New law limits opioid prescribing to 7 day supply

Calling it the most comprehensive state measure to date in combating the opioid addiction and overdose crisis, Massachusetts Gov. Charlie Baker this week signed legislation that in its final form reflected the art of the compromise. The new law now mandates substance abuse evaluation after overdose and limits initial prescriptions of opioids to seven-day supplies.

The governor received less than he originally sought, but a leader in the state's addiction treatment community says Baker largely succeeded in beginning to change the conversation about opioid prescribing and its consequences for some.

“The governor had said that his proposals were ideas intended to move the needle on the issue, and that this is about doing something different,” says Raymond Tamasi, president and CEO of Gosnold on Cape Cod.

Tamasi last year served on a governor-supported task force that issued recommendations that have formed the basis for numerous Baker administration initiatives, including the legislation he submitted for state lawmakers' consideration. Tamasi says that more than half of the task force's 65 recommendations have been implemented so far.

Services for survivors

What appears to have been the most hotly debated component of the legislation in recent weeks involved the attempt to engage more opioid overdose survivors in treatment services. Baker originally proposed allowing for 72-hour holds of persons with substance use disorders who pose a danger to self or others, much in the same way that short-term mental health commitments are allowed in the state. The final legislation instead mandates that patients treated for overdose in hospital emergency rooms receive a substance abuse evaluation within 24 hours and be presented with treatment options that they could pursue post-discharge.

Tamasi says the main concerns over the 72-hour hold proposal were logistical in nature, primarily over whether the addiction treatment community would have the capacity to serve an influx of newly identified patients in a timely fashion. He believes that what will evolve in the state will be a move to place addiction specialists in emergency settings for evaluations, something that Gosnold already is implementing at two hospitals.

Tamasi adds that Gosnold also is working with 15 local police departments as the law enforcement agencies shift their approach to addressing opioid use in their communities. Under this effort, he says, staff recovery specialists with Gosnold (generally not licensed clinicians) usually meet individuals and their families in their home settings and seek to engage them at a time when they may be ambivalent about treatment.

He says of the potential success of these types of approaches, “A lot depends on the skill set of the person seeking to engage the individual.”

Tamasi adds that the new law's provision on hospital emergency services also “engages the hospitals in a more meaningful way.” However, “I'm not sure it's going to produce tons of people saying, 'I want to go to treatment,'” he adds.

Reducing opioid supply

The other high-profile element of the new law will limit writers of initial prescriptions of opioids to prescribing a seven-day supply; the governor's original proposal was for a three-day maximum. Tamasi characterizes this provision as a good first step.

“It gets us away from the situation where a patient goes in for a tooth extraction and ends up with a month's worth of Vicodin,” he says.

Tamasi believes the provision will be effective, insofar as overly aggressive opioid prescribing has been a major contributing factor to the prescription opioid and heroin crises across the country.

Other provisions in the new law include training initiatives for the healthcare and law enforcement communities, as well as a requirement that local school districts adopt drug prevention policies and assess students' substance abuse risk.

Does it go far enough?

Given that some of the concerns about the effects of a 72-hour hold centered on a lack of treatment capacity in the state, does the governor's claim that this is the most comprehensive state legislation in the nation hold up? Some treatment leaders want to see more direct investment in treatment services.

Tamasi says, “This legislation comes with the intention of committing the resources to support it.”

Yet he also warns that the answer to the opioid crisis involves more than adding bed capacity, and should include broadening the system of care so that individuals are receiving the community-based support they need to sustain recovery.

Of the 22,000 detox admissions in the state last year, Tamasi points out, more than 9,000 were individuals with multiple admissions. More detox beds and more treatment slots certainly won't cure all, he suggests.