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.
