A version of this column was originally posted on WBUR CommonHealth
In the midst of an opioid addiction crisis that has claimed a startling number of lives, the State Senate has passed a bill intended to help prevent opioid addiction. It’s a more comprehensive effort than most have realized.
You’ve mostly read about the proposed expansion of SBIRT screenings in public schools – a proposal initially deemed controversial, with people believing it involved blood samples and lab testing. Even my mother called to report her concerns, and conveyed that my 88 year old aunt was also opposed. For the record, the Senate bill does not include any drug testing. It does include a verbal survey and assessment, of students, to gain a better understanding of trends and risks among youth.
Lost in the misunderstanding and reporting on the screening proposal was that the entire bill, comprising more than a dozen distinct policy initiatives, reflects a thoughtful and coordinated approach to substance abuse prevention. Much more than a haphazard assortment of mandates and prohibitions, it is a determined effort – our boldest and most creative yet – at a cultural change to rein in our over-reliance on the pharmaceutical products that create addiction.
And we need this change. Our health care systems push unconscionable quantities of opioid pills into our communities, not by malicious intent (though some of that exists), but due largely to simple inertia and complacency. So we’ve put forward a bill that examines every node of the system, and that challenges some of the underlying assumptions about how we should handle the prescription drugs that are fueling this crisis. The bill requires pharmaceutical manufacturers, prescribers, pharmacists, insurance companies and patients to all take an active role in not only combatting the epidemic, but also in promoting more affordable healthcare with better outcomes.
Consider these five particularly noteworthy changes:
Drug Stewardship: Pharmaceutical manufacturers must be responsible for the safe use and disposal of their products, not merely through passive labeling and warnings, but through tangible stewardship steps such as funding and operating mail-back and take-back programs. Massachusetts would be the first state in the Nation to demand a state-wide stewardship program.
Prescriber Trend Notification: Prescribers would regularly be compared against their peers, and informed (not warned or penalized, only informed) when their prescribing numbers exceed the average among their peers of a similar specialty, practice setting and geography.
Access to Pain Management: A three-fold approach would encourage the use of non-opioid pain management drugs, demand more coordinated and comprehensive insurance coverage of non-opioid pain management alternatives, and test a model that allows primary care providers to quickly access pain management specialists for consultation.
Patient Choice in Opiate Volume: Patients would be authorized, after consultation with prescribers, to receive their opioid prescriptions in any quantity up to a prescribed maximum, rather than directed to receive the fixed amount written by the prescriber. Massachusetts would be the first state in the Nation to provide for patient choice in filling prescriptions.
Voluntary Non-opiate Directive: Another first, in Massachusetts patients would be empowered to register their desire not to be administered or offered an opiate, not as a request that may or may not be honored by their provider, but as a legally binding medical directive, with appropriate safeguards for emergency situations.
These policies refute some of our traditional assumptions. For example, that overprescribing is a problem that begins and ends with the prescriber. This bill blames no one in particular for creating the problem, but makes everyone sustaining the status quo responsible for fixing it. We could become the first state in the nation to make manufacturers responsible for their products not by litigation and prosecution, but by the assertion as a Commonwealth that responsible corporate behavior is a minimum condition of the manufacturers’ licenses to do business with us.
The Senate’s bill also makes opioid safety a patient-driven priority. For all the time and effort we’ve spent educating the general public on the risks of opioid addiction, we’ve given the average patient and family very little say about their exposure to these drugs. We are changing that, completely. The patient would be in control, not only in the doctor’s office, but also before arriving at the office (non-opiate directive), after leaving the office (choosing the fill quantity), and in their own neighborhoods and homes (stewardship programs).
Further, we have rejected the old notion of a zero sum game between prescription safety and pain management. We are balancing the push to reduce our consumption of pills, with a push to replace those pills with real treatment. We are requiring insurance companies to present a comprehensive menu of pain management options. We are making information and expertise more readily available to primary care providers, so that they do not face the limited choice of either prescribing dangerous pills or leaving their patients without any treatment for their pain.
The bill also shifts, in a subtle but important way, one of the primary purposes of the Prescription Drug Monitoring Program (PMP). By gathering data on prescription trends, then making that data personal to each prescriber, we are nudging high prescribers to consider their choices thoroughly. This will make the PMP a powerful tool for education and best practices, not a tool solely for monitoring and enforcement. The information we can distribute to prescribers will also be, in many cases, the only counterbalance to marketing efforts by pharmaceutical sales teams.
I have been proud to work on this legislation, and hope to see it passed without delay. As we continue to innovate, getting at the roots of our collective and inappropriate dependence on prescription pills, I hope that more health care institutions and professionals will join us, as many already have. We are in a fight to save lives, and to save families. Each of us needs to be willing to discard the habits and assumptions that have led us so deep into this crisis.