Massachusetts Medical Society: MMS Testimony on the CARE Act

MMS Testimony on the CARE Act

The Massachusetts Medical Society (MMS) appreciates the opportunity to provide comment on H.4470, An Act for Prevention and Access to Appropriate Care and Treatment for Addiction, the Joint Committee on Mental Health, Substance Use, and Recovery redraft of Governor Baker’s CARE Act. The MMS recognizes the severity of the opioid epidemic in our Commonwealth, and we have been engaged alongside Governor Baker, Chairwomen Garlick and Friedman, and our fellow stakeholders in working to address this public health crisis. As we do so, the MMS wishes to continue to emphasize the importance of identifying public health strategies with the highest evidence-base in this fight to save lives. To that end, we wish to express our support of several provisions within this bill, as well as our concerns with some other provisions, enumerated below.

Support for Provisions Regarding Naloxone, Prescriber Education, and Partial Fill

Treatment of patients with substance use disorder with all FDA-approved medications is a vital, evidence-based tool in our arsenal to combat the opioid epidemic, and the MMS therefore commends the provisions of this bill that would contribute to increasing capacity and quality of this treatment. We particularly commend the House for proposing a novel program to support physicians through instant availability of peer-to-peer consultation for pain management and substance use disorder treatment.

The MMS strongly supports the provisions of this proposed legislation that would strengthen the existing standing order mechanism for the dispensation of naloxone throughout the Commonwealth. This legislation would increase access to Naloxone, thereby saving lives through overdose prevention. In addition, we commend the addition of policy to clarify insurance coverage for persons presenting to pharmacies to obtain naloxone.

We also wish to commend the provision in this bill that would strengthen the existing laws regarding partial fill. If passed, this legislation would ensure that patients who had elected partial fill could then return to the pharmacy to fill the remainder of the prescription. A fully functional partial fill policy will protect patients’ need to manage their pain, and will also lessen the likelihood of diversion of unused opioids.

Opposition to Provisions Regarding Electronic Prescribing of Controlled Substances and 72-Hour Involuntary Commitment

While the MMS supports the intent of the CARE Act, we take issue with several provisions in the revised bill that would enact policy that lacks the evidence base of many of the policy proposals cited above.

MMS opposes the current proposal to eliminate the ability for patients to receive prescription medication by paper prescription. The MMS recognizes the potential benefits of electronic prescribing, and that the electronic prescribing of controlled substances is a worthy upgrade for many physician practices in Massachusetts. We urge, however, a balanced approach in determining the best means by which to legislate that transition, so as to maximize those benefits and avoid unintended pitfalls, especially since there is little data that the source of the current overdose epidemic is related to fraudulent prescription pads. If passed as written, this mandate would require costly and cumbersome practice changes that would infringe on many patients’ timely access to prescription medications and many physicians’ ability to maintain their practices sustainably. In an attempt to decrease the cost and complicated nature of these prescribing platforms, the MMS is also working with the AMA to engage the DEA in a process to amend their antiquated electronic prescribing regulations to allow for more streamlined, efficient platforms that still comply with today’s security standards.

We urge revision of this mandate to allow for a more narrowly tailored policy, such as those successfully implemented in other states. Maine, for example, limited the electronic prescribing mandate to only the prescribing of opioids, rather than all controlled substances including stimulants often prescribed in pediatric practices. In addition, New York amended their law to exempt physicians who prescribed a low number of prescriptions.  Lastly, no state in the country has applied an e-prescribing mandate to all drugs, including those that are not federally controlled substances. If passed as written, this would prohibit physicians and other prescribers from calling in simple prescription medication such as a statin or an antibiotic. MMS urges revision to only include Massachusetts Schedule II-V drugs. The Medical Society is concerned that without these exceptions, physician practices that are in no way linked to the current opioid crisis, such as pediatricians’ offices prescribing occasional medications for ADHD, could be required to expend thousands of dollars for electronic prescribing software, or worse, could stop prescribing controlled substances altogether. 

The MMS opposes the provisions of this bill that would create a mechanism for a 72-hour involuntary commitment, for several reasons.

First, MMS continues to have concern that there are not assurances of sufficient infrastructure to care for patients who have been involuntarily civilly committed. The current inpatient substance use treatment infrastructure is not built to accommodate locked, involuntary care, which requires particular facilities. If every patient involuntarily committed under this proposal does not have immediate access to the right bed, they will be boarded in emergency rooms- resulting in substandard care for the patient, and further straining on hospital resources. There are further concerns that if general adult locked beds are at a shortage, those for pediatric or medically complex patients will be even more difficult to find. And even if sufficient infrastructure could be assured, the current research on the efficacy of involuntary commitment for SUD is unclear due to a lack of rigorous study of this issue.[i] There is no research to suggest that this treatment option will save lives. Therefore, more studies are needed before Massachusetts should institute a law with far-reaching consequences.

While the CARE Act has been accompanied by pledges of additional funding to address the care of patients with SUD, that funding would save more lives if allocated to areas supported by strong evidence, such as the commendable consultation and support programming for prescribers addressed above and evidence-based comprehensive care for those with immediate need.

Medication Assisted Treatment in Jails and Prisons, Innovative Harm Reduction

The MMS is grateful for this opportunity to work with the legislature to combat the opioid epidemic. We urge that policies enacted to do so have a strong grounding in scientific literature. 

The provision of all three forms of medication-assisted treatment in correctional facilities is one such policy. Evidence from the Massachusetts Department of Public Health compiled last August shows that the opioid-related overdose death rate is 120 times higher for recently incarcerated persons. We urge the Committee to pass a version of this bill that will change that statistic by requiring correctional facilities throughout the Commonwealth to provide all three forms of medication-assisted treatment, as is already offered in our own Franklin County, and as the Rhode Island legislature has already done, to great success.

The Medical Society supports the language proposed in the comprehensive criminal justice reform which would ensure incarcerated persons have access to the full spectrum of MAT in all jails and prisons in Massachusetts. Since robust data continues to emerge confirming the feasibility and efficacy of MAT in jail and prison settings, we urge substitution of the full language as proposed in the criminal justice bill rather than the study language proposed in this bill. 

In addition, we hope as well that the Committee will consider the establishment of a pilot supervised injection facility, under the auspices of and following a study by the Department of Public Health. Such a provision would enact a life-saving harm reduction mechanism backed by thirty years of rigorous data. As many other cities across the country consider seriously such proposals, we urge the legislature to adopt such language empowering the Department of Public Health to look at this life-saving option.

We are eager to discuss any of the above comments with the legislature, and we look forward to collaborating on these and other efforts moving forward.

[i] Abhishek Jain, M.D., Paul Christopher, M.D., Paul S. Appelbaum, M.D. April 2018. Psychiatric Services. 69(4), April 2018. Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work?

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