American Journal of Law & Medicine

Combatting Massachusetts's Opioid Epidemic: Reducing the Social Stigma of Addiction through Increased Access to Voluntary Treatment Services and Expansion of Mandatory Clinician Education Programs

INTRODUCTION                                                    836    I. OPIOID ADDICTION: DEFINITION & CAUSES                     838   II. SUDDEN INCREASE IN MEDIA COVERAGE OF OPIOID ADDICTION:        RACIAL IMPLICATIONS                                      840  III. GOVERNOR BAKER'S BILL: STEP                               842   IV. RECOMMENDATION FOR FURTHER ELIMINATING THE OPIOID        EPIDEMIC: MODIFICATION TO BAKER'S BILL                   842       A. CONTINUE TO INCREASE ACCESS TO VOLUNTARY       TREATMENT SERVICES                                        844       B. EXPAND MANDATORY CLINICIAN EDUCATION PROGRAMS          850       C. PROPOSED TEXT FOR AMENDING BAKER'S BILL                853         1. Objective guidelines for police officers         to prevent accusations of racial bias when         declining to charge individuals in         possession of drugs                                     853         2. Specific requirements for clinicians regarding         education of prescription opioids                       855    CONCLUSION                                                   856 

INTRODUCTION

The opioid epidemic is a significant global health problem affecting the health and economy of our nation. (1) Massachusetts currently faces an increasing prescription opioid crisis, resulting in addiction, heroin use, and accidental overdose deaths. (2) While other states are certainly experiencing this same problem, former Massachusetts Governor Deval Patrick declared the problem a Public Health Emergency in 2014. (3) By declaring the opioid epidemic a Public Health Emergency, Governor Patrick took "extraordinary legal action[]," which is normally only invoked for public health issues such as acts of terrorism, epidemics of serious, contagious diseases, and natural disasters. (4) Massachusetts does not define a public health emergency, granting the governor discretion in deciding when to declare such an event. (5)

The National Institute on Drug Abuse estimates that in 2012 approximately 2.1 million people in the United States abused opioid painkillers. (6) Between 2004 and 2015, approximately 6,600 Massachusetts residents died from opioid-related overdoses. (7) And in 2014 alone, there were 1,089 opioid-related overdose deaths in Massachusetts. (8) "Experts cite a number of contributors to the exponential increase in the amount of patients treated with opioids, including providers' inappropriate prescribing or inadequate counseling and monitoring, patients' misuse or abuse of drugs, sharing of pain pills with relatives or friends, [and] 'doctor shopping' to obtain multiple prescriptions.... " While treatment can be an effective means of preventing death in many cases, the majority of people suffering from substance addiction do not receive the treatment that they need. (10) In fact, fewer than twelve percent of those Americans who were addicted to opioids in 2014 received treatment. (11) According to the Massachusetts Department of Public Health, 89% of individuals addicted to opioids do not receive treatment for their addiction, while close to 95% of those surveyed indicated that they personally believed they were not in need of treatment. (12)

In the fall of 2015, Massachusetts Governor Charles Baker proposed a bill to limit the amount of prescription opioids that medical professionals could prescribe to their patients. (13) Specifically, Baker proposed limiting the supply of prescription painkillers to a three-day supply, with few exceptions. (14) On January 13, 2016, the Massachusetts House unanimously passed a bill to address the opioid-crisis, which was similar to Baker's proposal but contained several important differences. (15) Notably, the House's proposal limited the supply of prescription painkillers to seven days, rather than Baker's proposed three-day limit. (16) On March 14, 2016, Baker signed the bill (commonly called "Baker's Bill") into legislation, which adopted the House's seven-day limit for first-time opioid prescriptions, among other provisions designed to improve prevention, treatment, and education of opioid abuse. (17)

The discussion surrounding this legislation has emphasized the "tension between the government's latest effort to stem the epidemic and doctors' belief that they know their patients' needs best." (18) This balance between governmental regulation and individualized medical concerns is certainly not novel, but given the widespread problem of painkiller addiction, many believe this bill is crucial to solving the urgent opioid crisis in Massachusetts.

This paper proceeds in four parts. Part I defines the problem of opioid addiction, examining the underlying causes as well as the significance of the epidemic. Part II discusses the reasons for current attention to the opioid epidemic. Since some argue this is largely due to an increase in the number of white addicts dying, part II considers the possibility of racially motivated reporting. Part III identifies the main provisions of Baker's Bill. (19) Part IV critiques Baker's Bill and proposes two modifications designed to remedy potential problems with the Act: (a) increasing access to voluntary treatment programs, and (b) expanding education and awareness about opioid misuse, particularly for clinicians and those prescribing opioids. Both of these recommendations encourage (and depend upon) shifting the focus on drug addicts from punishment to rehabilitation. (20) Finally, part IV(c) proposes specific textual amendments to Baker's Bill. These amendments suggest objective guidelines for police officers exercising their discretion in connecting addicts with treatment, and address specific, mandatory requirements for clinician education.

I. OPIOID ADDICTION: DEFINITION AND CAUSES

Opioids are painkillers, or medications prescribed by medical professionals to eliminate moderate to severe pain. (21) Common opioids include Vicodin and OxyContin. (22) This class of drugs provides pain relief to an individual by managing the severity of pain signals that are sent to the brain. (23) When an opioid is ingested, it attaches to an opioid receptor, which reduces pain by producing "a sense of well-being and pleasure." (24) Once an individual begins to use prescription drugs continuously over an extended period of time, the drug becomes less effective; thus, the individual often begins increasing the dose in order to feel the drug's effects. (25) This is known as tolerance. (26) When large amounts of opioids are ingested, the chemical can drastically decrease an individual's breathing and level of consciousness. (27) When an individual overdoses on opioids, "the victim becomes unresponsive to stimulation and/or breathing becomes inadequate." (28) While not all opioid overdoses ultimately result in death, many do. (29)

In Massachusetts alone, experts estimate that every day an estimated four people die from an accidental or unintentional opioid overdose. (30) Further, opioid addiction spans all communities, ethnicities, and age groups, affecting males and females, teenagers and adults. (31) Financially, the opioid addiction costs the United States an estimated $125 billion dollars annually. (32) And while prescription opioid addiction on its own is a serious health crisis, four out of every five heroin users were addicted to opioids before they began using heroin. (33)

There are several different and interrelated causes of opioid addiction (and specifically the recent dramatic increase in opioid-related deaths), which further contribute to the difficulty of identifying solutions. (34) Prescription providers, patients' improper or nonmedical use of drugs, and the fragmented health care system as a whole, all play significant roles in increasing access to prescription drugs and addiction. (35)

First, the opioid crisis has resulted largely from an increase in the amount of prescription painkillers that are issued by health care professionals. (36) Addicts are able to either visit multiple doctors or use different methods to obtain painkillers without physicians discovering or even realizing how many prescriptions have been written. (37) Moreover, doctors and other health professionals prescribing opioids often lack the training required to recognize signs of addiction. (38) If doctors lack the requisite knowledge to identify either addicts or those prone to become addicts, they may inadvertently prescribe too much of an opioid. (39) In addition, some prescribers operate "pill mills" by prescribing painkillers inappropriately, in order to make a profit. (40)

Second, pharmaceutical companies have been utilizing "aggressive marketing" strategies to increase sales of prescription drugs. (41) In particular, New Hampshire Attorney General Joseph Foster recently indicated that his office would be investigating the pharmaceutical industry's role in deceptive marketing. (42) Specifically, the investigation sought to examine whether drug companies misleadingly advertised prescription drugs, exaggerating their ability to manage pain and downplaying the risk of addiction. (43)

Third, and finally, there has recently been an increase in "social acceptability for using medications for different purposes." (44) Since prescription painkillers are prescribed by a medical doctor - primarily for the use of pain management - many believe that using these painkillers recreationally and for non-medical purposes is safer than using other drugs. (45) Unfortunately, the risk of developing an addiction to prescription painkillers is dangerous, widespread, and can lead to heroin addiction. (46)

The main concern surrounding opioid addiction is the need to balance the legitimate demand for painkillers with the current abuse and overdose crisis. Lawmakers, health care professionals, and public health officials must confront the increasingly serious problem of opioid addiction, while ensuring that legitimate individuals in need of pain medication have access to an appropriate amount of pain medicine. (47) Approximately 100 million Americans experience chronic pain, demonstrating the widespread need for the legitimate use of opioids. (48) The Massachusetts Medical Society negatively responded to Governor Charlie Baker's proposed bill in Fall 2015, finding that '"[i]t doesn't necessarily allow for the clinical judgment of physicians--to adjust their prescriptions for different patients with different situations.'" (49) The reaction to the amended bill, which provided for a seven, rather than a three-day limit on prescription pills, was more positive; President of the Massachusetts Medical Society Doctor Dennis Dimitri called the new time limit "reasonable." (50) During the first nine months of 2015, there were 791 accidental opioid-overdose deaths, (51) thus prompting Governor Baker to act as quickly as possible in implementing Baker's Bill.

II. SUDDEN INCREASE IN MEDIA COVERAGE OF OPIOID ADDICTION: RACIAL IMPLICATIONS

Although former Massachusetts Governor Patrick declared the opioid epidemic a Public Health Emergency in 2014, opioid addiction is certainly not new. (52) Actually, the opioid crisis arguably began surfacing in the United States during the late 1990s when pharmaceutical companies first promoted OxyContin, advertising it as less addictive and thus prompting its widespread use to manage pain. (5) And yet in 2014, Governor Patrick requested unprecedented legal measures to combat the epidemic. (54) Why was there such a sudden increased interest in opioid addiction, despite a not-so-recent problem? While it is true that opioid-related deaths increased from 338 to 1,173 between 2000 and 2014, (55) according to a study conducted by the Journal of the American Medical Association the percentage of white heroin users increased from approximately 55% of all users in 1960 to 90.3% in 2010. (56) Meanwhile, the percentage of non-white users decreased from approximately 45% in 1960 to 10% in 2010. (57) This drastic increase in the number of white individuals addicted to prescription drugs and heroin has led many to wonder if opioid addiction became more widely publicized--at least in part--because more white people are dying. (58) More generally, death rates for middle-aged white Americans are steadily increasing, according to a study conducted by the 2015 Nobel Memorial Prize Winner in Economic Science, Angus Deaton and his wife, Anne Case. (59) One key contribution to this increase in middle-aged white deaths is substance abuse--including overdoses of prescription opioids. (60)

In October 2015, the Director of the White House Office of National Drug Control Policy Michael Botticelli addressed the opioid (specifically heroin) crisis, commenting on the striking shift from minority to white drug addicts. …

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