Baker proposes limits on pain prescriptions
Gov. Charlie Baker gave lawmakers on Thursday new ideas to confront the scourge of opioid addiction gripping thousands across the state, filing legislation that focuses on limiting access to powerful painkillers that can lead to addiction and allowing doctors to involuntarily hold patients for treatment.
The two main provisions of the bill, which were met quickly with criticism from doctors and civil rights advocates, would limit physicians from prescribing to new patients more than a 72-hour supply of a prescription opioid and doctors would be allowed to hold patients for up to 72 hours for substance abuse treatment without seeking a court order for an involuntary commitment if the patient presents a risk to themselves or others.
"For the past two years, I and many others have listened to far too many stories from people who come home from the doctor's office, the dentist or the hospital with 30, 40, 50, 60, 80 tabs of all kinds of opioids when a handful would do. This has got to stop," Baker said during a press conference at the State House.
The governor's bill also includes education components for doctors, student athletes and parents, new prescription monitoring requirements and an update to the civil commitment law that would prevent women with substance abuse issues from being placed at the MCI Framingham prison, instead diverting them to a hospital setting.
While the state's leading physician group applauded the student education components, the Massachusetts Medical Society raised "deep concerns" that its president said could undermine the effectiveness of programs already in place.
Arguing that limiting prescription quantities could "impede effective pain management," MMS President Dr. Dennis Dimitri said, "This limitation undermines clinical judgment that may be necessary in non-emergency situations."
Dimitri also said that requiring doctors to check the state's prescription monitoring program every time they prescribe an opioid, as Baker proposed, would disregard long-standing doctor-patient relationships, and allowing doctors to commit patients involuntarily might have the opposite effect of its design.
"We recognize that substance use disorder and addiction is a disease, but we believe the involuntary commitment portion of the bill is problematic, as it raises issues of civil liberties, as well as presents unintended consequences, as it may discourage patients from getting needed treatment," Dimitri said.
The Senate this fall adopted comprehensive opioid addiction prevention legislation, meaning the House could incorporate some or all of the governor's recommendations into its own bill. While House Speaker Robert DeLeo has expressed strong interest in passing legislation this session, he has not put a timetable on action and has said he wants to give Mental Health and Substance Abuse Committee Chairwoman Rep. Elizabeth Malia time to review all the options.
"I look forward to collaborating with my colleagues in the House, the Baker Administration and all stakeholders to ensure that addiction is treated as a disease rather than a choice, and that we are providing the most effective support for individuals battling substance addiction," DeLeo said in a statement.
Malia said in an interview that she is "really excited" that the governor has sparked a "much more realistic discussion of what's available for treatment and how severe and widespread the problem is," but did not give the impression that the House could act quickly on either the governor's or Senate's proposals.
"This is going to do a lot to open up absolutely necessary discussions and reflects many of the things members of the committee have been seeing and hearing for the past several years," Malia said.
Health and Human Services Secretary Marylou Sudders said that in 2014 doctors in Massachusetts wrote 4.6 million prescriptions for opioids totaling more than 255 million pills to a population of just over 6.7 million people. The Department of Public Health estimated 1,256 people died of unintentional opioid overdoses in 2014, up from 939 the previous year.
Baker was joined at the press conference by Sudders, Department of Public Health Commissioner Monica Bharel, former senator and AFL-CIO of Massachusetts President Steve Tolman and Dr. Sarah Wakeman, a substance abuse disorder specialist at Massachusetts General Hospital.
Wakeman said the 72-hour supply limit, with exceptions for emergencies, would not undermine a doctor's ability to use their clinical judgment about who should receive opioid therapy.
Comparing addiction to diabetes and lung disease, Wakeman said, "Addiction is a disease caused by a mix of genetics and exposure. As physicians and legislators and community members, we can't do anything about the genetics, but we can do something about the exposure to minimize the risk."
Sudders said since taking office in January the Baker administration has already allocated an additional $114 million for substance abuse prevention and treatment, started a bulk Narcan purchasing program and shortened the timeframe for reporting to the prescription monitoring program.
The administration has also brought 165 new treatment beds online since June, according to Sudders, and will add an additional 30 beds by next summer, starting with 15 in January at Taunton State Hospital, to accommodate the women diverted from prison to a clinical setting for addiction treatment.
Jesse Rossman, a staff attorney at the American Civil Liberties Union on Massachusetts, said the group supports ending civil commitments of women not convicted of a crime to MCI Framingham, but voiced concern over the idea of allowing doctors to hold patients for 72 hours.
Baker, in explaining the involuntary commitment provision, recalled former basketball star Chris Herren telling him that when he was in the throes of addiction his friends kept him the hospital long enough to convince him to get treatment.
"The proposed legislation isn't about being surrounded by your friends or your family," Rossman countered. "This would authorize the government to restrain an individual without prior approval from a judge and requires a deep look."
Baker said his proposal for substance addiction would mirror the laws that allow doctors to hold patients whose mental health state poses an immediate risk to themselves or others.
"I appreciate the fact that this is a controversial idea but it's one that needs to be part of the larger conversation about how we prevent additional addiction on the front end," Baker said.
The governor's bill also drew some quick backlash as Baker faced radio show callers with concerns about access to pain medications. One caller said she was worried about access to opioid medications to treat her chronic back pain and another expressed concern that patients taking pain medication are being viewed as addicts.
Sudders and Bharel said there would be exemptions from the prescription limits for emergency situations and patients with chronic pain or receiving hospice care.
The bill would also require physicians who prescribe controlled substances to receive at least five hours of training every two years on pain management techniques and the identification of high-risk patients for substance abuse. The Massachusetts Medical Society said it's unclear whether the provision is redundant with state regulations that already require pain management courses. Since courses through the MMS were made available for free to all prescribers in May, 1,955 prescribers have taken a total of 4,785 courses, according to the society.
All public schools in the Massachusetts Interscholastic Athletic Association would be required to provide education for parents, coaches, trainers, volunteers and medical professionals associated with high school sports on the dangers of opioid use. Sudders said the curriculum would be provided to schools by the state to be incorporated into already-mandatory head-safety training sessions, thereby requiring no additional funding for cities and towns.
Massachusetts Association of Health Plans President Lora Pellegrini said the directive in Baker's bill that insurers must file plans for opioid management and safe prescribing practices with the Division of Insurance "isn't problematic for us," adding that it could be "very educational."
Pellegrini also offered general praise for the civil commitment and involuntary treatment provision in the bill, and said she looks forward to having the dialogue promised by Baker on how to make his policy recommendations work with carriers, providers and other players in the medical field.
"As a standard rule, we support treatment rather than using the criminal justice system to solve problems for people addicted to opioids," she said.
In an attempt to improve access to the five recovery high schools in Boston, Springfield, Worcester, Beverly and Brockton, the administration hopes to direct the state public health and education officials to develop a plan to help cover transportation costs for students to attend these schools.
Once the plan has been developed, Sudders said the administration could seek to provide necessary funding in the fiscal 2017 budget.
The governor's proposal does not contain several key elements from the Senate's opioid abuse prevention bill, including mandatory drug screening for students and an option for patients to request that a pharmacist only partially fill their opioid prescription.
While requesting additional funding in a budget bill still pending for school drug screening, Baker said he believes it should be optional for school districts, and said the partial-fill provision raises unanswered legal questions about whether it's allowed under federal law.
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