2019 MDDCSAM Legislative Wrap-Up

by Joe Adams, M.D. Chair, MDDCSAM Public Policy Committee

MDDCSAM members provided written and oral testimony on the bills listed:

Public Health - Prescription Drug Monitoring Program – Revisions:    PASSED

PDMP:   HB 25 / SB 195 Del Barron / Sen Kelley. 

This bill requires the Prescription Drug Monitoring Program (PDMP) to identify possible misuse or abuse of a monitored drug and report these findings to the prescriber, and may seek input from the program’s Technical Advisory Committee (TAC).   

The program is also now required to identify possible violations of law or breaches of professional standards, with input from the TAC on methods to identify these, and to provide education to the prescriber in these cases.  If the program has determined that outreach and education to the prescriber has been inadequate to address these, the program may refer these cases to the Office of Controlled Substances Administration (OCSA) for investigation.    The TAC has 10 days to review the case before referral to OCSA.  If OCSA finds a violation or breach, it may take corrective action, such as revoking a Controlled and Dangerous Substances (CDS) license, and may refer the case to a licensing entity such as the Board of Physicians.

The bill was the culmination of several years of effort to modernize the program, with collaboration between MDDCSAM, The Maryland Dept of Health, MedChi and other stakeholders.   This bill provided, for the first time, the ability to meaningfully identify and address problematic over-prescribing of opioids (and benzodiazepines) which continue to drive the opioid epidemic to a significant extent.  Much depends on the ongoing development of methods for identifying patterns of problematic prescribing and also effective methods of education and feedback to prescribers.   Researchers at Johns Hopkins are refining methods for identifying problematic prescribing, and Vanderbilt University is helping to develop educational methods in Maryland that have shown promise in improving prescribing practices.  MDDCSAM members are monitoring these exciting developments through the PDMP Advisory Board, meetings of which are open to the public.   The number of opioid prescriptions in Maryland has decreased by 23% between 2016 and 2018 similar to national trends, but the rate is still about three times higher than baseline per capita rate in 1990s.

Correctional Services - Opioid Use Disorder Examinations (OUD) and Treatment:      PASSED

House Bill 116/Senate Bill 846  Del Barron / Sen West

This bill was a huge victory, putting Maryland in the forefront of this national effort, second only to Rhode Island, for providing OUD treatment “Behind the Walls’    It requires access to all three FDA approved medications for the treatment of OUD, whichever is most appropriate as determined by medical personnel, with addiction counseling at the level of community standards.  When fully implemented in January 2023 this will apply to jails and local correctional facilities state-wide, but not to state prisons. 

Four counties volunteered to be first to roll this out:  Howard, Montgomery, Prince George’s and St. Mary’s.    The State will pay for these services in part with funds from federal sources.  MDDCSAM played an essential role in the negotiations on the bill, and participated in a series of preliminary work groups. 


The bill promises to change forced opioid withdrawal, untreated OUD in prisoners, and preventable overdose deaths in returning citizens.  One quarter to one third of adults with OUD cycle in and out of incarceration every year;  this creates an opportunity and a challenge.   We are encouraging treatment providers to develop relationships with staff at the Governor’s Office on Crime Control and Prevention and the Maryland Correctional Administrators Association to provide assistance as the local detention centers explore how to meet the new demand for treatment.   There will be an ongoing need for advocacy to guide the implementation and educational opportunities for detention center staff. 

In Rhode Island, after the implementation of MAT for OUD in incarcerated individuals, and a system for continuing treatment after release, the percentage of people with fatal overdoses who had been recently incarcerated declined from 14.5% to 5.7%, a 60% decline in mortality. 

Green, T et al. Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System JAMA Psychiatry. 2018;75(4):405-407

Medical Cannabis - Provider Applications - Opioid Use Disorder:   FAILED

House Bill 33/Senate Bill 893    Del Glenn / Sen Zirkin

Again the legislature considered a bill that would add OUD to the list of qualifying conditions for treatment with medical cannabis.   MDDCSAM led the opposition with help from many members and supporters through an effective Action Alert.  The House Health and Government Operations Committee did not vote on the measure.  Amendments in the Senate Judicial Proceedings Committee allowed medical cannabis for OUD treatment only if the patient had tried all other traditional treatments and was unsuccessful, or if the patient would use cannabis in conjunction with traditional therapies.  MDDCSAM felt that the effect of any listing of OUD as a potential qualifying condition for medical cannabis could be interpreted as promoting or endorsing it.  We helped the legislators understand that, at this time, there is no evidence that cannabis is effective for OUD.  

There was confusion on this point because there has been a decline in prescription opioids, and opioid overdoses, in medical cannabis states compared to other states.  But this is consistent with possible effectiveness for pain, or possibly preventing opioid use in pain patients, a promising finding in itself.   One of the authors of the study that described these findings, Colleen Barry Ph.D. of the Hopkins Bloomberg School of Health, said,  “. . . my colleagues and I found that the annual rate of opioid overdose deaths decreased substantially — by 25 percent on average — following medical marijuana laws, compared to states that still had bans.  Our study should not be used to tout the use of marijuana to treat opioid addiction, a particularly upsetting misinterpretation.   (‘Overdoses Fell with Medical Marijuana Legalization’    New York Times, April 26, 2016).   Other data shows an association between marijuana use and opioid use disorder on an individual level, and the lack of evidence for medical cannabis for OUD was supported by a new report by the Maryland Medical Cannabis Commission.

During the Senate hearing a 2018 article was cited: ‘Emerging Evidence for Cannabis' Role in Opioid Use Disorder’  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135562/ in the journal Cannabis Cannabinoid Research.  But on review MDDCSAM concluded that this conclusion was not supported.   Also, relapse to opioid use is common in early recovery, and unlike approved treatments, cannabis would not protect against overdose and could increase overdose deaths. 

Unrelated to the above, there will be a legislative effort in the 2020 General Assembly session for cannabis legalization, likely in the form of enabling a ballot initiative in November 2020.  This is related to pressure to make up a projected budget shortfall.  Legislative leadership also announced a new Senate/House workgroup to examine issues around legalization, and MDDCSAM will be participating in these discussions.

Health Insurance Coverage for Mental Health Benefits and Substance Use Disorder Benefits – Treatment Criteria:     PASSED

HB 599  / SB 631  Del Kelly/ Sen Augustine

The original bill would have required commercial carriers in Maryland to file annual parity compliance reports measuring adequacy of behavioral health provider networks, etc.   Carriers are noncompliant with the law that requires parity between behavioral health and somatic treatment, and MDDCSAM, as a member of the ‘Parity At 10’ Coalition https://parityat10.org supported the bill along with many behavioral health stakeholders.

These provisions were removed and the bill that passed required carriers to use the ASAM Criteria for all medical necessity and utilization management determinations for substance use benefits, for the first time in Maryland, a standard required in many other states.   This is an important development since it prohibits seemingly arbitrarily denial of SUD treatment as “not medically necessary” in a manner that is not transparent. 

Health Insurance – Payments to Non-contracting Specialists and Non-contracting Non-physician Specialists:   FAILED

House Bill 837/Senate Bill 761   Del Sample-Hughes / Sen Klausmeier

This was the other bill introduced at the request of the Parity at 10 Coalition, intended as an incentive to carriers to expand their networks by requiring a specific reimbursement rate for approved out-of-network SUD and mental health services.  Addressing this problem was a specific recommendation in the Governor Hogan’s Opioid Taskforce.   MDDCSAM will continue to participate as a member of the Parity at 10 Coalition as legislative leaders have committed to continue to work on this issue, and there will likely be meetings with legislators and the Maryland Insurance Administration on these important issues. 

Maryland Medical Assistance Program - Managed Care Organizations - Behavioral Health Services AKA the “Carve-In bill”:   WITHDRAWN

House Bill 846/Senate Bill 482   Del R. Lewis / Sen Kelley

This was an effort by the Managed Care Organizations (MCOSs) to eliminate the Public Behavioral Health System in Maryland, i.e. to end the existing carve-out in Medicaid and have all SUD and mental health services managed by ten separate MCOs, along with somatic treatment.   This was brought to the attention of the Behavioral Health Coalition, of which MDDCSAM is a member,  by the MCOs in January who offered to take providers’ concerns into consideration as possible amendments to the bill that they had been working on, according to them, with Maryland Department of Health (MDH) Secretary Robert Neall for several months.    MDDCSAM opposed the bill, along with most other members of the Maryland Behavioral Health Coalition.

The Coalition responded by having two other bills introduced, one which offered a managed behavioral health system as an alternative structure to consider:  And the other to create a workgroup to look at ways to improve and measure the outcomes of the system

All of the three bills were withdrawn.  The first alternative bill was HB 938/SB 975 – Behavioral Health Transformation Act of 2019.    The Workgroup bill was  HB 941/SB 976 – Public Behavioral Health System - Implementation Plans to Improve Efficiency, Accountability, and Outcomes – Workgroup.

It was felt that such a large structural change needed much more discussion and input from stakeholders.

MDDCSAM expressing support for a stakeholder process that would examine the current system and identify ways to make improvements, and if need be, change how the system is financed and administered.   MDDCSAM will continue to work as a member of the Behavioral Health Coalition throughout the year in preparation for these issues returning in 2020. 

Public Health - Overdose and Infectious Disease Prevention Site Program  -  WITHDRAWN

House Bill 139/Senate Bill 135    Del Joseline Peña-Melnyk. / Sen Feldman.

AKA ‘Supervised Consumption Sites’ or ‘Safe Injection Sites.’  MDDCSAM communicated the potentially profound potential of these sites to help many more people engage in treatment.   The great majority of people with SUD are not in treatment in part because of lack of treatment availability, but also in large part because of a feature of SUD itself, that many of those affected are not fully ready to change.  Around the world over one hundred of these facilities have been effective at keeping people alive and also providing services to people in all states of readiness – including precontemplation – in ways that people are ready to accept.    Over time this leads to many people becoming ready to accept more help.     While these bills were withdrawn, there is growing interest in this and other harm reduction strategies among legislators.  Delegate Joseline Peña-Melnyk, made it clear she is interested in helping her colleagues learn more about this strategy during the interim.  MDDCSAM worked along with the Maryland Harm Reduction Coalition to support these bills.  

Medical Directors Bills: Public Health - Opioid Maintenance Therapy Programs – Medical Director Requirement and Qualifications   House Bill 35:      WITHDRAWN

Outpatient Mental Health Centers – Medical Directors – Telehealth:  PASSED

House Bill 570/Senate Bill 178

There were two bills introduced dealing with community-based provider medical directors. HB 35 was specific to changing required qualifications for medical director of opioid treatment programs (OTPs). The Maryland Association for the Treatment of Opioid Dependence (MATOD) took the lead in trying to work with the sponsor of the bill and requested a meeting with the Behavioral Health Administration (BHA) to discuss regulatory changes to the qualification requirements instead of putting them in statute.

In addition, HB 570/SB 178 was intended to allow medical directors to satisfy any regulatory requirement to be onsite through the use of telehealth. The bill as introduced would have applied to outpatient mental health centers (OMHCs) as well as OTPs. In the last few days of Session, legislators from Baltimore City started proposing amendments because they believed the bill would remove accountability from the small number of OTPs they have concerns about. After much discussion, the bill was amended to apply only to OMHCs as the use of telehealth more meaningfully addresses workforce shortages in those clinics as opposed to in OTPs.

There appears to be a renewed and significant interest among several City legislators to better understand how OTPs are regulated and to what entities complaints and concerns from the community should be directed. As many community concerns are often based on a lack of understanding of the medications used in treating substance use disorders, having MDDCSAM’s expertise could be valuable.

Maryland Medical Assistance Program - Coverage - Hepatitis C Drugs  -  PASSED

House Bill 962/Senate Bill 598    Del Wilkins  /  Sen Nathan-Pulliam

This legislation requires Maryland Medicaid to provide treatment to enrollees who test positive for Hepatitis C, regardless of fibrosis score, which is a severity measure currently used in eligibility determination. While the bill’s mandate is subject to budget limitations, the General Assembly also fenced off $1.3 million within the Medicaid budget to be used for this purpose. The amount is based on the fiscal note to the bill, which is based on information from MDH.   Governor Hogan had already provided funding in the budget to lower the fibrosis score restriction to F-1 beginning July 1, 2019. The Governor has discretion as to whether or not to spend the $1.3 million that the legislature fenced off. Public pressure will be needed to ensure that all people enrolled in Medicaid have access to the cure.

 


HIGHLIGHTS OF LEGISLATION EVALUATED BY MDDCSAM IN 2018
by Joe Adams, M.D. Chair, MDDCSAM Public Policy Committee
April 12, 2018

The following are from the Maryland General Assembly in 2018, unless otherwise noted.


House Bill 88 / Senate Bill 1083 Public Health - Prescription Drug Monitoring Program - Revisions - FAILED
The bill failed since different versions were passed in the House and Senate which were not reconciled.
MDDCSAM provided oral and written testimony in SUPPORT WITH AMENDMENTS. 
Briefly, MDDCSAM wanted to see current law strengthened so that the PDMP data could be utilized more effectively to address the opioid epidemic by reducing over-prescribing. Maryland is unusual among the states in the number of barriers preventing utilization of PDMP data. MDDCSAM wanted to slightly limit the role of the Technical Advisory Committee (TAC) so that failure of the capacity of the TAC to review each case would not necessarily prevent reporting to professional boards. Other provider organizations wanted to change a standard of "possible breach of professional standards" to "probable breach..." in some circumstances, which MDDCSAM opposed. MDDCSAM attempted to allow the program to use "patterns of prescribing strongly associated with overdose deaths" as a basis for possible feedback and education to prescribers, instead of just "possible misuse or abuse" of controlled substances, i.e. doctor shopping on the part of patients. MDDCSAM agreed with other provider groups (1) in opposing reporting of PDMP data to the Office of Controlled Substances Administration (OCSA, which is like the state's version of the DEA, staffed by pharmacists, with jurisdiction over CDS licenses), (2), in opposing reporting of PDMP data to local health officers, and (3) in opposing unsolicited reporting of PDMP data to law enforcement.


HOUSE BILL 161 Budget Reconciliation and Financing Act of 2018 - PASSED
Appropriations Committee
MDDCSAM provided oral and written testimony in the Appropriations Committee to SUPPORT WITH AMENDMENT to restore the 3.5% funding increase for community behavioral health programs, which had been originally enacted in last year’s HOPE act. 
This level of funding was restored.


HB 922 Maryland Department of Health – “Pill Mill” Tip Line - PASSED
MDDCSAM provided oral and written testimony to SUPPORT with a minor amendment. Originally the bill would direct the MD Dept of Health to establish a Tip Line for anonymous reporting of possible over-prescribing to be investigated by the appropriate licensing board. As passed, the Department will identify a method for establishing a Tip Line for this purpose, with the information forwarded to the appropriate licensing board. The bill passed with two additional amendments: (1) the Secretary of Health will conduct an extensive review of data on individuals who suffered fatal overdoses involving opiates and other controlled substances, utilizing the records of numerous state agencies, and report the findings, including utilization of various services, with recommendations, every year beginning in July 2019.
And (2) that the MD Dept of Health examine the feasibility of establishing a Hub and Spoke model program in the state, and report findings by January 2019.


HB 1092 / SB 703 Behavioral Health Crisis Response Grant Program – Establishment - PASSED
MDDCSAM provided oral and written testimony in SUPPORT.
The final bill directs the MD Dept of Health to award grants to local behavioral health authorities to expand and develop behavioral health crisis response programs, with funds to supplement, not supplant, other funding, with $3 million, $4 million, and $5 million per year for three years: 2020 to 2022.


SB 835 Maryland Medical Assistance Program - Collaborative Care Pilot Program - PASSED
MDDCSAM provided oral and written testimony in SUPPORT WITH AMENDMENT.
Provides $550,000 per year for four years to establish a Collaborative Care Pilot Program by the MD Dept of Health for Health Choice patients in primary care, in up to 3 sites. The original bill established psychiatric reviews and consultation by a psychiatrist. Our recommended amendment was essentially adopted, providing for psychiatric and substance use disorder reviews and consultation by a psychiatrist, an addiction medicine specialist, or other behavioral health medicine specialists.


HB 1744 Child Abuse and Neglect – Substance Exposed Newborns – Reporting - PASSED
MDDCSAM offered oral and written testimony OPPOSED
The bill removes the current exemption in which women who deliver substance-exposed babies do not need to be reported to Social Services if they are getting MAT for SUD.
This expanded reporting is now required by federal law. MDDCSAM, with other advocates, proposed amendments providing that an investigation/home visit by the local Dept of Social Services would not be required in certain cases, but the amendment was not adopted. Takes effect June 2018. (Treatment providers should ideally inform pregnant women about this routine reporting to the local Dept of Social Services, and encourage them to remain in treatment. Providers should also probably reach out to their local DSS office to make sure they understand the use of MAT).


SB 765 / HB 772 MD Medical Assistance Program - Clinical Services Provided by Certified Peer Recovery Specialists Workgroup and Report - PASSED
MDDCSAM provided oral and written testimony in SUPPORT of the original bill which would have had the Medical Assistance Program provide clinical services by Certified Peer Recovery Specialists. As amended, the bill directs the Secretary of Health to convene a stakeholder workgroup to make recommendations related to reimbursement of certified peer recovery specialists, with a report by December 2018.


SB 288 Public Health - Overdose and Infectious Disease Prevention Supervised Drug Consumption Facility Program - FAILED
MDDCSAM provided oral and written testimony in SUPPORT.
Would have provided for community-based organizations to be able to establish Overdose and Infectious Disease Prevention Supervised Drug Consumption Facility Programs, in which people with SUD would bring in their own drugs to use in a supervised setting. MDDCSAM felt that this would help decrease overdoses, would decrease stigma, and would help some participating people to be successfully referred to SUD treatment, in this difficult-to-reach population.


HB1452  Controlled Dangerous Substances Registration - Authorized Providers - Continuing Medical Education - PASSED
MDDCSAM: Submitted written testimony to SUPPORT WITH AMENDMENTS.
The original bill would have required CDS registrants (Controlled & Dangerous Substances) to provide evidence of 2 hours of CME related to CDS with each CDS license renewal. Concerns expressed within the MDDCSAM Public Policy Committee included potential conflicts of interest of groups providing CME, and the quality of the CME, considering that CME can be influenced by Pharma even if accredited by ACCME (Accreditation Council for CME). MDDCSAM offered amendments limiting somewhat the organizations that could provide CME. These amendments were not adopted. The bill was passed, amended to require attestation of 2 hours of CME related to CDS before only the initial CDS license application, or the first renewal if registration was before Oct 2018.


HB 1207 Public Health - Ibogaine Treatment Study Program - FAILED
MDDSAM provided oral and written testimony OPPOSED. (MDDSAM was the only group to provide oral testimony in opposition).
The bill would have provided funds for the MD Department of Health to provide $250,000 per year for two years to an academic medical institution to study of ibogaine treatment.


HB 771 Public Health - Opioid Overdoses - Prohibition and Rehabilitation Order - FAILED
MDDCSAM provided oral and written testimony OPPOSED. The bill would have criminalized overdose by requiring first responders to issue a citation with a referral to treatment, and failure to follow through would result in a fine up to $50. If not paid, the individual could be imprisoned.


HB 499 Health - Standards for Involuntary Admissions and Petitions for Emergency Evaluation – Modification - FAILED
MDDCSAM provided oral and written testimony in the form of a Letter of Information without taking a formal position.
MDDCSAM expressed its understanding of the reasons behind the bill, but felt that involuntary admissions after an overdose would likely be ineffective, unaffordable, and could have deleterious effects.


Washington D.C. Parity Law: Dr. Alvanzo, on behalf of MDDCSAM, along with ASAM, submitted a letter in support to the D.C. City Council. B22-0597 would require all health benefit plans offered by an insurance carrier to meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and submit an annual report to the Department of Health Care Finance.


RE: Council Bill 18-0184 Zoning - Use Regulation - Health-Care Clinics
Land Use and Transportation Committee, Baltimore City Council
MDDCSAM provided oral and written testimony in the Baltimore City Council to OPPOSE this bill which would change the current zoning law to require that health care clinics locating in commercial zoning districts be approved for conditional use by ordinance of the Mayor and City Council, rather than the Board of Municipalities and Zoning Appeals (BMZA). In other words, any health clinic would need to go through the Mayor and City Council before opening in Baltimore. This bill was clearly aimed at OTPs. We believe it would contribute to discrimination and stigma of SUD, would limit access to health care services, especially for SUD, and would be an unprecedented approach to approving the location of health care clinics.