Council attempts to correct past errors with opioid treatment bill

For many years, community health advocates, substance use disorder counselors and health care providers have decried the antiquated laws and stigma that have thwarted their efforts to reduce opioid addiction in the District. As The Washington Post recently reported, over the past year 279 people died of opioid overdoses in the District, with more than 70 percent of the cases involving fentanyl.

In September 2017, DC Council member Vincent Gray, chair of the Committee on Health, sought to modernize the city’s approach with the introduction of the Opioid Abuse Treatment Act of 2017, drawing initial support from Chairman Phil Mendelson and Council members Charles Allen, Anita Bonds, Mary Cheh, Jack Evans, David Grosso, Kenyan McDuffie, Brianne Nadeau, Robert White Jr. and Trayon White Sr. After a 15-month wait, the bill — now called the Opioid Overdose Treatment and Prevention Omnibus Act of 2018 — won approval in December, with unanimous votes at the council’s final two meetings of the year.

Allen, Ward 6 council member and chair of the Committee on the Judiciary and Public Safety, tweeted on Dec. 17 about the impact of the opioid epidemic. “The scope of this challenge is massive. Nationally, it’s estimated 650,000 will die over the next 10 years from opioid overdoses. Picture that if you can … a group nearly the size of DC’s entire population will die in the next decade from opioid overdoses.”

The legislation appears to be in tandem with the subsequent release by Mayor Muriel Bowser and the DC Department of Behavioral Health of a strategic plan dubbed “LIVE. LONG. DC.” The plan aims to discourage opioid use and misuse in the District and to reduce opioid-related deaths by 50 percent by 2020. “This plan was created in response to the specific needs of our community and focuses our resources on increasing awareness and prevention, enhancing treatment offerings, and strengthening recovery supports,” the mayor says in a Dec. 24 news release.

The opioid epidemic in the District has been quietly fought among black men in DC for many years. Efforts to reduce dependency and stigma have been stagnant at best. The bill shows a more aggressive approach to the crisis and addresses many key issues, including eliminating requirements for prior authorization and for step therapy, which has patients start with lower-priced treatment before turning to more costly but effective measures; increasing coverage for treatment for Medicaid-dependent patients; changing hospital discharge protocols; and decriminalizing possession of fentanyl testing kits. Implementation of the bill will require a budget allocation of $332,000 over a four-year period to fund an annual report on the District’s treatment capacity and any gaps therein, according to the fiscal analysis prepared by the DC chief financial officer.

Red tape has blocked many Medicaid patients from accessing treatment options. The bill removes the current requirement for a patient to obtain prior approval from their Medicaid provider before obtaining medications with buprenorphine/naloxone. These approvals have expiration dates and can take days to go into effect.

Nekia White, a licensed clinical social worker with Unity Health Care, testified in December 2017 about the detrimental effects of these practices to the recovery process: She and others repeatedly see “patients who have finally decided to pursue recovery or who are already active in recovery and have their prescriptions in hand only to be frustrated because the pharmacy is unable to release the medicine they need due to a prior authorization that has yet to be approved.”

“I have encountered this scenario too many times in my experience with prior authorizations,” White said.

Many people who suffer from substance use disorder in DC and seek treatment are subjected to step therapy, a method criticized by the American Medical Association. Step therapy is a process in which opioid dependent patients must show failed response to less expensive treatments before gaining approval to try more costly ones. For some patients time is of the essence and repeated trials with ineffective treatments can be discouraging.

A key entry point for treatment is the emergency room. According to a study in the Journal of the American Medical Association, emergency room intervention that included buprenorphine treatment “significantly increased engagement in addiction treatment.” Section 14 of the bill is aimed at improving hospital discharge procedures for patients who have been treated for a drug overdose. Traditionally, patients are given a list of treatment providers to contact after they are discharged. The bill proposes that, in addition to a treatment referral, patients be provided with a prescription for naloxone, an intranasal spray that reverses opiate overdoses, before leaving the hospital facility.

Dr. Corina Freitas, family physician and psychiatrist-in-training at the DC Department of Behavioral Health (DBH), expressed concern about hospital discharge protocol. In testimony before the committee she stated that “discharge protocols already exist such as DBH’s Assessment and Referral Center for directing patients towards a specific clinic. However, this neither constitutes nor ensures clinically appropriate follow-up and at times is not practically feasible for a clinic to accept more patients. Thus we suggest requiring hospitals to ensure proper follow-up post discharge by making an appointment for the interested patient prior to discharge.” Section 103 of the bill now proposes that by “January 2020 hospitals develop protocols that include identification, treatment, discharge, and referral of patients with opioid use disorder.”

From the public health side, the bill provides for decriminalizing drug-testing kits that are utilized to check for the presence of fentanyl in a drug supply. Under District law, drug kits — a popular harm reduction tool — are considered paraphernalia and are illegal. This hampers syringe exchange programs, which aim to lower the risk of overdoses. The council adopted emergency legislation in 2017 that allowed nonprofits such as Helping Individual Prostitutes Survive (HIPS) to distribute drug kits, but it is set to expire on March 20. The same provisions, however, are included in the permanent bill the council approved last month.

At the Health Committee’s Nov. 28 markup of the bill, Grosso highlighted the bill’s focus on public health rather than criminalization, according to the committee report. “We need to double down on our efforts to make targeted investments in proven treatment and prevention solutions,” he said.

Even with passage of the Opioid Overdose Treatment and Prevention Omnibus Act, Allen acknowledged that there’s more work to be done on this issue, although he does see it as a step forward. “This isn’t the only answer, but is part of a smart & strong response to opioid use disorders in the District,” he tweeted.