Massachusetts Medical Society: Testimony Relative to “An Act Relative to Combatting Addiction, Accessing Treatment, Reducing Prescriptions, And Enhancing Prevention (CARE)”

Testimony Relative to “An Act Relative to Combatting Addiction, Accessing Treatment, Reducing Prescriptions, And Enhancing Prevention (CARE)”

The Massachusetts Medical Society (MMS) appreciates the opportunity to provide comment on this important legislation. The MMS recognizes the severity of the opioid epidemic, and we have been engaged with you and your leadership alongside Governor Baker, his administration, and our fellow stakeholders in working to address this public health crisis. We applaud the Governor’s efforts in this area, through both filing this proposed legislation, pledging to dedicate state Medicaid funds to meeting the needs of persons with substance use disorder, and through many of the important federal initiatives he addressed in letters accompanying this bill. 

Education, Naloxone, and Partial Fills

The MMS strongly supports the educational provisions put forward in this bill. Providing evidence-based education to children and young people regarding substance use disorder will be essential to bending the opioid overdose curve and stopping this epidemic. The MMS applauds the Governor’s continued emphasis on education and prevention.  We have been engaged in parallel educational efforts, and have made our opioid-related educational materials freely available online since 2015. As of November 2017, over 13,000 individual clinicians had taken one or more of these education courses, and almost 37,000 courses have been completed. We will continue this commitment moving forward.

We also commend the provisions in this bill to strengthen the existing standing order mechanism for the dispensation of naloxone throughout the Commonwealth. The MMS has long recognized the lifesaving importance of naloxone, and we have made naloxone education for patients and prescribers a top priority. While the existing standing order policy has served the state well, the revisions proposed in this bill would ensure that even more patients have consistent access to naloxone without a prescription from their doctor.

The Medical Society also wishes to provide its support to the “partial fill” provisions of this bill, which would clarify, in light of new federal legislative changes, that a patient may return to a pharmacy after receiving a partially filled prescription to receive the remainder of the prescribed medication.  We hope that this revision will significantly increase the uptake of this option to receive a partially filled medication. Partial fills can be an important tool in reducing the amount of unused prescription medications left in medicine cabinets, which can be ripe for diversion. We hope that the legislature will adopt this language, and that it will also consider additional provisions contained in S. 1099 to ensure that physicians are notified when a patient has partially filled a prescription, and to clarify that patients will not be subjected to multiple co-payments or greater cost-sharing because they elected to receive their prescription over multiple fills.

Electronic Prescribing

The Medical Society shares the Governor’s goal to increase electronic prescribing of controlled substances throughout the Commonwealth. To be clear, the Medical Society believes that electronic prescribing holds the promise to improve experiences for patients and physicians alike and to increase security of these prescriptions. We are working to further improve the underlying federal requirements and regulations pertaining to e-prescribing of controlled substances. Specifically, we are working with our Congressional delegation and the American Medical Association to urge the Drug Enforcement Agency to modernize and streamline their e-prescribing regulations. Once DEA regulations are updated, the implementation of e-prescribing of controlled substances can be encouraged with even less disruption to clinical workflows and at less expense.

The current DEA regulations have led to security protocols that do not always easily fit into physicians’ workflows, and which have led to compliant-EPCS systems to be very expensive. While over 95% of physicians in Massachusetts prescribe non-controlled substances electronically, less than 15% of physicians do so for controlled substances.

The current DEA regulations, for example, reference security standards that do not allow two-factor authentication to be performed by low-cost, high performing biometric devices such as cell-phone fingerprint readers. In addition, the requirements related to identity proofing and audits could easily be streamlined without compromising the security of the program.

At present, electronic prescribing of controlled substances is a worthy upgrade for many physician practices in Massachusetts. For some, however, the costs of compliance with a mandate to purchase this functionality could be so high as to compromise their ability to care for patients. This sizable investment may not be in the best interest, for example, of a small pediatric practice that occasionally prescribes a controlled substance for attention deficit disorder. For these reasons, some states referenced in these policy discussions, such as Maine, have limited their e-prescribing mandate to only opioids, rather than all controlled substances. The Medical Society continues to share concern that a mandate as currently drafted could disproportionately affect patients’ access to solo and small group physician practices and physicians nearing the end of their career who have the technology to prescribe controlled substances.

We also wish to note that, as currently written, it appears that these provisions would eliminate paper prescriptions for all prescription drugs, not only for federally controlled substances. This interpretation would severely inhibit the practice of medicine which has long relied on more flexibility for the prescribing of non-federally controlled substances like antibiotics. We therefore urge reconsideration of that language.

When appropriate, electronic prescribing can provide security and convenience to patients and physicians alike. The MMS urges balance in determining the best means by which to enact policy regarding the electronic prescribing of controlled substances, so as to maximize those benefits and avoid unintended pitfalls, especially for physicians in smaller practices and those that prescribe controlled substances at lower rates.

Prescribing Oversight Board

The Medical Society has long promoted the importance of assuring best prescribing practices, and believes that inappropriate, aberrant prescribers should be held accountable in the interest in protecting patients. We continue to believe, however, that professional licensing boards and other existing enforcement mechanisms in the state are the most appropriate path for achieving these aims rather than establishing a less-experienced, narrowly crafted Prescribing Oversight Board.

Not only does the Board of Registration in Medicine have a comprehensive infrastructure designed to investigate and hold physicians accountable with the most current standards of care, but the state has also implemented other checks and balances on opioid prescribing. The Department of Public Health has a Medical Review Group, required by regulation, that meets to discuss matters of suspicious prescribing and of concerning use of the prescription monitoring program. The Medical Review Group meets regularly, and, via an annual report to the legislature, reports on its metrics concerning the cases it reviews, and those which it reports to the appropriate licensing boards. With statistics in Massachusetts pointing to an over 20% reduction in opioid prescribing, including a 47% reduction in prescribing to opioid naïve patients, we believe that many of the policies and reforms aimed at improving opioid prescribing are taking shape. We must continue to ensure that that best prescribing practices are promoted, but this must be done in a manner that does not foster climates of fear that discourage treatment for people living with pain.

In addition, the Medical Society has significant concerns about granting such a board with the authority to endorse clinical practices and suggest appropriate dosing. The Board of Registration in Medicine has adopted prescribing guidelines to which physicians are held accountable. It also has experience in determining when intrusion into clinical practice is warranted, and when providing deference to clinical judgment—especially in the context of broad reaching guidelines— is most appropriate. The Medical Society believes these provisions would significantly jeopardize the balance between holding accountable prescribers while also allowing prescribers to meet the pain needs of their patients.

Involuntary Civil Commitment

The MMS also wishes to note concerns regarding the provisions of this bill that would expand involuntary civil commitments in Massachusetts. We recognize the severity and potentially lethal nature of opioid use disorder, and we agree on the need for intensive interventions to treat this disease; however, involuntary treatment is associated with an increased risk of overdose death. The 2015 Massachusetts Department of Public Health Chapter 55 Report states that “Clients who received involuntary treatment were 2.2 times as likely to die of opioid-related overdoses and 1.9 times as likely to die of any cause compared to those with a history of voluntary treatment only.” Patients discharged from an involuntary hospital stay during which they experienced withdrawal have a heightened susceptibility to overdose if they return to using drugs. Furthermore, involuntary commitment is a significant abridgment of a patient’s civil liberties, which must be counterbalanced by a significant benefit to that patient in order to be justified. For these reasons, the MMS contends that involuntary commitment for substance use disorder will not effectively address the opioid epidemic.

Conclusion

The MMS hopes to continue working with the Governor, the legislature, and fellow stakeholders to combat the opioid crisis through this and other efforts. We hope to see the above concerns allayed in future iterations of this proposed legislation. We also hope, in recognition of the severity of this crisis, to see several additional evidence-based interventions promoted in this legislation. One such intervention would be the provision of Medication-Assisted Treatment provided to eligible patients onsite in emergency departments; another would be the establishment of a pilot supervised injection facility, under the auspices of and following a study by the Department of Public Health. 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.

Share on Facebook

Find Your Legislator

Click here to enter your address and get a list of your federal representatives, state legislators, and your local polling place.

Find Your Legislator »

Mass. State Agencies

State House - Mass. State AgenciesRapid access to resources about MassHealth, Public Health, Board of Medicine, and more.

Read More »

FacebookTwitterLinkedInYouTube

Copyright © 2018. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

(781) 893-4610 | (781) 893-3800 | Member Information Hotline: (800) 322-2303 x7311