AIMING HIGH ON THE OPIOID CRISIS:
A Comprehensive Approach to Combatting Addiction to Opioids
Let’s Aim High
We need to end the opioid epidemic – the most serious public health crisis of our time. No more tragic deaths from overdoses. No more lives ruined by addiction. No more families torn apart. No more communities ravaged.
We need people of all ages to be educated about the dangerously addictive nature of opioids and the existence of alternatives for managing pain to drive down demand for them.
We need to address the underlying health and social challenges that can lead to substance use disorders like opioid addiction, including providing the treatment resources needed for people dealing with mental illness, behavioral health issues and stress, and ensuring people have access to jobs, housing and other necessities for a stable and healthy life.
We need to stop doctors from unnecessarily prescribing opioids that lead to addiction, and we need them and their patients to rely more on alternative approaches to pain management.
We need to stop pharmaceutical companies who make opioids from engaging in misleading marketing of their products, require that they warn doctors and consumers of the highly addictive nature of their products, and hold them accountable for the significant role they played in creating the opioid crisis by making them pay to help solve it.
We need to stop the flow of illegal and dangerously addictive opioids like heroin, fentanyl and carfentanil into our communities.
We need to eliminate the stigma associated with substance misuse and addiction and recognize it as the sickness it is, not a moral failing.
We need to respond to those suffering from addiction with compassion, help and support by ensuring they have access to the treatment they need, not treating them like criminals.
We need to establish a robust, easily accessible supply of treatment and recovery services across Massachusetts that actually meets the demand for those services.
We need to ensure that no one suffering from addiction – no one – is denied access to the treatment and support they need because of their health insurance coverage or the cost.
We need to give family members, significant others and friends of those suffering from addiction the support they need to not only help their loved ones, but also to help themselves manage through the challenges of having a loved one who is addicted.
Most important, we need to see that achieving these outcomes is not only in the interest of those suffering from addiction and the family members impacted by their addiction. It’s in our collective interest. Ending this epidemic will result in stronger, safer, healthier and more productive communities. It will result in a higher quality of life for everyone.
And, it is the right thing to do. We have a moral responsibility to do everything we can to prevent more people from suffering from the sickness of addiction and to help those who are addicted.
Not Satisfied with the Status Quo
As a candidate for Governor, I hear from people in every corner of this state who have been affected by the opioid crisis. Based on a poll conducted by Blue Cross Blue Shield of Massachusetts in January 2018, people in Massachusetts believe the opioid crisis is the most serious problem facing the state today. More than half of the people surveyed know someone addicted to opioids, and one-quarter of those surveyed know someone who died from an opioid overdose. The poll shows that very few people believe the opioid crisis is getting any better 1.
Massachusetts continues to be among the states with the highest rate of opioid-related overdoses and overdose deaths2. According to the state Department of Public Health, it is estimated that 1,977 people died of an opioid overdose in 2017, slightly less than the 2,155 opioid overdose deaths estimated in 2016 and significantly more than the 1,352 people who died of an opioid overdose in 20143. Nearly six people every day die here from opioid overdoses4. Opioids killed or were suspected of killing four-and-a-half times more people than died in car crashes in 2015, the most recent year statistics were updated5. Massachusetts is home to the highest number of opioid-related emergency room visits and opioid-related inpatient stays6.
While data suggests that the rate of overdose deaths declined for the first time last year, this decline is likely due in large part to greater use of the overdose-reversing drug Narcan as Department of Public Health data indicates that EMS incidents involving Narcan administration increased in 2017 to their highest level7. There is no evidence that overdoses themselves are declining or that the number of people suffering from opioid addiction is declining. In fact, Department of Public Health quarterly data show that the number of opioid-related incidents and the number of opioid-related overdoses among all EMS incidents have both increased through the first three quarters of 2017, the most recent period for which data was provided8. Boston experienced a 20 percent increase from 2016 to 2017 in calls involving heroin or suspected heroin in opioid overdoses9.
While heroin-related deaths have inched slightly downward statewide, the rate of fentanyl present in the toxicology of opioid-related deaths continues to rise, reaching 81 percent in 201710.
Education efforts in schools and across Massachusetts more broadly are not nearly as robust as they should be11.
While new laws and other efforts have worked to reduce the number of opioids being legally prescribed, there are still way too many pills being prescribed. In the last three months of 2017 alone, there were 594,000 prescriptions written for opioids12. Restrictions aren’t being enforced, and more can and should be done to keep these highly addictive, dangerous pills out of people’s medicine cabinets and off the streets.
The supply of treatment and recovery services is not sufficient to meet the demand. According to a survey of addiction treatment providers conducted by the office of Senator Elizabeth Warren, even though about 600 new treatment beds had recently been added across the state, survey respondents said waiting lists for treatment remain commonplace. More than half of the survey respondents had waiting lists for inpatient care for as long as three weeks and 90 percent of residential recovery homes that provide long-term care following inpatient stays reported waiting lists where patients can wait as long as 90 days for placement13. A recent Blue Cross Blue Shield Foundation Report indicates that a failure to collect data about our behavioral health service delivery system contributes to a lack of knowledge about the amount of behavioral health services provided across our state’s health care system and the extent to which gaps in service delivery needs exist14.
Lack of access to opioid addiction treatment services is also a result of the fact that health insurance too often doesn’t cover the costs of treatment and recovery. Insurance companies generally do not currently cover the cost of recovery coaches and often limit coverage for medication-assisted treatment and for inpatient and outpatient treatment. And despite federal and state “parity laws” requiring insurers to cover behavioral health disorders at the same level as physical health problems, low reimbursements for behavioral health care often result in less access. Consequently, people suffering from addiction who want treatment and recovery are not able to access it and end up relapsing15.
People suffering from addiction are too often still being treated like criminals instead of being given the treatment they need. Governor Baker has been sending people who are suffering from addiction and who have not been accused of committing any crime to be locked up by the Department of Corrections (DOC)16. In addition, correctional facilities in Massachusetts are denying approved addiction medications to those in need. That’s despite data from the Massachusetts Department of Public Health indicating that the opioid related overdose death rate is 120 times higher for people released from prisons and jails, compared to the rest of the adult population in the state17.
Too many family members, significant others and friends with loved ones suffering from addiction are struggling and need support.
Principles and Proposals
I have experience dealing with the impacts of the opioid crisis. When I was CEO of CeltiCare Health Plan, the number one health condition affecting our members was addiction. The opioid epidemic was taking its toll on our membership, and we needed to act.
We acted with a sense of urgency. Through a company-wide effort, we developed a comprehensive set of initiatives to attack the problem and get better outcomes for our members who were suffering from addiction. We helped members fight addiction by removing restrictions for addiction treatment so they could more easily receive the treatment they needed. We put restrictions on prescribers to help stem the flow of prescription opioids in the community. We educated family members about the use of Narcan to reverse overdoses. And we established innovative partnerships with community providers to support members through care management, peer supports and other necessary social supports.
For these and other innovative efforts to combat the opioid epidemic, the Boston Globe recognized CeltiCare Health Plan as a “Game Changer” in 201618.
As your Governor, I will bring the same sense of urgency and comprehensive approach to fighting the opioid crisis statewide. Here are some of the actions I will take to address the problem:
Education is a key component to ending the opioid epidemic. The more knowledgeable people are about the dangers of opioids and alternative approaches to managing stress and pain, the less likely they will be to use opioids in the first place. The more people understand that addiction is a sickness and not a moral failing, the more compassionate and supportive they will be in helping people who suffer from addiction. The more physicians understand the dangers of prescribing opioids and alternatives to pain management, the less people will become addicted as a result of pain-killers prescribed by the doctors they trust.
Current education efforts are insufficient. As Governor, I will take the following actions:
- Increased Education in Schools. Require that students learn the dangers of opioids and other addictive substances, alternative approaches to managing pain, and healthy ways to cope with stress and to address mental health and behavioral health issues. I would also provide the necessary state funding, training and other support to school districts to meet the requirement.
- Robust Public Service Announcement Campaign. Launch a much more robust public service announcement (PSA) campaign than currently being undertaken about the dangers of opioids. The scope of this PSA campaign should be akin to the highly successful anti-tobacco campaign. People throughout Massachusetts should be repeatedly reminded of the addictive, dangerous nature of opioids and the destructive consequences of using them.
- Warnings from Physicians and Pharmacists. Require that physicians who prescribe opioids and pharmacists who fill the prescriptions provide oral warnings and a standard written warning about the risk of opioid addiction to any person to whom they prescribe or provide opioids. I will also provide the state resources necessary to enforce the requirement and establish consequences for physicians and pharmacists who fail to comply.
- Training on Safe Prescribing Patterns and Alternatives to Opioids. Make training about the dangers of opioids, safe prescribing patterns and alternative approaches to pain management a condition of licensure for physicians, dentists, and other appropriate health care providers. In order to help health care providers meet this requirement, ensure easy access to such trainings through continuing medical education opportunities, online webinars and other forums.
In addition to expanding education and awareness of the dangers of opioids, we must take steps to prevent these dangerous drugs from getting into the hands of individuals who don’t absolutely need them. As Governor, I will take the following actions to further prevent the misuse and supply of opioids and to reduce the demand for them:
- Enforce Prescription Limits and Require Patient/Provider Contracts. Enforce the 7-day limit on first-time opioid prescriptions. The limit established by law in 2016 is not effective as long as physicians continue to ignore it without consequence. I would ensure state resources are available to hold physicians who ignore the prescription limit accountable. I would also require that insurance companies and MassHealth take the same steps we took at CeltiCare Health Plan to deny coverage for any first-time opioid prescription in excess of seven days and enforce that requirement on payers. Lastly, in the event a physician determines longer-term opioid prescriptions are appropriate for people suffering from chronic pain, I would impose the same requirement we imposed at CeltiCare Health Plan, consistent with the recognized standard of care, that patients sign a contract documenting their understanding of the risks of opioids.
- Increase Access to Alternative Pain Management Options. Require that health insurers and MassHealth expand coverage for alternative pain management options, including medical marijuana, acupuncture, chiropractic services, and other evidence-supported treatments determined to be effective and appropriate for coverage by an independent panel of clinical experts.
- Expand Safe Disposal Options. Take steps to ensure there are sufficient, well-advertised sites in every community throughout Massachusetts for the safe disposal of unused opioid pills, including at pharmacies, public safety facilities and other locations.
- Stop Pharmaceutical Company Marketing and Hold them Accountable. Prevent pharmaceutical companies from proactively marketing opioids to physicians and consumers and require them to include warnings of the highly-addictive, dangerous nature of opioids on any descriptive materials and packaging similar to warnings required for alcohol and tobacco. Pharmaceutical companies marketed and sold these drugs knowing their potential for abuse and failed to disclose the dangerous nature of the pills they manufacture. Consequently, I would also work with the Attorney General to hold pharmaceutical companies accountable for the epidemic and seek restitution for the costs associated with fighting the opioid epidemic they helped create, similar to the 1998 legal settlement with the tobacco industry that has resulted in significant annual payments from the industry to state governments.
- Address Underlying Health and Social Factors that Lead to Substance Use Disorders. Invest in our mental health and behavioral health care system to ensure people have access to the treatment they need and don’t need to turn to opioids or other substances for relief. In addition, we need to address the social determinants that can lead to instability and substance use disorders, including access to employment, housing and other necessities for life stability.
Treatment and Recovery
We need to do a much better job supporting those suffering from addiction through treatment and recovery. We need to eliminate barriers to accessing treatment options that have been proven to be effective, and we need to try new approaches to getting better outcomes for people suffering from addiction. We also need to support the spouses, significant others and friends of those suffering from addiction.
- Safe Injection Facilities. To get people help, we must first keep them alive. To reduce the tragic number of overdose deaths and get people suffering from opioid addiction the treatment they need, I support legislation proposed by Sen. William Brownsberger (S1081) and endorsed by the Massachusetts Medical Society and the Massachusetts Hospital Association, which would legalize safe injection facilities where health care professionals and trained staff can help prevent overdoses and guide users into available treatment. In Vancouver, Canada and Sydney, Australia, where safe injection facilities are legal, they have seen a corresponding reduction in overdose deaths and drug use, an increase in people receiving treatment and no increase in drug trafficking or crime19. San Francisco and Philadelphia are moving forward as the first US cities to allow these facilities. As we lose nearly six people per day to this epidemic, we need to take bold action to address the crisis, including establishing safe injection facilities.
- Increase Access to Medication Assisted Treatment (MAT). Studies show that those suffering from opioid addiction who use MAT, including methadone, buprenorphine (Suboxone) or naltrexone (Vivitrol), are less likely to overdose or relapse. Studies, including systematic reviews of the research, have found that MAT cuts all-cause mortality among opioid addiction patients by half or more20.
Given its effectiveness, I will expand access to MAT by taking the following steps:
- Insurance Coverage – Require health insurers to provide co-pay free coverage of Methodone, Suboxone and Vivitrol for those who need it (until co-pay free coverage provided through a single-payer system).
- Expand Suboxone Access – Launch a campaign that includes financial incentives to encourage primary care physicians to become federally certified to administer Suboxone treatments to significantly increase access to Suboxone in Massachusetts. Currently, there are only 3,000 doctors, nurse practitioners, and physician assistants in Massachusetts who have undergone the buprenorphine training, according to the US Substance Abuse and Mental Health Services Administration. But it’s not known how many of them work in primary care or prescribe the medication21.
- Access to MAT in Corrections Facilities – Consistent with the proposal by the Massachusetts Medical Society and the Association for Behavioral Healthcare, require the Department of Corrections and the county sheriffs to evaluate all inmates for drug dependency by an addiction specialist and provide all FDA-approved MAT for addiction to inmates when medically appropriate, including allowing those incarcerated to continue receiving the MAT they were receiving before incarceration. In 2017, Rhode Island became the first state to offer all three MAT drugs to its entire prison population and it saw a decline in overdose deaths among recent inmates of more than 60%22. Massachusetts should follow suit. Nationwide, 65 percent of inmates meet the medical criteria for substance use disorder, but just 11 percent receive treatment while incarcerated23. Compared to the rest of the adult population, the opioid-related overdose death rate is 120 times higher for inmates released from Massachusetts prisons and jails24. Nearly one of every 11 individuals dying from opioid-related overdoses had histories of incarceration in Massachusetts jails and prisons25. In 2015, nearly 50 percent of all deaths among those released from incarceration were opioid-related26.
- Medical Marijuana as Treatment Option – Require health insurance coverage of medical marijuana as a treatment option for those suffering from addiction when prescribed by a physician. States like Maine, Nevada and Maryland have examined the idea, though no state has yet to adopt the requirement. Massachusetts should lead by adding heroin and opioid addiction to the list of disorders for which a doctor can prescribe medical marijuana in circumstances where the physician determines there is evidence-based support for doing so.
- Comprehensive Treatment System. The current behavioral health care system in Massachusetts, including substance use disorder treatment services, is significantly under-resourced and inadequate to meet the demand for treatment services. There are still many necessary and effective services that are not covered by health insurance, and there are many others for which supply is limited due to workforce and provider shortages. Consequently, individuals with addiction disorders too often do not have timely access to the treatment services they need in their local communities to successfully return to and remain in their communities after an overdose or detox event.
As Governor, I will promptly undertake a comprehensive system review and ongoing data collection to ensure we understand: 1) the gaps in our behavioral health and substance use disorder service delivery and treatment system, and 2) where workforce capacity and/or reimbursement and insurance coverage is insufficient. This review will allow us to identify the investments we need to make to increase the supply of treatment services and to attract and retain the treatment providers we need to meet the demand for those services.
I will also work immediately to address the following deficiencies in our addiction treatment system:
- Peer Support Services – Require health insurance coverage of certified and trained recovery coaches and recovery support navigators to help engage those suffering from addiction in their own treatment and recovery. Peers who have struggled with addiction themselves and are in recovery have been shown to be effective at offering support, encouragement, and help to those suffering from addiction as they navigate the challenges of the treatment and recovery process.
- Access to Post-Detox Rehabilitation Facilities – Increase the supply of post-detox rehabilitation treatment facilities across the state. There is a severe shortage of rehabilitation facility services statewide and the programs/beds that exist are clustered in a few areas of the states. When someone enters a rehabilitation service far from home it makes the transition back to services in their communities that much more difficult. When they leave detox and do not have access to more extended rehabilitation support to assist them with the choice to remain substance free, stabilize in their recovery and practice the skills they need to live a sober life, they are much more likely to return to the circumstances that previously sustained their addiction and resume their substance use. This is especially true with adolescents and young adults.
- End Treatment Facilities Run by DOC – End the practice of having the Department of Corrections run addiction treatment facilities for people who have been civilly committed to treatment under the state’s “Section 35” law. People suffering from addiction who are civilly committed for treatment – and who have not committed a crime – are often sent to the Massachusetts Alcohol Substance Abuse Center, which opened in 2017, and is run by the Department of Corrections. The Department of Corrections treats individuals in these facilities more as inmates, frequently denying them the necessary treatment – including MAT – that can help them overcome their addiction27. Behavioral health care professionals, not the Department of Corrections, should be the ones providing treatment to those suffering from addiction. We also should be making it as easy as possible for those who are civilly committed under Section 35 to maintain connections with friends and family; visits should be allowed and those civilly committed should no longer be charged for making phone calls.
- Access to Sober Homes – Increase the supply of certified sober homes in communities throughout Massachusetts. Sober homes are a place for individuals to live and feel safe in a setting that is free from drugs and alcohol. Individuals are able to connect with others who have experienced addiction and get connected with resources in the community to maintain recovery. According to the Blue Cross Blue Shield Foundation report on Access to Behavioral Health Services, there are only 83 sober homes in Massachusetts with just over 1,000 beds28. We need to expand the number of sober homes and ensure they’re providing the proper supports for long-term recovery.
- Increase Recovery High Schools – Increase the number of recovery high schools in Massachusetts to give young people suffering from addiction the treatment and support they need to graduate from high school and succeed in recovery and in life. There are currently only five recovery high schools in Massachusetts, and Governor Baker vetoed language in the 2018 budget to increase access to recovery high schools29. Yet, the national data shows these programs are working. In a 2009 study evaluating students at more than a dozen recovery schools, participants said they only stayed sober 32 percent of the time before entering their respective schools, compared to 82 percent after they began their programs. Among some other findings, the study showed that over 70 percent of the students said they were performing better academically in their recovery schools and nearly 60 percent said they felt better emotionally30.
- Support for Families and Friends. Provide support for organizations like Learn to Cope that give loved ones of those suffering from addiction the support they need. Opioid addiction affects not only the people suffering from addiction, but all those who love them as well. Parents, siblings, significant others and friends struggle to help and support loved ones who are addicted to opioids. Knowing the best way to do so is often challenging. And, in their efforts to be supportive, loved ones often endure personal hardships, financial costs, stress and life disruptions. We need to provide loved ones of those who suffer from opioid addiction the help and support they need.
- Gibson A, Degenhardt L, Mattick RP, Ali R, White J, O’Brien S. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction 2008;103:462-8. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM576377.pdf