By Felice J. Freyer
The bill on opioids that the Massachusetts Legislature approved late Tuesday contains several provisions that have nothing to do with combating opioid addiction, but instead aim to help people often seen as casualties of that fight — those suffering from chronic pain.
Spooked by worries about addiction and poorly trained in pain management, many physicians have reduced or stopped prescribing medications for pain, and some avoid pain patients altogether, advocates say. At the same time, insurance often doesn’t cover other types of treatment for pain.
“Physicians don’t know what to do for people’s pain,” said Cindy Steinberg, policy chair for the Massachusetts Pain Initiative. “They don’t want to prescribe anymore. They’re dropping people with pain from care even if they do not take opioids.”
To address this problem, the bill would establish a program through which physicians can consult a team of pain-management specialists. The experts will advise them on pain therapies and refer them to local practitioners of alternative treatments.
Another provision in the bill would require health insurers to cover the full array of pain treatments, which could include acupuncture, chiropractic, physical therapy, and maybe even massage and yoga. Before the requirement goes into effect, the Health Policy Commission would study the issue and recommend to the Department of Insurance which therapies should be required.
Asked for comment Wednesday, representatives of the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts said they would work with regulators on identifying evidence-based treatments and noted that they already cover many non-opioid treatments.
The measures to address pain were absent from the opioid bill the governor proposed and also from the version the House approved. But advocates pushed to get them in the Senate bill and they made the final version.
“I’m so thrilled,” Steinberg said. “There’s 25 million people with severe pain and 2 million with opioid use disorder in the US. It’s incredibly important that we take care of both of these groups.”
In contrast to the pain provisions, which drew little public notice, a measure requiring medications to treat opioid addiction in correctional settings kept legislators wrangling over language late into the evening Tuesday.
“For some people, they’re just uncomfortable with this notion that you give drugs to a person who has an addiction that’s chemical-based,” Senator Cindy F. Friedman, chairwoman of the Joint Committee on Mental Health, Substance Use, and Recovery, said Wednesday.
Also, correctional officials were very concerned about how to manage such a program and its costs. But Friedman said federal grant money is expected to help.
In a compromise, the bill calls for a three-year pilot program, starting in September 2019, at correctional facilities in five counties: Hampden, Hampshire, Middlesex, Norfolk, and Franklin. These facilities will provide medications that treat opioid addiction — methadone, buprenorphine (known by the trade name Suboxone), and Vivitrol, a once-a-month shot — to inmates who had a prescription when they arrived, and also to inmates 30 days before release.
“When we do this pilot, if we figure out a way to do it right, then we will do it across the board because we will know how it works,” Friedman said.
The legislation would also require the state Department of Correction, starting in April 2019, to institute a medication-assisted treatment program at four facilities: the two women’s prisons, MCI Cedar Junction, and a Plymouth treatment program for civilly committed men.
At Cedar Junction, where prisoners stay for 90 days before being assigned a permanent spot, methadone and buprenorphine would be used to help patients withdraw from opioids.
Additionally, all prisoners would get an assessment by an addiction medicine specialist 120 days before release. The specialists will establish a treatment plan that could include medications. If so, prisoners would be transferred to one of the four facilities that provide the medications.
Correctional officials have long opposed providing methadone and buprenorphine behind bars because they are opioids that can be sold or stolen for illicit use.
But Middlesex County Sheriff Peter J. Koutoujian, president of the Massachusetts Sheriffs Association, said that even though sheriffs worried about security and costs, they always wanted to offer the treatment. “It’s not a change of heart,” he said Wednesday.
The sheriffs objected to an across-the-board mandate, but welcome this pilot program intended to test the waters, he said. “We think it’s an important enough endeavor that we’re willing to step into this territory and see how it works,” Koutoujian said.
The legislation, which requires the governor’s signature before it becomes law, won praise Wednesday from the presidents of the Massachusetts Medical Society and the Massachusetts Health & Hospital Association. Dr. Alain A. Chaoui, the medical society’s president, called it “thoughtful, measured, and evidence-based.”
Other notable provisions in the bill include:
■ Requirements that hospital emergency departments initiate medication-assisted treatment for patients who are treated for overdoses.
■ A program to enable primary care doctors to remotely consult experts in addiction treatment (similar to the one for pain patients).
■ Changes to the makeup of the Board of Registration in Nursing, including that members have expertise in substance use, behavioral health, and chronic pain.
■ Requirements for electronic prescribing of controlled substances.
■ Strengthened regulatory powers governing mental health and addiction programs, including the ability to require that new licensees are equipped to care for people suffering from both addiction and mental illness.
I think the “punchline” here is 25 million pain patients, 2 million opioid abusers. It’s good that they’re taking a look at both populations, also that they’re looking at the penal population; “I didn’t get in trouble every time I used, but every time I got in trouble I had been using!”
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