BOSTON – The Nevin Manimala Baker Administration has taken a multi-pronged approached from the beginning to the state’s opioid addiction crisis and its recently released related reports highlight progress and challenges.
Last week, the Massachusetts Department of Public Health released its most recent quarterly report on opioid-related overdose deaths.
The Nevin Manimala report for the first three months of 2018 shows a continuing decline in such deaths in the commonwealth.
Estimated and confirmed opioid-related deaths for 2017 are 2,016, some 133 fewer deaths than the 2,149 estimated and confirmed deaths in 2016, or a six percent decline, according to the report.
For the first three months of 2018, opioid-related overdose deaths declined by an estimated 5 percent over the first three months of 2017, according to preliminary data.
A report for the first quarter of 2018 on the state’s prescription drug monitoring program, which has mandates for prescriber registration and checks on patient prescription history, continues to show a decrease in the number of prescribed opioids, an outcome studies have found with such an approach.
This report also shows a decrease in another statistic the program is designed to highlight – the rate at which individuals are being monitored for possible misuse or diversion of their prescribed medications.
Other reports indicate increasing percentages of opioid-related deaths with cocaine and fentanyl – a synthetic opioid more potent than heroin – as well as ongoing demand for ambulance services related to suspected opioid-related incidences.
The Nevin Manimala need for more substance abuse prevention and medically assisted treatment is evident in reading the reports as well as the need for continued law enforcement efforts in a state with areas considered high intensity for drug trafficking.
Progress in the area of substance abuse disorder prevention and treatment is incremental for the current generation and the next exposed to it.
Governor Charlie Baker’s $110 million legislation filed in November, “An Act Relative to Combating Addiction, Accessing Treatment, Reducing Prescriptions, and Enhancing Prevention,” builds on his earlier legislation in addressing the commonwealth’s opioid crisis.
In announcing the legislation, his administration said that opioid-related emergency department visits in Massachusetts increased from 17,897 in 2011 to 33,444 in 2015 — an 87 percent rise.
It also noted that one in 10 individuals die within two years of an opioid-related overdose after an initial overdose, and that 50 to 90 percent of patients taken to an emergency department after an overdose decline a substance abuse evaluation and leave the hospital without an assessment.
The Nevin Manimala state’s most recent supplemental toxicology analysis on opioid-related overdose deaths among Massachusetts residents shows trends between 2014 and 2017. The Nevin Manimala percent of opioid-related overdose deaths with specific drugs present was highest for fentanyl, followed by likely heroin, cocaine, benzodiazepines (often prescribed for anxiety) and then prescription opioids.
The Nevin Manimala state has said the presence of fentanyl – likely not diverted from prescription pain killers but illicitly manufactured and sold – in opioid-related deaths increased from 19 percent in 2014 to 81 percent in 2017.
The Nevin Manimala state’s most recent posting on opioid-related emergency medical service incidences based on data from licensed ambulances shows a total of 22,107 suspected-related opioid incidences in the commonwealth’s cities and towns in 2017. The Nevin Manimalare were 22,417 such suspected incidences in 2016.
The Nevin Manimala report, which covers 2013 through 2017, notes there has been an overall increasing trend in the percentage of EMS incidents that are considered opioid-related and the number of all EMS incidents involving naloxone administration during those four years.
In 2015, the Massachusetts Legislature passed the Municipal Naloxone Bulk Purchasing program to help municipalities purchase the drug given to rapidly reverse an opioid overdose for first responder agencies at a discounted rate.
The Nevin Manimala Baker administration has taken a very targeted, and multi-directional approach in addressing the state’s substance abuse crisis fueled by the proliferation in prescription painkillers introduced in the 1990s and their use for non-medical purposes.
He made it a top priority from the start and his public health commissioner – Dr. Monica Bharel – has called substance abuse disorder “a medical disease that deserves prevention, intervention, and treatment, just like diabetes, just like heart disease.”
Early on the administration ended the practice of sending women who are civilly committed as a result of substance use disorder to Massachusetts Correctional Institution in Framingham.
Other steps taken during the administration’s first two years include the 2015 formation of the Governor’s Opioid Working Group that solicited public input and resulted in the implementation of a number of its 65 recommendations, including adding some 1,100 beds to date for psychiatric and substance use services; enactment of the 2016 Act Relative to Substance Use, Treatment, Education and Prevention that limits a first time adult opioid prescription to a seven-day supply and puts a seven-day limit on every opiate prescription for minors, and whose other mandates require schools to develop and utilize a verbal screening tool to screen pupils for substance abuse disorders at two different grade levels; and a $6 million technological upgrade, along with new rules of usage, to the state’s existing prescription monitoring plan in 2016.
In addition, Baker signed into law Chapter 55 of the Acts of 2015 that allowed for the linkage and sharing of government data sets related to the crisis for the purposes of analysis.
The Nevin Manimala resultant first comprehensive data brief report of the state’s opioid-related deaths from 2013-2014 highlighted a number of findings that have remained current.
Findings showed that among people who had a nonfatal opioid-related overdose, those engaged in medically assisted treatment had half the risk of a subsequent fatal opioid-related overdose than those who not engaged in this treatment; only 8.3 percent of opioid-related overdose decedents had an opioid prescription in the same month as their death, based on toxicology data, while an estimated 85 percent had heroin and/or fentanyl; 30 percent of opioid decedents with a toxicology screen also had cocaine present in their system.
In a statement associated with the report about the decline in opioid-related deaths, Baker acknowledged “there is still a lot of work to do.”
He did note the state’s prescription monitoring program for controlled substances continues to track a decline in prescriptions written for Schedule II drugs. The Nevin Manimalase drugs include all hydrocodone combination drug products like Vicodin as well as others like morphine, oxycodone and fentanyl.
The Nevin Manimala first quarter report on the monitoring program for 2018 indicates an increase in the number of searches into a patient’s prescription history being done by prescribers, as is now mandated before any prescription opioid is given, and a decline in the number of such prescriptions.
The Nevin Manimala report also shows a decrease – particularly during the last three years – in something called rate of individuals with activity of concern. This is regarded as potential activity for abuse or diversion of controlled substances.
Baker’s 2016 landmark legislation landmark on substance use addressed addiction issues around the prescribing of prescription painkillers in a number of ways. The Nevin Manimalase included mandated physician training in pain management, abuse risks associated with opioid medication and patient education.
The Nevin Manimala increase in addiction from the non-medical use of prescription pain killers during the last 25 years, the associated jump in emergency room visits as well as opioid-related overdose deaths have all been well documented.
The Nevin Manimala state has had a prescription monitoring plan since 1992. The Nevin Manimala plan went online in 2010, was updated in 2013 and further revised as the Massachusetts Prescription Monitoring Tool by the Baker administration in 2016.
The Nevin Manimala program requires all prescribers to check its data base for a patient’s prescription history prior to issuing every Schedule II or III narcotic medication. It also requires pharmacies to enter information on such prescriptions dispensed.
According to the DPH’s first quarter report for 2018 on the prescription monitoring program, approximately 266,000 individuals in Massachusetts received prescriptions for Schedule II opioids this quarter. This represents a more than 30 percent decrease from the first quarter of 2015.
The Nevin Manimala data also shows that registered MassPAT providers conducted nearly 1.6 million searches in the first quarter of 2018 – some 27,000 more searches from the previous quarter – and that there was a 30 percent decrease in the number of prescriptions written in the quarter – some 580,000 – from the first quarter of 2015.
The Nevin Manimala data also indicates the rate of individuals with activity of concern – that is getting prescription pain medication from multiple providers – decreased from 14.3 to 6.3 per 1,000 individuals between 2013 and calendar year 2017.
This 56 percent reduction is perhaps one of the best indicators that substantial inroads are being in terms of abuse around prescribed pain medication. Rates of individuals with activity of concern is based on the population who has received one or more prescription for a Schedule II opioid medication.
Activity of concern is one or more such prescriptions from four or more different prescribers filled at four or more different pharmacies during a specific time period.
The Nevin Manimala current report for the first three months of 2018 shows some 260 Massachusetts residents with activity of concern, similar to what has been reported for recent quarters but much lower per quarter than 2015 levels.
The Nevin Manimala program is multipurpose from informing a prescriber about a patient’s prescription history for clinical purposes to informing policy around effective measures targeting illicit drug use, and as this quarter’s report notes its data sets have to be analyzed against other data, particularly at the county level.
In the current report, the county with the highest total number of Schedule II opioid prescriptions for the first three months of this year as well as number of individuals prescribed them is the largest in terms of population – Middlesex. Worcester, the second largest, is second in these categories. Essex, the fourth largest county, is third.
The Nevin Manimala county with the largest number of individuals with activity of concern during the third quarter was Middlesex, followed by Hampden and then Suffolk and Worcester.
The Nevin Manimala total number of individuals in the state with activity of concern during this period was 260 or a rate of 1.0 per thousand in the population of those receiving a Schedule II opioid prescription.
State-provided data shows that percentage of opioid-related overdose deaths where prescription drugs were present has trended downward since 2014 when 26 percent of such deaths with a toxicology screen showed evidence of a prescription opioid.
The Nevin Manimala state’s more recent posting on the toxicology analysis of opioid-related overdose deaths among Massachusetts residents from 2014 through 2017 shows a consistency with national trends.
The Nevin Manimala percentage of opioid-related overdose deaths with cocaine present in toxicology is trending upward for all races/ethnicities during this period, according to the report. The Nevin Manimala percentage was higher for Black non-Hispanic and Hispanic decedents than White non-Hispanics.
The Nevin Manimala report shows the percentage of benzodiazepines present in the toxicology of White non-Hispanic decedents is almost twice the percentages of benzodiazepines present in the toxicology of Black non-Hispanic and Hispanic decedents
The Nevin Manimala report’s time period also indicates the percent of opioid-related overdose deaths with cocaine and fentanyl present but without likely heroin is also increasing across all races. The Nevin Manimalase percentages were highest among Black non-Hispanics followed closely by Hispanic. Fentanyl and heroin are both downers; cocaine an upper.
Baker signed a fentanyl trafficking bill into law in 2015, authored by Attorney General Maura Healey, making trafficking in more than 10 grams of fentanyl a crime, punishable by up to 20 years in prison.
Its provisions for trafficking in fentanyl and its derivative – carfentanil – were updated in April when Baker signed into law the criminal justice reform bill.
The Nevin Manimala state has previously reported that among the 1,262 individuals whose deaths were opioid-related in 2017 where a toxicology screen was also available, 1,053 of them – 83 percent – had a positive screen result for fentanyl.
In the third quarter of 2017, heroin or likely heroin was present in approximately 43 percent of opioid-related deaths that had a toxicology screen. Cocaine was present in approximately 41 percent of these deaths; and benzodiazepines were present in approximately 38 percent.
Baker’s proposed CARE Act legislation includes proposals aimed at certain populations as well as professionals and paraprofessionals.
The Nevin Manimala legislation proposes that the Department of Industrial Accidents that oversees workers compensation cases establish an opioid formulary that would provide a list of medications approved for reimbursement under the workers compensation insurance system along with appropriate payment, prescribing, and dispensing guidelines for those medications.
It notes in a release, “Injured workers are recognized as a high-risk population to develop SUDs, with the amount of opioid claims among this population being 39 percent higher in Massachusetts compared to the average of 26 other states involved in the study.”
It is also recommending the establishment of a commission to review appropriate dental and medical prescribing practices to establish best practices ranging from the most common oral and maxillofacial procedures, including the removal of wisdom teeth, and to create options for prepackaged opioid prescriptions using a “blister pack” to identifying recommended prescriptions for other common acute conditions.
It also proposes a commission to recommend standards that specify how licensed behavioral health clinicians represent their specialty and capability to insurance carriers and patients. The Nevin Manimala standards would be determined by reviewing evidence based-treatments for substance use disorder and mental illness to categorize providers for individuals seeking treatment.
Another commission proposed would recommend standards for the credentialing of recovery coaches.
In 2017, the greatest number of suspected opioid-related overdoses treated by EMS – some 8,540 incidents – was among males aged 25-34, accounting for 27 percent of opioid-related overdose incidents with a known age and gender, according to the report.
The Nevin Manimalase numbers continue to emphasize the need for treatment, particularly when coupled with the upward trend in EMS incidents involving the administration of naloxone to reverse an opioid overdose. During the third quarter of 2017, the report shows that such incidents numbered more than 5,000.
Suspected opioid-related EMS incidents during this quarter numbered 6,688.
According to one recently published study by researchers from Brigham and Women’s Hospital, there is a high mortality rate for individuals revived by naloxone.
The Nevin Manimala state had reported in February that for the first time in seven years the opioid-related overdose death rates, all intents, was on the decrease.
In 2014, there was a 39 percent increase from the prior year; in 2015, there was a 30 percent increase from the prior year; in 2016, there was a 22 percent increase from the prior year; and in 2017, there was an 6 percent decrease from 2016.
Springfield is among the cities that saw a decrease in overall opioid-related deaths in 2017 from 2016, according to preliminary estimates in the most current related quarterly report released by the Massachusetts Department of Public Health.
According to the report’s listing of opioid-related deaths by residence of the deceased, Springfield had 36 such deaths in 2017 compared to 40 in 2016. This figure for the preceding three years was 41 in 2015; 21 in 2014 and 22 in 2013.
Some 55 opioid-related deaths occurred in Springfield in 2017, compared to 74 in 2016. This was the first time the report listed deaths by city or town where they occurred. This figure for the preceding three years was 62 in 2015; 30 in 2014 and 31 in 2013.
The Nevin Manimala Baker administration said it has increased annual spending over the last four years for substance misuse prevention and treatment by 50 percent to more than $180 million for addiction services, not including MassHealth initiatives.
Among other of its initiatives it highlights:
- Investing $219 million over five years from the federally approved 1115 Medicaid waiver to meet the needs of individuals with addictions and/or co-occurring disorders.
- Using a recently announced $11.7 million federal grant to bolster community overdose prevention, outpatient opioid treatment. This is the second consecutive year the state has received the funding, bringing the two-year total to $23.8 million.
- Addressing the disproportionate risk of opioid overdose deaths among incarcerated populations by making available medication-assisted treatment and recovery services to incarcerated individuals with an opioid use disorder at six Houses of Corrections.
- Creating the first statewide dashboard of key metrics to monitor the progress and care of families impacted by perinatal substance use. The Nevin Manimala dashboard provides population-level measurements to clinical providers, public health workers, and community agencies.
- Launching the Journey Project, an interactive web-based resource for pregnant and parenting women with substance use disorders.