Doctors open to seven-day opioid limit in House bill
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House Speaker Robert DeLeo, members, health advocates announce details of opioid bill.
The House's move to counter Gov. Charlie Baker's proposal to limit the supply of opioids that can be prescribed to first-time patients succeeded in rallying a key interest group to its side, but doctors who value their medical discretion may seek to have prescribing limits sunset after a test of their effectiveness.
House leaders outlined a bill Monday afternoon that House Speaker Robert DeLeo described as necessary to fight the "public health crisis" of opioid addiction, proposing steps to reduce the number of opioids being prescribed and ease the path for addicts seeking to access treatment.
Baker called for a three-day supply limit of opioids for first-time patients, but the House bill slated to surface for debate on Wednesday would extend the limit to a seven-day supply for first-time adult patients and all prescriptions for minors.
"We felt that is was important to, practically speaking, provide an ample number of days for somebody who has dealt with serious pain injury, recognizing that that individual has to physically go back for a new prescription," House Ways and Means Chairman Brian Dempsey said at a press conference in the Members Lounge.
The Massachusetts Medical Society resisted Baker's call for a three-day supply limit on first-time opioid prescriptions, but MMS President Dr. Dennis Dimitri told the News Service Monday that the physicians group was "willing to be compromising" on the seven-day limit.
"I think it's fair to say we recognize there are too many opioids circulating in the community at large. One of the ways to address that is to take a look at the volume of prescriptions at the front end. We think that looking at a seven-day initial limit as was mentioned in this bill is a reasonable compromise," Dimitri said.
Suggesting there was a lack of evidence to support the effectiveness of any limit on prescription size in combating abuse, Dimitri said he would like to see "some sort of consideration for a sunset provision" if the limit proves ineffective or detrimental to a doctor's ability to treat a patient.
"In an ideal world we really think that physicians should be allowed to apply their clinical judgment, their expertise, their learning. But we realize there's also a very specific crisis situation that we're in right now so we are willing to be open-minded and somewhat compromising on this and put a number out there to make physicians stop and think," he said.
Baker, who spoke with DeLeo and Senate President Stanley Rosenberg about the bill during their weekly meeting Monday, said he prefers his proposal, but recognizes that even a seven-day limit would be a "material change from the status quo."
"I think three is a better number than seven. Three is consistent with the (Centers for Disease Control) recommendations. But like I said, Massachusetts has had no limit historically on this and in 2014 prescribers wrote 220 million pills of Schedule II and Schedule III medications for a state that only has six million people in it, most of whom are healthy most of the time," Baker said.
DeLeo announced the bill at a press conference flanked by dozens of lawmakers and those representing the interests of hospitals, doctors and the recovery community.
"Our goal with this legislation is to create a safety net, a new standard in acute care settings, a new best practice designed to ensure the proper assessment and discharge of patients who seek voluntary treatment and I am confident that our plan is a balanced, pragmatic approach to addressing patient care and ensure that our most vulnerable populations have the access to treatment that they need," said Rep. Elizabeth Malia, the House chair of the Substance Abuse and Mental Health Committee.
Massachusetts Hospital Association President Lynn Nicholas also rallied to the House's bill, calling it "an effective and responsible way to attack opioid misuse on several fronts."
The House Ways and Means Committee began on Monday polling the final version of the bill (H 3944) before it hits the floor on Wednesday with a deadline of 4 p.m. on Tuesday for members to vote. Amendments to the bill must then be filed with the clerk by Wednesday morning at 10 a.m.
Both Dempsey and DeLeo promoted the legislation as a follow-up to the 2014 substance bill that guaranteed insurance coverage for up to 14 days of inpatient care. Coupled with the $27 million in a mid-year budget bill approved last year for additional treatment beds, provider rates and the overdose reversal drug Narcan, Dempsey said the state has increased its spending on substance abuse 65 percent since fiscal 2013, up to $138 million from $83 million.
"I wish we didn't have to spend all that money," Dempsey said.
The House bill, which has also moved through the Mental Health and Substance Abuse and Health Care Financing committees, also scraps Baker's proposal to allow emergency room doctors to hold patients involuntarily for up to 72 hours to try and get them into treatment.
DeLeo said that in addition to questions about its constitutionality he worried about hospitals' ability to accommodate those patients.
"I don't see how a hospital is going to be able to either care for them or for that matter care for those that have some other physical ailment that are there in the emergency ward," DeLeo said.
Nicholas said the Massachusetts Hospital Association supports the House's alternate approach of requiring substance abuse evaluations within 24 hours before discharge of any patients presenting with an overdose or signs of addiction. "They do it, but there will clearly be more resources applied to this with this expectation," Nicholas said about hospitals' ability to comply with the requirement. "I think with community and hospital resources together they'll step up to the plate and be able to do even more than they're doing already. The bar has been raised."
The legislation would also require physicians to crosscheck the state's Prescription Monitoring Program database before prescribing any opioids, and requires schools to develop substance abuse education programs.
Though the House is expected pass the bill on Wednesday, it could be awhile before a final piece of legislation lands on Baker's desk for his signature. Malia said she and her staff have had many conversations with the Senate about the substance of the bill, and she anticipates further debate both in conference committee and as part of the budget process about items that the Senate approved in its opioid bill last year that were excluded from the House bill.
DeLeo, however, said that given the number of "moving parts" in both bills negotiations would not be simple. "It may take some time," he said.
The branches do agree on a number of key issues, including extending civil liability protections to first responders that administer Narcan, requiring insurers to report all denied claims for substance abuse treatment to the Health Policy Commission and requiring doctors to note in medical charts why certain high-risk drugs were prescribed instead of a drug with a lower risk of abuse.
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