Tag Archives: Massachusetts

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.

 

 

Will Massachusetts Pass Meaningful Criminal Justice Reform Legislation?

I wish to thank Jean Trounstine for contribution to this post.

On June 19, 2017, I spent the afternoon and early evening at the Massachusetts State House listening to testimony regarding several bills aimed at reforming incarceration policies. The large Gardner Auditorium was packed with people wearing T shirts calling for the end to mass incarceration, solitary confinement, mandatory minimum sentencing, and parole reform, and for “jobs not jails.” The members of the Joint Committee on the Judiciary listened intently to testimony from criminal justice experts, legislators, sheriffs, attorneys, physicians, and people personally impacted by criminal justice policies. With the exception of a representative of the association of Massachusetts District Attorneys, speakers from all over the Commonwealth spoke to failures of current policies to keep people safe, to safeguard human rights of prisoners, and to provide appropriate health care services to justice-involved individuals.

It all seemed so promising. If only this whole crew hadn’t been there before.

Nearly all of the bills have been proposed in the past (albeit sometimes in slightly different forms). None of the bills seemed terribly controversial, at least to me. None proposed a complete overhaul of the criminal justice system. Rather, the bills, cumulatively, addressed several of the most obviously ineffective or inequitable current practices.

House Bill 74 – implementing programs to reduce recidivism

The first bill introduced, House Bill 74, calls for implementing the recommendations made as part of an extensive review conducted by the Council of State Governments Justice Center and chaired jointly by Governor Baker, the Lieutenant Governor, Senate President, Speaker of the House of Representatives, and Chief Justice of the Supreme Judicial Court.

As a sociologist, I often find political discourse and machinations to be a bit confusing. In this case, it was hard to get my head around reiterations that “all the players” were involved in crafting this legislation.  Other proponents expressed pride that “all justice partners”; that is, representatives from all three branches of state government, worked on the bill. I also heard the term “all the stakeholders”.  However, there did not seem to be any representation of incarcerated or formerly incarcerated men and women on the committee that crafted the bill. Surely “all the stakeholders” include the people most directly affected by these policies. Indeed, I’d argue that they – not politicians or bureaucrats — have the most at stake in decisions regarding prison policy.

Though many people involved with the court and prison systems had hoped for far-reaching recommendations from this review and committee, the bill focuses rather narrowly on reducing recidivism. While that certainly is an important goal, it does not speak to disrupting the school-to-prison pipeline or to other policies and social conditions that send people into the prison system to begin with.

The recommendations to reduce recidivism center on prisoner education, opportunities for early release for good behavior, and post-release supervision. A centerpiece of  the bill calls for rewards for good behavior (for example, completing vocational training programs). The rewards consist of shaving days off the sentence and adding them to the period of parole (community supervision). I strongly support efforts to reduce incarceration rates, but I am concerned that lengthy and intensive supervision on parole can lead to re-incarceration due to technical violations of the conditions of parole. In my own ongoing research with criminalized women in Massachusetts, I’ve seen intensive supervision with requirements for frequent meetings with parole officers, urine tests, proof of attending programs, etc. interfere with the ability to hold down a job and manage the myriad other responsibilities that are part of modern life.

H.74 emphasizes expanding programs of various sorts: pre-trial, during incarceration and post-incarceration. Programs can be good, bad or indifferent, but programs are not a substitute for the material resources most justice-involved people desperately need: Housing, decent jobs that pay living wages, family reunification. I am particularly troubled by a lack of clarity regarding mandatory program attendance for pre-trial individuals. Given that people who are awaiting trial have not been found guilty of a crime, it is be problematic to require them to attend any sort of program.

The consensus at the hearing is that the measures to reduce recidivism outlined in this bill should be the start, not the totality, of criminal justice reform in Massachusetts. No one testified against the bill but many said in their testimony that it did not go far enough.

S819 and H741 – bills eliminating mandatory minimum sentences for low level drug crimes

More substantively, Senator Creem spoke to S819 and H741 – bills eliminating mandatory minimum sentences for low level drug crimes. She, and other supporters of the bills, made the important points that mandatory minimums have not been effective in reducing drug use; they have led to mass incarceration; they have ruined lives of young people locked up for years on trafficking chargers for what essentially amounted to sharing illicit substances with friends; and they clearly have disproportionately impacted racial minorities. There were also panels of sheriffs, defense attorneys, impacted people, and Senators Evandro Carvalho and Sonia Chang-Diaz, both who represent districts where mandatory minimums are levied with unrelenting consistency.

Collectively, they made the point that mandatory minimums undermine the American system of justice by putting power in the hands of prosecutors rather than judges. Prosecutors decide whether the charge will be one that automatically triggers a mandatory minimum or not. And prosecutors can use the threat of mandatory minimums to encourage people to “choose” to plead guilty to a lesser charge. Opponents of this practice argued that prosecutors in essence function as judges, taking away from individuals the right to a trial in front of a judge who hears arguments both from the prosecution and the defense, and who can evaluate the particular circumstances of the individual and the case.

The only opposition to ending mandatory minimums came from DA Conley of the District Attorney’s Association. Conley argued that judges are “out of touch with what goes on in communities” and that prosecutors should properly have sentencing discretion. Many people testifying after the DA rebutted his claims, some of which were not based in fact.

House Bill 3121, Senate Bill 779, An Act Related to Parole

A panel of lawyers, activists, and two formerly incarcerated testified about the importance of reforming the broken parole process in Massachusetts without which packed prisons keep expanding. They spoke of how the Parole Board needs more expertise from sociologists, psychologists, addiction and mental health specialists, and juvenile justice experts. In other words, to judge the fate of our prisoners, our Board needs more than criminal justice backgrounds. Two formerly incarcerated men talked of how the process had been daunting and almost impossible to deal with without attorneys. Massachusetts currently has a dismal paroling rate which is also costing the state $53,000 for each prisoner who could be concluding their sentence in the community, going to school, working, and at least aiming to give back to their communities.

H.2248 and H.2249 – bills limiting the use of solitary confinement

Speakers testified regarding a bill to reform (oversee, control and minimize) the use of solitary confinement in Massachusetts jails and prisons. Attorneys, advocated and families of prisoners described its overuse in the Commonwealth; to the long-lasting damage it causes prisoners; and to its utter failure to make prisons or communities safer.

A representative of Maine’s ACLU testified that six years ago Maine passed solitary confinement reforms similar to those proposed in Massachusetts. In that time, Maine reduced the use of solitary confinement by 90%; prisons have become safer; and medical and emergency rooms visits have been reduced.

H719, H720, H721, H2248, H2249 – bills regarding treatment of mentally ill prisoners

Rep. Ruth Balser introduced five bills regarding the treatment of mentally ill and addicted prisoners. Among other measures, she called for Department of Mental Health oversight of mental health services in Department of Corrections facilities.  (These services currently are outsourced to private companies.) The bills generated little discussion. I’d like to believe that this reflects a clear consensus regarding the important issues addressed in the bills.

H 3494 — creating a medical parole board to consider medical release from prison

This bill would allow for early release of people with extremely serious or terminal conditions. Physicians testifying in favor of the bill spoke of paraplegic prisoners, prisoners undergoing intense chemotherapy, and prisoners with blood terminal disorders developing infected sores from the use of shackles. No opposition to the bill was voiced at the hearing.

Two bills regarding women were heard

H.3586 – An act relative to justice-involved women

Representative Kay Khan presented H.3586 which brings together a call for careful collection and analysis of data, policies and programs for justice-involved women.

The bill requires the commissioner to evaluate the program delivery system for existing programming for parenting skills and related training for incarcerated women and the effectiveness of these programs. In my own research I see women repeatedly cycle through programs of various sorts. I have found it near impossible to learn whether these programs are proven effective. Often, no data are available at all. At best, data regarding the completion rates of programs are available. Completion rates, however, do not get at whether programs actually contribute to individuals going on and implementing the skills taught in the program.

The bill also calls on the commissioner to develop programs with a focus on family preservation and reunification. In my research I have seen that a great deal of the programming for justice-involved women encourages women to “put yourself first” and “do you!” Given that the vast majority of justice-involved women are mothers – and that all justice-involved women are daughters, sisters, cousins, etc. – it is appropriate for program emphasis to be placed on family preservation and reunification. Let me be clear, these goals are not simply a matter of instilling the right attitude in women or even teaching them skills. These goals require that concrete, material resources such as appropriate housing are put into place for justice-involved women and their families. Many of these women need affordable housing, comprehensive day care and after school programs, and hiring practices that make it feasible for parents with criminal records to be become employed.

 Senate Bill 770, An Act providing community-based sentencing alternatives for primary caretakers of dependent children who have been convicted of non-violent crimes

Late in the day, way past school pick-up time, dinner time, kids’ bath time and homework time, we got to hear testimony from formerly incarcerated mothers and their children.

When mothers are sent to prison, their children become collateral captives, following their mothers into the institutional circuit and often ending up in foster care or living with an extended family member who may be less able to parent than the incarcerated mother.

In many cases, the children of incarcerated mothers are given into the custody of family members, a scenario that is not without problems. Often, the caregiver is a grandmother who, while well-intentioned, is not physically able to keep up with young children.  Children hear relatives speak ill of their incarcerated mothers, or feel forced into choosing loyalty to their mother or to another family member. In a few cases, custody actually has gone to a family member who sexually abused the mother when she was a child, or who implicitly or explicitly allowed that abuse to go on.

Foster care, of course, carries its own set of problems, ranging from frequent changes and churns to the well-documented overuse of prescribed psychotropic medications. For mothers, separation from children is experienced as a severe and ongoing trauma. These mothers frequently describe feelings of extreme helplessness, powerlessness, guilt, anxiety and panic, often leading to increased prescriptions of psychotropic medication.

The testimony of formerly incarcerated mothers and the testimony of children of incarcerated parents made it clear that it is in the interests of families to keep mothers at home, in the community, with adequate support (except, of course, in those few cases where mothers have engaged in acts of violence.) Creating community based sentencing alternatives for primary caretakers of dependent children will allow many more children to benefit from the on-going presence of their mothers at the same time as it will allow mothers to develop the resources, skills and support networks that they need in order to be effective parents.

This bill, too, has been heard before. Lining up to testify felt a bit like a reunion. Maybe this time we’ll see some real change.

 

Penny and Pound Foolish: Governor Baker’s MassHealth Savings Plan

After running on a campaign of new and smart ways to reduce government spending, Massachusetts Governor Charlie Baker (R) has proposed budget cuts for fiscal year 2016 that are neither new nor smart — going after the low-hanging fruit of government funded Medicaid (MassHealth) for the Commonwealth’s poorest, sickest and most vulnerable residents. Most of the proposed savings to MassHealth in Gov. Baker’s plan are merely a matter of bookkeeping – shifting costs from fiscal year 2016 to fiscal 2017. But the Administration also aims to reduce spending by requiring over one million residents enrolled in MassHealth to prove that they are still eligible. Though the Administration has not provided an estimate of how many ineligible people are enrolled, Baker’s budget team estimates that this move will save the Commonwealth $210 million.

The immediate plan is for the Commonwealth to contact 1.2 million people who were automatically re-enrolled in MassHealth when the Health Connector (‘Exchange’) website experienced technical failures in 2013. Each of these people will receive two letters asking them to reconfirm their eligibility. After 60 days those who do not respond will lose coverage. That may not sound unreasonable, but as a sociologist who works with low income women, I suspect this plan presents disproportionate hardships for residents who do not have permanent addresses or who struggle with understanding government forms and with gathering the required documentation; that is, the people who most need consistent healthcare coverage. Individuals who lose eligibility will be allowed to re-certify in the future, but the immediate effect will be disrupted care and an uptick in expensive emergency department usage.

The scanty information released by Governor Baker’s office indicates three categories of potentially ineligible people who would be eliminated from the MassHealth rolls. The most straightforward are people who still are on MassHealth plans but have moved out of state and receive coverage elsewhere. These people, however, would not seem to account for much spending given that they have other insurance where they actually live so are unlikely to use MassHealth benefits. The second category is people who have had a change in income sufficient to place them over the eligibility threshold. Given the absence of a meaningful economic recovery for low wage workers in Massachusetts, this category likely consists of individuals and families whose current earnings push them marginally over the eligibility line. Switching these people from MassHealth to the heavily subsidized insurance policies that they are eligible for through the Health Connector is unlikely to make much of a difference in the budget.

A third category – people who are purposely cheating or “working the system” — has not been explicitly singled out in statements from the Governor’s office. But given 2010 gubernatorial candidate Charlie Baker’s fake electronic benefit cards that said: “Deval Patrick’s Massachusetts EBT Welfare Card. Swipe me for booze, cash, cigarettes, and/or lottery tickets at taxpayers’ expense,” weeding out Medicaid cheaters certainly lurks behind the call for re-certification. Again, we have no information regarding numbers, but we do know that hunts for fraudulent welfare claims consistently turn up very little cheating and thus very little cost-saving. Last year, for example, Maine Gov. Paul LePage (R) released data intending to prove widespread welfare abuse but in fact showed that 99% of all welfare benefit transactions were legitimate and legal.

The re-certification process in and of itself will be costly. If we calculate (modestly) 15 minutes for a government worker to process a straightforward re-certification, the 1.2 million re-certifications will take approximately 300,000 hours. And if we assume (modestly) a salary of $15 / hour for the workers who process re-certifications, the bureaucratic cost will come to 4.5 million dollars – a substantial chunk of what the Administration is looking to cut from the MassHealth budget and money that surely could be spent in a manner more conducive to protecting the health of Massachusetts’ residents.

These numbers are just an estimate, and I assume the Governor’s staff has more accurate numbers. But even if I’m off by 50%, we’re still looking at a cost cutting plan that is likely to cost the Commonwealth a great deal both in terms of salaries and in terms of health.

For more on the larger picture of  health care coverage click:  Health Insurance Roulette: The House Always Wins