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Testimony: Involuntary Treatment for Substance Use Disorder, Senate Democratic Policy Committee

Statement of The Hospital and Healthsystem Association of Pennsylvania

For the

Senate Democratic Policy Committee

Submitted by
Michael Consuelos, MD
Senior Vice President for Clinical Integration

Pittsburgh, Pennsylvania
December 8, 2017

Leader Costa, Madam Chair, Members of the Senate Democratic Policy Committee, on behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), thank you for inviting us to speak on the issue of involuntary treatment as a means to battle the commonwealth’s opioid epidemic. My name is Dr. Michael Consuelos, and I am the senior vice president for clinical integration at HAP. HAP represents and advocates for nearly 240 acute and specialty care hospitals and health systems across the commonwealth.

Joining me today are Dr. Mitchell West and Stuart Fisk from the Allegheny Health Network and Dr. Michael Lynch from UPMC. They will be sharing their professional and clinical insights throughout this panel presentation.

Policymakers, community leaders, and health care providers throughout the commonwealth and across the country are grappling with the impact of the opioid crisis. And, we all want to provide meaningful solutions for individuals suffering from addiction and support to their families.

Alongside our member organizations, including the Allegheny Health Network and UPMC who are joining me today, we are fighting the opioid epidemic in numerous ways. More specifically, we have advanced prescribing guidelines, we continue to support the use of Medically Assisted Treatment (MAT), and are facilitating regional efforts to stem the abuse of opioids such as the South Central PA Opioid Awareness Coalition.

Every day, hospitals and health systems work with key stakeholders to adopt meaningful policy changes to improve our collective response to the opioid epidemic. Our common priorities include:

  • Preventing new cases of opioid addiction by promoting safe prescribing, and implementing the state’s prescription drug monitoring program
  • Treating people who are already addicted by expanding access to treatment and recovery
  • Increasing access to life-saving overdose medications
  • Focusing care for moms and infants impacted by opioid abuse
  • Reducing the supply of opioids in our communities

I think we can all agree that a one-size-fits-all approach does not address the complexity of opioid abuse, but rather the implementation of community-specific best practices.

The hospital community is here and available to be a resource and partner with you in addressing this nationwide health crisis. In doing so, we hope to provide helpful guidance about the legislation being discussed here today––guidance that is based on the collective perspective of Pennsylvania’s top clinical professionals.

HAP has reviewed each of the legislative proposals on involuntary treatment that have been introduced, including the current amendment to Senate Bill 391. In doing so, we heard consistently from our members, that the commonwealth must understand that there is no research that supports involuntary treatment as a viable path to reducing overdose deaths.

The proposal that is the focus of this hearing would amend the Pennsylvania Drug and Alcohol Abuse Control Act to allow for involuntary examination and treatment under certain circumstances. More specifically, it mirrors the process enumerated within the Mental Health Procedures Act.

While we appreciate the intent of the amendment and the effort to protect individuals who suffer from substance use disorder from being criminalized, the hospital community still has significant concerns about the amendment. Substance abuse is a disease and should be treated as such. All good evidence points to voluntary entry into treatment as the most efficacious road to recovery.

When considering involuntary treatment legislation for substance abuse, state policymakers must consider the following key points:

Key Clinical Concerns regarding Involuntary Treatment

  • There is no published medical evidence that shows involuntary treatment for opioid abuse disorder is efficacious. In fact, there are concerns that the addict may actually be at higher risk of overdose after an involuntary period of abstinence since their tolerance is reduced. Investigators have published studies that show increased risk for overdose deaths after 28-day detox and rehab stays (Gossop et al. 1989 and Strang Et Al. 2003).
  • A 2007 study published in the New England Journal of Medicine (Binswanger et el.) found that inmates were 129 more times more likely to die of overdose than the general public during the first two weeks after release from prison. This has recently been replicated by Massachusetts in its report entitled, “An Assessment of Fatal and Nonfatal Opioid Overdoses in Massachusetts” (2011–2015), which showed that the risk of opioid overdose increased by 120 times after prison release. Prison is seen as an involuntary abstinence treatment regimen.
  • Involuntary inpatient treatment should only be considered after all other possible treatments have been considered and an overdose alone should not be an automatic trigger.

The hospital emergency department (ED) is not the right place to hold individuals awaiting involuntary treatment. The ED is the place to initiate a “warm-handoff” to local treatment providers. Physicians also are investigating the introduction of MAT in the ED to decrease the immediate need to use opioids after an overdose and while the patient is awaiting placement in a treatment program.

Ensuring Sufficient State/Federal Resources

  • The most common frustration for families seeking treatment for their loved ones is the lack of treatment options and the long waiting lists for inpatient facilities. Medical providers share that same concern.
  • Increasing the number of individuals placed in facilities as a result of involuntary treatment will only worsen this challenge. Further, it will place those patients who actually want to receive treatment for their addiction at tremendous risk––their wait for the treatment they need could become much longer.
  • While the intent of the proposed amendment is to rely on a process that will not flood an already stressed system, it does not ensure that there will be sufficient capacity for patients seeking treatment voluntarily and for individuals forced to receive care.

Whether it is treatment for opioid addiction or essential services for other behavioral health diagnoses, the commonwealth must invest additional financial resources to bolster the ability of hospitals and all other health care providers to care for patients with behavioral health needs.

Programming, Staffing and Facility Challenges

  • A patient recovering from an overdose may have any number of different reactions to the care being provided to him or her. Determining exactly what staff or room configuration may be needed to care for an overdose patient can be extremely difficult.
  • In almost all cases, hospitals are not equipped to safely hold patients who are being forced into involuntary treatment. For instance, for extreme cases, most hospitals have very limited facilities to “lock” in patients to ensure their safety as well as the safety of other patients in a hospital.
  • In addition to facility challenges, hospitals may not have ready access to staff with the expertise to provide the wide range of care that may be needed for an overdose patient who is facing forced treatment. This could include clinical staff or security personnel.

Budget and Cost Concerns

  • In many cases, families will bear the cost of involuntary treatment and legal fees associated with the process. For example, Ohio has had Casey’s Law (Involuntary Commitment for drug abuse) in place since 2012, and it is our understanding that it is rarely used due to these costs.
  • It is unclear as to how state, federal and commercial insurance plans might provide at least partial coverage for patients waiting in a hospital setting for involuntary examination and treatment. Ensuring that available coverage is maximized is critically important.

In conclusion, while the hospital community cannot support the amendment to Senate Bill 391 as drafted, we remain committed to partnering with the commonwealth in fighting the opioid crisis. Thank you again for the opportunity to share our thoughts on this legislation. We welcome any questions you might have.

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Topics: State Advocacy, Substance Use Disorder

Revision Date: 12/8/2017

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