MMS Testimony Relative to H. 3817, An Act Relative to Substance Use Treatment, Education, and Prevention

Before the Joint Committee on Mental Health & Substance Abuse

Good Morning, my name is Dennis Dimitri; I am the president of the Massachusetts Medical Society and a practicing family physician in Worcester. I applaud the Governor, the Legislature and so many others who have demonstrated great leadership in attacking the addiction crisis. This is the number one public health priority for the Medical Society. For over a year we have had a task force of medical experts who have been addressing issues related to opioid prescribing and patient care.    

As physicians, we remain our patients’ best allies in addressing the consequences of opioid abuse. We are responsible for relieving their pain and suffering while at the same time balancing risks of addiction.

We commend this Legislature for its thoughtful, multi-pronged approach to addressing this crisis and thank it for significantly increasing funding for addiction services, insurance coverage, and enhancements to the state’s Prescription Monitoring Program (PMP). We strongly support these and other measures. 

The MMS too, has been busy: developing new opioid prescribing guidelines that were adopted by the Massachusetts Board of Registration in Medicine, disseminated to every practicing physician in the Commonwealth, and integrated into the practice of medicine;  providing free pain management continuing medical education to all prescribers, not just our members; and working closely with the commissioner of DPH and the EOHHS to bring together the deans of the four Massachusetts medical schools to create a first in the nation shared set of medical education core competencies for the prevention and management of prescription drug misuse that was announced by the Governor last week. Yet, there is more to be done. 

Before you today is H.3817, An Act Relative to Substance Use Treatment, Education and Prevention. We support many of the Governor’s recommendations including better treatment funding, improving the PMP, and utilization of an opioid management plan and other provisions.

The Governor invited additional dialogue regarding Section 2 of the bill which places a 72-hour limit on first time opioid prescriptions to patients, with certain emergency exceptions. We are responding to be sure we address the individual needs of our patients and we look forward to working with other stakeholders to develop additional clinical exceptions allowed for in regulation. The MMS guidelines developed in June already call upon physicians to prescribe to patients with acute pain the minimum dosage necessary for the shortest needed time in order to minimize risk. 

Regarding the Governor’s proposal, we urge the Committee to consider a seven day limit and incorporate a sunset provision. We understand that there will be exceptions addressing end of life and cancer care, and we continue to support incorporation of clinical judgment, fully understanding the severity of the significant challenges confronting the Commonwealth and our patients. 

From a practical point of view consider the impact of a 72-hour limit on patients. Opioid prescriptions cannot be “called” in to the pharmacy, and only 2% of physicians have the capability of electronically prescribing opioids as they might a standard antibiotic prescription. 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.  An elderly or disabled or poor patient, especially one without a helping caregiver or transportation could be left to suffer. 

We are extremely concerned about the risk of unused opioids being diverted, and we have a goal of reducing the overall number of opioids that are prescribed.  One way to do that is to allow “partial fills” of prescriptions, helping patients to 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. Another consideration is enabling the PMP to push information to physicians indicating how their prescribing patterns compare to their peers. Programs such as this have reduced opioid prescribing in other states.  We welcome the opportunity to work with you on developing language to allow for these concepts.

I also would like to comment on Sections 6-11 allowing 72-hour involuntary hospitalization for addiction treatment. The addiction medicine colleagues that I have heard from have raised concerns that such commitment cannot work without access to 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 aftercare are at higher risk for opioid overdose.

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. 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.

Lastly, Section 3 calls for accessing the PMP every time an opioid is prescribed. In the last session, the Legislature passed a law mandating the use of the PMP the first time an opioid or benzodiazepine is prescribed. We believe that it would be prudent to keep the existing law in place without modification at this time. As improvements are realized with the new PMP, we can better determine optimal use.

Let me close with a personal perspective. I am a family physician treating patients of all ages and circumstance across the entire socioeconomic spectrum. I take care of patients with cancer and end of life issues. I take care of patients and families with addiction issues and chronic pain issues. I understand how complex this is and how much of a crisis it has become. I have reexamined my own prescribing patterns and I have called upon my colleagues across the Commonwealth to do the same. 

Addiction is a chronic disease, which is difficult to overcome. 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. We look forward to working with you, your colleagues in the House of Representatives and Senate, Governor Baker, his administration, Attorney General Healey and other stakeholders in creating a multidisciplinary solution to this horrible problem affecting our Commonwealth and our country.

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