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?
