GOV. CHARLIE BAKER on Monday unveiled his second legislative proposal to deal with the opioid epidemic, focusing primarily on expanding access to treatment, demanding more vigilance on opioid prescriptions, and providing education on addiction in schools.
Since hospital emergency rooms are witnessing a sharp rise in opioid-related visits (33,444 in 2015), the governor’s bill attempts to use this point of contact to steer more patients into treatment. The bill expands the number of emergency room staff who can do substance misuse evaluations and requires hospitals to “affirmatively engage” patients in voluntary treatment by connecting them to a recovery coach or getting them on medication-assisted treatment. Medication-assisted treatment revolves around the use of drugs to treat addiction; the three drugs most often used are methodone, buprenorphine, and Vivitrol.
If the patient refuses to take advantage of voluntary treatment, Baker’s bill also allows emergency room staff to authorize an involuntary transfer to a treatment facility. It also would allow “medical professionals,” in addition to family members and police officers, to pursue a civil commitment in the courts.
Baker unveiled his legislation a day after the Department of Public Health said opioid-related deaths fell by 10 percent in the first nine months of 2017 compared to the same period in 2016. Officials said opioid prescriptions have dropped by 29 percent since the state’s prescription monitoring tool was overhauled.
At a State House press conference, Baker talked at length about the lack of standards in opioid addiction treatment and two commissions he hopes will establish standards for behavioral health clinicians and recovery coaches. Here is an edited version of his remarks.
BAKER: Over and over again, one of the major things we heard from families was how difficult it was to find the right person, the right provider, the right organization to help them deal with this issue for their family member. In the addiction space, we don’t make it easy at all for families. And that creates issues around what gets paid for and what doesn’t get paid for. A bunch of people have talked about the importance and the value of recovery coaches. But if you walk out this door and you start having a conversation with people about what a recovery coach is, what they do, who they are, you’ll get dozens of different answers to that question. The message, therefore, you get from a lot of the folks on the pay side is if you established some sort standard for what a recovery coach actually is and certify and credential them, we’ll figure out a way to incorporate that into what we reimburse. The goal here is to basically create standards and structures for a lot of aftercare elements so it’s easier for families and the people dealing with addiction to figure out where their best opportunity is going to be to get better. One of the biggest problems we have right now is they detox and then they’re kind of on their own for everything that happens after that. In the long run, that’s never going to solve this problem.
In other forms of health care, if you have a presenting set of circumstances, there’s a big body of knowledge based on how old you are, what your stage is, what your history is, what’s going to work best for you. We don’t have anything like that for the most part in addiction treatment.
If you look at most of the data, it shows people come through the inpatient part of the system in many cases more than once a year, sometimes three or four times a year. And that’s because we’re not doing what we should be doing on the aftercare piece. Part of the reason we’re not doing what we should be doing on the aftercare piece is because we haven’t focused on creating an evidence-based approach and certification model that people can pay for and can gauge on the plan side, the provider side, and on the family and the patient side. We have to create an aftercare model that people can believe in, support, and pay for so people can actually deal with the detox piece associated with what the inpatient care is about and then have the supported services they need to deal with this on an aftercare basis.
Q: You are pushing treatment, but you also seem to be ramping up criminal charges.
BAKER: The vast majority of our efforts in the criminal justice space have to do with traffickers, people with major amounts of drugs to begin with, especially fentanyl. Secondly, [they have] many, many, many trafficking arrests and processes through the legal system. It bothers me. It bothers me a lot. The traffickers are hiding behind people who are dealing with substance use disorder, which is really what’s going on. If we’re serious about dealing with traffickers, we should be serious about dealing with traffickers. We’ve had a fentanyl bill pending in the Legislature for two years. Fentanyl is now present in 81 percent of the deaths in Massachusetts. If fentanyl wasn’t part of 81 percent of the deaths in Massachusetts, you would have seen a lot more progress in dealing with the death rates in Massachusetts. If your fundamental problem is a substance use problem, we should be providing you access to treatment that makes sense and will actually work for you. A huge part of what this administration and this Legislature and this governor and this government has been up to the last few years is dramatically expanding our capacity to provide treatment for people who need it. And now we’re chasing what we see as some of the gaps in treatment. There’s clearly a gap here with respect to the aftercare piece. It’s not credentialed properly. It’s not certified properly. It’s not paid for. We don’t collect data on it. When people talk about evidence-based care in that space, there’s not a lot of information outside of what a particular provider organization knows about their own population. We would never accept that in cancer or heart disease or congestive heart failure or diabetes or other forms of chronic illness. Yet we accept it here. This is where we really need to focus on the treatment side. But if we think it makes sense to give traffickers an out, I think we’re wrong.
Q: With the drop in the opioid overdose death rate, do you think the problem is getting better or are we just doing a better job at responding to overdoses?
BAKER: I think it’s probably a bit of both. The way I would describe it is if you have a 30 percent reduction in prescriptions, that’s progress. But you’re starting off a base of 4.5 million prescriptions. One of the things we do is make sure we’re doing a better job around setting standards for prescribing guidelines and then referring people who are violating those guidelines to the appropriate board of registration that oversees them. Certainly the availability of Narcan has made a big difference and certainly the availability of more treatment has made a difference.
Q: What’s your reaction to the drop in opioid-related deaths?
BAKER: It’s the first reduction year over year that we’ve had in 15 years. That’s got to be a positive. But the part I can’t answer yet is what the increasing prevalence of fentanyl has been in the overdose and death data. If you go back four to five years, fentanyl wasn’t even in the conversation and we still had a run rate on deaths that looked like this. [Points upward.] Now that fentanyl is involved in four out of every five deaths and present most of the time in a lot of overdoses, it’s a much harder question to answer.
Q: What’s your goal on death rates a year from now?
BAKER: We said when we got into this that the first goal was to break the back of the trend – break the back of the trend on prescribing, break the back of the trend on overdoses, and break the back of the trend on deaths. I would say we are starting to make progress on that. But let’s face it, no one here, and I certainly don’t think anyone in Massachusetts, is going to view this as mission accomplished until we get to the point where we drive these numbers down to what I would call almost de minimis categories. And that’s going to take a long time. It took 15 to 20 years to get here in the first place. This is one of those issues where you can’t afford to get distracted. You have to stay on it.