Tough Pill to Swallow – State Mulls a Bold Strategy Against Opioid Abuse

Gov. Charlie Baker knew his bill would ruffle a few feathers. That was the point.

He said as much when he reminded lawmakers last month that Massachusetts doctors, in 2014, wrote more than 4.4 million prescriptions for Schedule II and Schedule III drugs — defined as medications with high to moderate potential for dependency and abuse — totaling more than 240 million pills.

“I should remind everybody that we only have six and a half million people in the Commonwealth of Massachusetts,” Baker said. “In the same year, over 1,200 people died of opioid overdoses. Simply put, the status quo is unacceptable, and it needs to be disrupted.”

Baker was testifying before the Joint Committee on Mental Health and Substance Abuse, alongside Boston Mayor Martin Walsh and Christopher Barry-Smith, the state’s first assistant attorney general, in support of “An Act Relative to Substance Use Treatment, Education and Prevention,” a bill the governor filed in mid-October to address an opioid epidemic in Massachusetts that claims the lives of nearly four residents every day, on average.

Dr. Robert Roose, chief medical officer of Addiction Services for the Sisters of Providence Health System, was part of a 16-member working group Baker assembled earlier this year to craft a plan to combat what medical professionals have been calling a statewide crisis, and said the bill’s components — including a 72-hour limit for new opioid prescriptions and involuntary hospitalization of patients who might pose a danger to themselves or others — originated from that group.

“We took our responsibility seriously, to come up with interventions and strategies to address the epidemic in a bold way,” Roose told HCN. “The premise we were operating from was that this epidemic is unlike any we’ve seen before, both in magnitude and breadth of who is impacted, and knowing the strategies we’ve attempted in the past likely would prove insufficient, we wanted to come up with bold, new strategies.

“Governor Baker’s bill does exactly that,” he went on. “These are provocative and bold ideas that have generated some discussion, if not controversy, throughout the medical community and healthcare systems, as well as, perhaps, with patients themselves and treatment advocates.”

Certainly, Dr. Dennis Dimitri is well-versed in the opioid issue, as president of the Mass. Medical Society (MMS), which has come up with its own broad series of strategies to combat the problem. He cited a recent poll by the Harvard School of Public Health showing that nearly four in 10 Massachusetts residents personally know someone who has abused prescription pain medications.

Therefore, he thanked the governor and lawmakers for their multi-pronged approach to addressing the crisis, including significantly increased funding for addiction services, insurance coverage, and enhancements to the state’s Prescription Drug Monitoring Program. “We strongly support these and other measures,” Dimitri said.

Still, not every detail of the bill — the logistics of which still need to be hammered out — will necessarily go down easy with the state’s physician community.

Drawing a Line

Take, for example, a provision in the bill limiting patients to a 72-hour supply the first time they are prescribed an opioid or when they are prescribed an opioid from a new doctor.

“Looking back over the past 20 years,” Roose said, “we have overprescribed for pain and done an insufficient job of educating patients in the community about potential risks of opioids. The medical community has been engaged with this issue increasingly over the past several years, but, clearly, what has been done is not enough.”

As a member not only of the governor’s working group but the Mass. Hospital Assoc. (MHA) Substance Use Disorder Prevention and Treatment Task Force, Roose has been heavily involved in discussions of prescription limits. While the limits themselves aren’t controversial, the details are a point of contention. While Baker seeks a four-day limit in his bill, the MHA prefers a five-day limit, while the Mass. Medical Society seeks a seven-day limit, calling four days simply too onerous for many patients.

“A patient with acute pain beyond the proposed initial 72-hour treatment period would have to return to their physician’s office, obtain a paper prescription, bring it to the pharmacy, and wait for it to be filled,” Dimitri said. “An elderly or disabled or poor patient, especially one without a helping caregiver or transportation, could be left to suffer.”

Dimitri understands the rationale behind limits. Citing statistics from the Centers for Disease Control, he noted that more than 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of people who misuse prescription pain medications are using drugs prescribed to someone else. That’s why the MMS proposed a seven-day limit last spring, which includes a sunset provision to take effect when the crisis abates, allowing prescribers to care for their patients on an individual basis.

Dimitri also encouraged lawmakers to consider allowing ‘partial-fill’ prescriptions, which, he said, would help patients “balance the need to relieve pain with an adequate supply of pain medications by only filling part of their prescription, with the ability to later go back if necessary to fill the rest.”

On the federal level, current Drug Enforcement Administration regulations prohibit partial-fill prescriptions, but the MMS has supported an effort by U.S. Rep Katherine Clark, who represents Massachusetts’ 5th District, to urge the DEA to change the partial-fill rules.

“We continue to support incorporation of clinical judgment,” Dimitri added, “fully understanding the severity of the significant challenges confronting the Commonwealth and our patients.”

Roose admitted many providers are leery about a prescribing limit as short as 72 hours, but also conceded that it might be an effective tool.

“A lot of work has been done by the medical community to recognize the risk of overprescribing or having excessive medications left around, but where do you draw the line?” he said. “On the face of it, physicians don’t want to be regulated; they don’t want to have their behavior dictated into statute. But, at this point, I think we have evidence suggesting that measures need to be taken to protect the community and the public health. We do want to reduce the availability of unused medications in the home.”

Barry-Smith agreed. “We’re confident that the Department of Public Health will work with the medical community to implement and, if necessary, refine that 72-hour limit,” he told the legislative committee, “but, as a general matter, there can be no doubt that additional safeguards on opioid prescribing are necessary.”

Added Walsh, “help means prevention, and I agree with the governor. A common-sense limit on first-time opioid prescriptions would provide an effective checkpoint to limit the flow of addictive narcotics into our homes and our communities.”

Against Their Will

Perhaps more controversially, Baker’s bill would grant medical professionals the authority to involuntarily commit an individual with a substance-abuse disorder for treatment for 72 hours if they pose a danger to themselves or others. Currently, such people can be held for treatment only through a court order — and the court system isn’t always available when a patient needs protection.

“We already have, in Massachusetts, a process of involuntary commitment for individuals in danger of substance abuse,” Roose said, noting that Baker’s proposed statute would streamline the process, recognizing that the critical moments of a substance-abuse episode can happen at any hour of the day, 365 days a year.

“Treatment is often delayed through other, voluntary routes. This could provide an avenue where individuals in immediate danger are transported to a facility, at least for evaluation by a medical professional,” he explained, adding that such a process would in no way replace or minimize the importance of available avenues for individuals and families to seek voluntary treatment.

“But it does take into consideration the fact that addiction is a disease that fundamentally impairs somebody’s control and judgment,” he went on. “While we need to, in my view, move toward decriminalizing substance abuse and offering treatment as opposed to punishment, we also need to provide treatment on demand when people need it, where they need it, and at the right level of care. This could provide another avenue for people in immediate danger to be stabilized and evaluated. That could save countless lives.”

However, Dimitri argued, addiction-medicine specialists have raised concerns that such commitment won’t work without access to more treatment resources and post-hospitalization care.

“There is a paucity of evidence that forcing hospitalization on patients not ready to make a change will be successful, and there is evidence that addicted patients released from hospitalization with no plans to pursue after-care are at higher risk for opioid overdose,” he told lawmakers. “My colleagues in emergency medicine and hospital leadership are concerned that this proposal could create a new standard of care requiring all patients who are suspected of having the potential to overdose to be involuntarily hospitalized. This will result in new demands on hospital medical and psychiatric beds that are already severely strained.”

Roose noted that increasing involuntary hospitalization could be an additional impetus for increasing additional capacity and treatment services in the state — a process that is ongoing, with dozens, if not hundreds, of new inpatient beds soon to be available in Massachusetts, including the four counties of in Western Mass.

Also, “requests for new programs have been released by the Department of Public Health in recent weeks,” he added. “I believe that the Department of Public Health and the administration recognizes capacity is insufficient and are making strides in response to that.”

Dimitri agreed, but said involuntary hospitalization might be putting the cart before the horse. “The Commonwealth has spent a tremendous amount of time and resources in trying to resolve the issue of emergency-department overcrowding, boarding, and diversion. This could further exacerbate that problem without actually benefiting patients. New funding has become available to expand capacity; let’s see what progress we can make before adding more stress to our system.”

While the concept might be controversial to some, Roose said, the devil is in the details.

“We need to answer questions about the logitistics, our capacity for treatment, how this will end up being implemented, and potential risks to providers who choose to — or choose not to — utilize this statute,” he said. “We know right now we don’t have adequate substance-abuse treatment in this state, but that should not be a reason, in my view, to not be creative in how we treat patients.”

Watchful Eye

Other elements of Baker’s bill aren’t as controversial. For example, practitioners would be required to check the state’s Prescription Monitoring Program (PMP) prior to prescribing an opioid to a patient, and would be required to fulfill five hours of training on pain management and addiction every two years.

“Monitoring is an extremely useful tool for providers,” Roose said, noting that it’s a tool to determine what prescriptions a patient has received and prevent duplicate prescriptions through different doctors at different pharmacies.

Dimitri noted, however, the Legislature’s recent law mandating the use of the PMP the first time an opioid or benzodiazepine is prescribed. “We believe it would be prudent to keep the existing law in place without modification at this time,” he said. “As improvements are realized with the new PMP, we can better determine optimal use.”

He also suggested enabling the PMP to ‘push’ information to physicians, indicating how their prescribing patterns compare to their peers. “Programs such as this have successfully reduced opioid prescribing in other states, and we welcome the opportunity to work with you on developing language to allow for these concepts.”

Dimitri also used his testimony to remind the committee that the MMS launched multiple efforts of its own last spring to combat the opioid epidemic. Among them are new prescribing guidelines since adopted by the Massachusetts Board of Registration of Medicine and disseminated to every practicing physician in the Commonwealth; free continuing-medical-education programs on opioids and pain management available to all prescribers in the state; and a collaboration with the commissioner of Public Health and the secretary of Health and Human Services to bring together the deans of the state’s medical schools in developing a first-in-the-nation set of core competencies for medical students in the prevention and management of prescription drug misuse.

Still, Barry-Smith said Baker’s bill is a strong additional step in the right direction.

“The bill is bold, it’s innovative, and, as the governor already stated, it makes crystal clear that the status quo will not suffice,” he argued. “Changes need to occur, and the first of those changes concerns prescribing practices.”

He cited a statistic that the U.S. has less than 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the world’s population but consumes 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the world’s opiate supply. “To address that problem, this bill puts in place education requirements for prescribers, seeks to increase the use of the Prescription Monitoring Program, and sets a general limit on most opioid prescriptions.”

Boston’s mayor testified that he supports the bill because “I know from personal experience that, to get people the help they need, we have to meet them where they are, whether it’s on the streets, in the hospitals, at home, at work, or at school.”

Walsh added, however, that healthy communities start with education, not just regulation. “This bill provides a tool to help educate parents and children about the dangers of misusing opioids.”

Stay Tuned

Roose also believes fighting the opioid crisis requires a multi-faceted, collaborative effort.

“The medical community is actively working with the administration and the Department of Public Health, addressing this issue,” he told HCN. “Certainly education is a big piece of this, and this bill, as well as efforts from the Mass. Medical Society and the Mass. Hospital Assoc., will increase provider education on appropriate prescribing, addiction, and how it can be treated.”

Dimitri said the state’s physicians stand ready to aid in the effort, no matter what the outcome of Baker’s bill.

“Addiction is a chronic disease that is difficult to overcome,” he said. “Reversing this epidemic will not be easy, but I am committed, as is the medical society, to do everything necessary to continue our efforts and increase our outreach for the benefit of our patients.”