Tag Archives: evidence-based medicine

A Plan to Tackle the Opioid Crisis: The Good, the Bad, and the Missing

The “CARE Act,” a bill addressing the opioid crisis, is moving its way through the Massachusetts legislature’s Joint Committee on Mental Health, Substance Use and Recovery. Proposed by Republican Governor Charlie Baker, “An Act Relative to Combating Addiction, Accessing Treatment, Reducing Prescriptions, and Enhancing Prevention” is offered as a “comprehensive approach to addressing the problem of opioid addiction.”

The CARE Act includes some excellent provisions (a call for evidence-based treatment), a few provisions that should be fleshed out (harm reduction), and one glaringly bad provision (expansion of involuntary civil commitment). It also fails to include a prevention plan that researches and addresses the root causes of the opioid crisis.

My comments on the CARE Act are based upon my research as a medical sociologist as well as my understanding of the research literature in fields relevant to the Act. For the past decade I have followed and documented the experiences of a cohort of women released from MCI-Framingham. All of these women have substance abuse challenges and the majority have cycled through a variety of in-patient and out-patient treatment programs within prison, public health services, and privately run facilities.

The Good: Calling for Evidence-based Treatment

The bill draws attention to knowledge gaps regarding drug treatment. At the current time treatment programs are not required to use evidence-based methods, clearly state what constitutes effective treatment, or prove that treatment is effective.

The Act calls for the establishment of a commission comprising representatives from the Department of Health and Human Services, the insurance industry, clinicians, and family members of individuals with substance abuse disorder or mental illness to review evidence-based treatment approaches to substance use disorders and mental health conditions. While the bill does not limit the commission to these individuals, the inclusion of researchers and scholars with up-to-date expertise regarding treatment effectiveness should be made explicit in the bill.

Assessment of Treatment Effectiveness: Throughout much of the drug treatment industry, outcomes are measured in terms of the percent of patients who complete the treatment program. Because treatment programs do not definitively cure substance abuse, and many of the same people cycle through multiple programs, the bill should specify a requirement of long-term outcome tracking consistent with evidence-based research standards.

The Good: Oversight of Treatment Facilities and Personnel

DMH and DPH Oversight Authority: Before licensing new treatment programs or approving the transfer of license for an existing program, DMH and DPH/BSAS will require that a facility demonstrate that it “provides the range and quality of services necessary to meet the current critical treatment needs of the Commonwealth’s patients.”

This provision should be expanded to itemize the minimum range and quality of services that are acceptable.

“Cherry picking”: Under the proposed law, treatment facilities will be required to “make treatment available to patients with public health insurance on the same basis as patients with private insurance.” This important provision aims to eliminate ‘cherry picking’; that is, practices designed to encourage patients who are seen as desirable and discourage patients deemed undesirable.

It would be useful to spell out how compliance will be assessed and non-compliance addressed.

Recovery Coaches: The bill calls for the establishment of professional credentials for recovery coaches; that is, lay mentors who may be helpful to individuals struggling with addiction. Currently, anyone can call him or herself a recovery coach without any kind of training, credentialing or supervision process. Some coaches volunteer their time; others are paid. Typically, the sole qualification for coaching is having been an addict in the past. Much of the attractiveness of referring substance users to recovery coaches is that their services are less expensive than those of trained health care providers such as social workers, psychologists, nurse practitioners and physicians.

Recovery coaches frequently are oriented towards twelve-step ‘abstinence only’ ideas that are shown in the research literature not to be effective. Because ‘evidence’ for the effectiveness of recovery coaches is anecdotal, the bill should be scrupulous in calling for research to evaluate diverse approaches to coaching.

Establishing a commission, as laid out in the bill, is a good first step towards ensuring that coaching is appropriate, effective and not used as a substitute for other treatment modalities. However, the make-up of the commission, as spelled out in the proposed bill, runs the risk of promoting coaching without adequate research or mechanisms for tracking the work and the long-term effectiveness of coaches.

The Bad: Expansion of Involuntary (Civil) Commitment

Involuntary (Civil) Commitment: The CARE Act seeks to regulate and expand the use of Section 35, which permits the courts to involuntarily commit someone who has an alcohol or substance use disorder and there is a likelihood of serious harm as a result of his/her alcohol or substance use.

While regulation is a worthy aim, expansion is not. The Commonwealth should exercise the utmost caution in confining individuals who have not been accused or tried for a crime.  Because this action abrogates the most fundamental principle of American democracy and concern for civil rights, it should not be seen as a standard part of the toolkit for addressing substance abuse problems.

According to numbers provided by the Massachusetts Department of Public Health, civil commitments have increased by 36% between 2010 and 2017. In 2017 the total number of commitments was 6,531. This number represents the failure to develop and fully fund other systems in the Commonwealth to prevent substance abuse and treat people with substance use disorder.

Civil commitment runs counter to the CARE Act’s call for evidence-based treatment. There is no medical or scholarly evidence supporting the effectiveness of involuntary commitment for substance use issues. To the contrary, there are suggestions in the research literature that involuntary commitment may cause harm in that immediately following a period of detoxification, an individual’s tolerance for opioids may decrease, thus setting up the individual for heightened risk of overdose upon release from the treatment program.

The bill calls for allowing involuntary confinement for up to 72 hours without a judicial hearing (as currently required under Section 35) inappropriately expands the use of civil commitment. According to the language of the bill,

“[A] physician may admit the person to the facility for care and treatment for up to 72 hours, during which time, staff of the substance use treatment facility shall attempt to engage the individual in voluntary treatment. … A person shall be discharged at the end of the 72-hour period unless the person has consented to treatment under section 35B. If the superintendent determines that the failure to provide continued treatment to the person would create a likelihood of serious harm by reason of an alcohol or substance use disorder, the superintendent shall file a petition under section 35 prior to discharge.”

Because it is unlikely that effective treatment can be provided in 72 hours, the 3 day holding period essentially amounts to a forced detoxification. Some individuals will return to the streets– dope sick – after the 72 hours. Some individuals may be too sick to provide meaningful informed consent to further in-patient treatment. Other individuals may find that already being confined increases the chances of a judge approving further confinement. While this policy suggestion is new so has not been studied, research shows that for defendants in criminal cases “being detained [as opposed to being out on bail] before trial significantly increases the probability of a conviction, primarily through an increase in guilty pleas.”

The bill does not eliminate the practice of sending people who have been civilly committed to jail. Currently, if a woman who is civilly committed also has an outstanding criminal case, she can be sent to a twenty day program at the state prison MCI-Framingham. However, if she is able to make bail, she will sent to a Department of Mental Health or Department of Public Health facility. This practice runs counter to treatment principles and discriminates against residents without the financial resources to pay bail.

There is no similar legal restriction regarding men. At the present time civilly committed men are sent to treatment facilities but if the use of Section 35 is expanded it is likely that there will be a shortage of space in men’s treatment facilities which may lead to civil commitment in jails.

Inappropriate Role for Police Officers: The Act proposes that in the case that a clinical professional is not available to assess and commit an individual under Section 35, “a police officer who believes that failure to treat a person would create a likelihood of serious harm by reason of an alcohol or substance use disorder may restrain or authorize the restraint of such person for transportation to an appropriate treatment facility.” Our American legal system calls for the separation of policing from judicial authority and from medical authority in order to ensure the protection of individual rights. Allowing police officers to decide on involuntarily commitment runs counter to this legal principle.

Exacerbating Family Tension: Data supplied by DPH indicate that the majority of individuals sectioned are under 24 years of age. It seems likely that in many or most cases parents’ are involved in requesting commitment. This situation often exacerbates family tensions. It would be useful for the commission created by the CARE Act to assess and share the services available to help families avert the adversarial situation of parents sectioning their kids.

The Missing: Prevention

The Act addresses prevention solely in terms of regulating physicians’ and dentists’ prescribing of pain medication. Over-prescription of opioids has a role in creating the current crisis, but the demand for narcotics has not been driven solely by prescribing practices. Better regulation certainly is important, but it is insufficient to focus solely on the “supply” side without attention to the “demand” side.

Data show that certain towns and communities in the Commonwealth are hot spots for the current opioid crisis. However, there is no research — and no call for research — into the social conditions that result in high levels of substance use and abuse in those particular communities. In order to get ahead of the opioid crisis, the Commonwealth must launch research as well as policies that look at the opioid epidemic as a symptom of deeper problems and not simply as the problem itself.

Without investigating the “demand” side, that is, looking at environmental and social conditions that give rise to the desire to use opioids, public responses will remain at the level of trying to fix the damage that already has been done. If we are indeed experiencing an opioid “epidemic,” then we must carry out standard public health measures regarding identification of the sources and epicenters of the epidemic as well as public health measures for addressing the spread of the epidemic.

The bill should establish a committee and fund basic, interdisciplinary research aimed at understanding why so many residents of the Commonwealth, and particularly young residents, are drawn to substances that they very likely know lead to serious illness or death.

The Incomplete: Harm Reduction

Naloxone Access: The Care Act calls for increased access to naloxone (Narcan) by directing the Department of Public Health to authorize every pharmacy in the Commonwealth to dispense naloxone and by protecting practitioners who prescribe and pharmacists who dispense naloxone in good faith from criminal or civil liability. While naloxone cannot prevent or cure addiction, it is a solidly evidence-based means for saving lives, at least in the short-term.

It would be useful to expand and improve training in naloxone usage, especially to help first responders and police officers understand that the cycle of addiction often includes numerous overdose events before an individual is able to desist from substance abuse. Friends and families of individuals treated with naloxone report inappropriate comments such as, “Why bother, he’ll just O.D. again” and “I’ve been at this address a dozen times already. Some people just don’t want to learn.” This kind of comment may dissuade people from seeking further treatment.

Syringe Exchanges and Safe Injection Sites: Beyond expanding access to naloxone (Narcan), the bill offers little in terms of harm reduction. As part of a multi-faceted approach to addressing the opioid crisis, the bill should expand syringe exchanges and call for the establishment of safe injection sites.

What you can do about this:

Contact your representatives as well as members of the Joint Committee on Mental Health, Substance Use and Recovery. Share your concerns and comments. Click here to find your representatives.