response or disclosure made by a pupil during a verbal substance use disorder 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, parent or guardian, except in cases of immediate medical emergency or a disclosure is otherwise required by state law. Such consent shall be documented on a form approved by the department of public health and shall not be subject to discovery or subpoena in any civil, criminal, legislative or administrative proceeding. No record of any statement, response or disclosure shall be made in any form, written, electronic or otherwise, that includes information identifying the pupil.
The Governor proposed that hospitals should be able to hold patients against their will when they present with substance abuse overdoses. I felt this was unwise, although well-intentioned and serious as a proposal. This provision was not in the Senate bill and is not in the conference report.
However, the conference report does include a mechanism to assure that people presenting with overdoses will get a substance evaluation and be offered treatment:
- Hospitals must give a substance evaluation to persons presenting with opiate-related overdoses within 24 hours.
- The findings are to be presented to the patient in person and in writing.
- A hospital is not to discharge the patient before the evaluation is occurred.
- Patients may consent to further treatment.
- The law explicitly that “Nothing in this section shall interfere with an individual’s right to refuse medical care.” So, patients remain free to leave against medical advice.
- Hospitals are protected from liability for releasing patients who do not wish to remain after stabilization.
I feel that this is a sound compromise approach that will lead to more people being evaluated for substance abuse and offered treatment without turning hospitals into jails.
Restrictions on Prescriptions for Opioid
I share the conviction that over-prescribing of opioid pain-killers has contributed to the opioid epidemic. At the same time, I am respectful of the reality that some people are afflicted by conditions that cause overwhelming pain. For them, opioid drugs are life-transforming and necessary.
The Governor initially proposed a limit to 72 hours for a first prescription for painkillers. This was greeted by considerable outcry from pain-control advocates. The House proposed an approach, which the Senate was receptive to, which limits first-prescriptions to a 7 day supply, but allows doctors to make longer prescriptions if they make written findings of chronic need. This is the sound approach adopted by the conference committee.
The final package also includes language that the Senate crafted after lengthy debate that effectively allows patients to choose to only partially fill a prescription for opiates.
A registered pharmacist filling a prescription for an opioid substance in schedule II of section 3 may dispense the prescribed substance in a lesser quantity than the recommended full quantity indicated on the prescription if requested by the patient provided that the prescription complies with subsection (c) of section 22. The remaining quantity in excess of the quantity requested by the patient shall be void. If the dispensed quantity is less than the recommended full quantity, the pharmacist or a designee shall, within a reasonable time following a reduction in quantity but not more than 7 days, notify the prescribing practitioner of the quantity actually dispensed.
The bill does include provisions requiring reporting on the volume of prescription of opiates. Pain advocates fear that this reporting will scare physicians away from making necessary and appropriate prescriptions. We will have to see how that goes.
Disposing of Prescription Drugs
I was pleased to see the bill create a drug stewardship program — a mechanism to force drug manufacturers to take responsibility for safe disposal of excess drugs through providing or contributing towards the cost of takeback programs.
Senate Press Release
Legislature Passes Substance Addiction Legislation to Enhance Continuum of Care and Prevention Efforts
Builds off 2014 landmark law and unprecedented budget investments
(BOSTON) – The Massachusetts Legislature passed substance addiction legislation that enhances intervention, prevention and education efforts, including the creation of a framework to evaluate and treat patients who present in emergency rooms with an apparent overdose.
This new practice, which will be covered by insurance, is designed to ensure the proper assessment and discharge of patients who seek voluntary treatment. If a patient refuses treatment, information on health and community resources will be provided. This framework reflects the 2012 University of Miami Medical School findings that voluntary treatment is more effective and affordable than involuntary commitment.
“We are in the midst of a public health crisis that is draining vitality from our hometowns, extinguishing lives and stealing souls,” said House Speaker Robert A. DeLeo (D-Winthrop). “Our focus on workable solutions, consensus-building and legislation that complements our budget investments has set a foundation for continual improvement. I wholeheartedly thank my colleagues for their creative, unassuming and compassionate commitment to paving a path for the recovery of thousands of our loved ones, and in fact, a path for our wounded Commonwealth.”
“The opioid crisis has ripped apart our communities and families. Over the past few years, the Legislature has focused on access to treatment, funding for substance abuse programs, and continuity of care. This bill focuses on preventing addiction, enhancing public education, and removing pills from circulation,” said Senate President Stan Rosenberg (D-Amherst). “Twelve recommendations of the Special Senate Committee on Substance Abuse are included in this legislation and they will make a real difference in fighting the opioid scourge in our communities. I thank my colleagues for their hard work on this bill and dedication to bringing an end to the opioid epidemic in our state.”
“This bill represents a significant milestone in the Commonwealth’s efforts to eliminate the scourge of substance abuse, which has had a devastating impact on thousands of families and has left no community untouched,” said House Minority Leader Bradley H. Jones, Jr. (R-North Reading). “There is still much work to be done, but the bill we are sending to the Governor today provides a solid foundation we can build upon to address this serious public health crisis moving forward.”
“The abuse and proliferation of opiates in our society poses a serious and continuing threat to the health and safety of our communities and that threat demands comprehensive and effective responses; this bill will directly oppose the spread of opioid abuse and support those who need access to treatment,” said Senate Minority Leader Bruce Tarr (R-Gloucester). “The unanimous support in the House and Senate demonstrates our united efforts to move forward with the best bill possible.”
“This conference report includes significant new policies that will help to fight the opioid epidemic impacting all corners of the Commonwealth”, said Representative Brian S. Dempsey (D-Haverhill), Chair of the Joint Committee on Ways and Means. “The seven day limit on first time opiate prescriptions and required substance abuse evaluations in emergency rooms are innovative new initiatives that will have a real impact on the lives of our constituents struggling with opioid addictions.”
“This bill has the ability to make a profound impact on people’s lives. We’re engaging the entire healthcare ecosystem – from patients to prescribers to providers to pharmaceutical companies and insurance companies – to aid in education and prevention,” said Senator Karen E. Spilka (D-Ashland) Chair of the Senate Committee on Ways and Means. “Thank you to my colleagues and all of the individuals, families and advocates who came forward to share their stories for working together on a holistic approach to reverse the course of the opioid epidemic that affects all of our communities.”
“The bipartisan compromise bill we passed today represents the strong commitment of the Legislature and Administration to addressing the opioid crisis by developing specific systems of education and prevention, intervention, and treatment,” said Representative Liz Malia (D-Jamaica Plain), House Chair of the Committee on Mental Health and Substance Abuse. “Among many key provisions, it creates a new standard in acute-care settings by requiring a licensed medical professional to conduct a substantive evaluation of individuals who present in an emergency department with an apparent opiate overdose. This new best-practice is designed to ensure the proper assessment and discharge of patients who seek voluntary treatment and provides for insurance coverage of the evaluation, arming providers with the necessary resources. I thank the Speaker for his leadership and support for this change in how we view and treat those suffering from the disease of addiction, and our Senate colleagues for prioritizing proposals to disrupt the status quo and stem the tide of this public health crisis. Change requires starting where we are and progressing incrementally, and I think this comprehensive piece offers that opportunity.”
“Substance use disorder continues to affect every corner of our Commonwealth and this next piece of legislation gives our schools and health care partners additional tools in the fight against this disease,” said Senator Jennifer L. Flanagan (D-Leominster) Senate Chair of the Committee on Mental Health and Substance Abuse. “This bi-partisan bill asks treatment and health care providers, educators, insurers, drug manufacturers, and public safety to come together to engage in these new prevention programs and to all do our part to combat substance abuse throughout the state.”
“This legislation works hand-in-glove with the governor’s opioid task force recommendations as well as recent significant funding increases to provide education, identification of persons at-risk, and smart ways to reduce the volume of opioid medications that can lead to illicit use,” said Representative Randy Hunt (R-Sandwich) and member of the conference committee.
“I am proud to have joined my colleagues in the Legislature and the Administration to work on this important bill,” said Senator Vinny deMacedo (R-Plymouth) and member of the conference committee. “I believe we have passed legislation that will dramatically improve the lives of those affected by substance use issues and educate people about the dangers of addiction in order to prevent this scourge from affecting future generations.”
“This legislation provides a meaningful framework for how we address the prevention and treatment of substance abuse disorder in the Commonwealth,” said Representative Jeffrey Sánchez (D-Jamaica Plain), Chair of the Joint Committee on Health Care Financing. “We are now another step closer in helping patients, families, and communities tackle this challenging issue.”
“With opioid related deaths at an all-time high in the Commonwealth, this legislation will put measures into effect immediately to address a crisis that touches nearly every family in Massachusetts,” said Senator James T. Welch (D- West Springfield), Chair of the Joint Committee on Health Care Financing. “The comprehensive prevention and treatment efforts included in the bill passed today are critical steps toward ending this devastating epidemic.”
The bill limits first-time opiate prescriptions to seven days for adults and all opiate prescriptions for minors to seven days, with exceptions for chronic pain management, cancer, and palliative care. Practitioners must now check the prescription monitoring program (PMP) each time they prescribe any opiate and correspondingly note that in the patient’s medical records.
From its discussions with numerous stakeholders and recovery groups, the Legislature recognizes the importance of empowering individuals as they grapple with addiction. As a result, this bill establishes a non-opiate directive form, allowing patients to include a notation in their records that they shall not be offered opiates. It also provides the option of a “partial fill” which allows patients, in consultation with their doctor, to request a lesser amount than indicated on the script; however, this language is permissive and pharmacists may use their discretion.
In an effort to build upon current prevention efforts, the legislation updates current law – which requires all public schools to have a policy regarding substance abuse education – by directing schools to report their plans to the Department of Elementary and Secondary Education (DESE). DESE will then consult with the Department of Public Health (DPH) to provide recommendations that will assist schools and ensure they are providing effective and up-to-date education. Additional education materials will be provided to all student-athletes.
Schools will annually be required to conduct a verbal substance abuse screening in two grade levels. These screenings are subject to appropriate ages and include an opt-out provision for students and parents. Additionally, school districts implementing alternative substance use screening policies may opt out of the verbal screening tool requirement.
To ensure that unused medications are safely collected and disposed of, this legislation requires manufacturers of controlled substances in Massachusetts to participate in either a drug stewardship program or an alternative plan as determined by DPH.
Over the past few years, the Legislature’s efforts related to substance addiction have focused on behavioral health and the prevalence of co-occurring disorders. This legislation requires the Health Policy Commission to conduct a study on access to dual-diagnosis treatment in the Commonwealth for children, adolescents and adults. To help ensure parity between behavioral and physical health care, the legislation also requires insurance companies to report annually on their denied claims.
This bill also:
• Requires that contact information for all insurers be posted on the bed-finder tool website and updates the law to ensure the site is available 24 hours a day;
• Requires that patients being discharged from substance addiction receive information on all FDA-approved medication-assisted therapies;
• Ensures civil-liability protection for individuals who administer Narcan;
• Updates the training guidelines for all practitioners who prescribe controlled substances;
This legislation follows a 65.2% increase in substance addiction funding since FY12 and the landmark substance addiction law passed in 2014 which, for the first time, mandated detox and stabilization coverage. The two bills are intended to complement each other and reflect a consensus-driven approach.