2019 MDDCSAM Legislative Wrap-Up: Updated October 2019

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. 

Because of this bill, the law now states that the Prescription Drug Monitoring (PDMP) Program shall   identify cases of possible misuse or abuse of a monitored drug,  and a possible breach of professional standards or violations of law on the part of a prescriber, and shall report these to the prescriber and provide education.   

In addition, for the first time the program may report cases of a possible breach of professional standards or a possible violation of law to a state agency (OCSA: the Office of Controlled Substance Administration) who may take action and in turn report the data to professional licensing boards.  
This may be done after the program has determined that education to the prescriber has been inadequate to address problems, and after the program’s Technical Advisory Committee has had a chance to provide guidance, if done within ten days.   This ‘unsolicited reporting’ is new in Maryland and is considered to be a best practice for Prescription Drug Monitoring Programs.   

This bill provided, for the first time, the ability to meaningfully identify and address problematic over-prescribing of opioids (and benzodiazepines) which continues to drive the opioid epidemic to a significant extent. 

Providing education to high-risk prescribers will be a challenge and also a great opportunity. 
Researchers at Vanderbilt University and elsewhere are developing educational methods that promise to improve prescribing practices.  The number of opioid prescriptions in Maryland has decreased by 23% between 2016 and 2018 similar to national trends, but the rate is still far higher than the baseline per capita rate in 1990s.  MDDCSAM is monitoring the progress being made through the Prescription Drug Monitoring Program.

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

MDDCSAM DEFEATED A BILL IN 2019 TO MAKE OUD A QUALIFYING CONDITION
FOR MEDICAL CANNABIS:

In March 2019, MDDCSAM was successful in opposing SB 893, a bill to add opioid use disorder (OUD) as a qualifying conditions for medical cannabis.  The bill would have promoted the notion that cannabis is effective for OUD treatment in the absence of evidence.  This would likely have contributed to the stigma around effective FDA-approved OUD treatments, and would likely have led to an increase in overdose deaths.    The lack of evidence for this was confirmed in the 2018 Maryland Medical Cannabis Commission Legislative Report: ‘Treatment of Opioid Use Disorder with Medical Cannabis,’ and was also summarized in the article: Humphreys K, Saitz R. 'Should Physicians Recommend Replacing Opioids With Cannabis?' JAMA, February 19, 2019 Volume 321, No. 7

As SB 893 was debated in the March 2019 hearing of the Senate Judicial Proceedings Committee, proponents cited an article described as containing evidence of the effectiveness of cannabis for this indication: www.ncbi.nlm.nih.gov/pmc/articles/PMC6135562/  However, this was one of a number of publications claiming that cannabis was a “promising” treatment for OUD and did not cite actual evidence.

Also cited at the time was a widely publicized report by Johns Hopkins researchers (Bachhuber MA et al, ‘Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern. Med. 174, 1668–1673, 2014).   Reporting that medical cannabis states had a 21% lower opioid overdose rate than other states, with data through 2010.  

UPDATE OCTOBER 2019:
A subsequent 2019 report reviewed an additional 7 years of data and found a 23% increase in opioid overdose deaths in medical cannabis states, and the association remained positive when states with cannabis legalization were included in the analysis.  Shover CL et al. 'Association between medical cannabis laws and opioid overdose mortality has reversed over time' PNAS June 25, 2019 116 (26) 12624-12626; https://www.pnas.org/content/116/26/12624

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

HB 599  / SB 631  Del Kelly/ Sen Augustine

As a result of this partial victory, for the first time Maryland commercial carriers are now required to use the ASAM Criteria for all medical necessity and utilization management determinations for substance use benefits as in many other states.   This is an important development since it prohibits seemingly arbitrary denial of SUD treatment as “not medically necessary.”  

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.

UPDATE OCTOBER 2019:
Representatives of MDDCSAM have continued as active members of Maryland’s Parity Coalition, have met with the Commissioner of the Maryland Insurance Administration (MIA) and with representatives of ASAM in studying how to ensure that the MIA will enforce the new law, and how other states are using the ASAM Criteria to promote parity for behavioral health treatment. 

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.   Behavioral health providers only became aware of this at the start of the session.   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.  The other would have created a workgroup to look at ways to improve and measure the outcomes of the system

All 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.

UPDATE OCTOBER 2019:

In July 2019, at the direction of the legislature, the Maryland Behavioral Health Administration convened a series of stakeholder “System of Care” meetings to “examine and make recommendations on how the state should provide, administer and finance behavioral health . . . that increases the coordination and quality of somatic and behavioral health care for Medicaid enrollees, is cost efficient, and promotes access to care,” with a briefing to the Senate Finance Committee and the House Health & Government Operations Committee prior to the 2020 Session.   MDDCSAM representatives have participated in many of these meetings in what has been described as a two year process.   This is a fundamental re-evaluation of Maryland’s behavioral health services which may have implications for the controversial issue of a “carve-out,” “carve-in,” or a possible hybrid model. For more information see these resources (12).

In addition, the Lt. Governor’s ‘Commission to Study Mental and Behavioral Health in Maryland’ (including substance use disorders’) has been meeting through 2019 with a final report due December 31, 2019.   Subcommittees are: Finance & Funding, Crisis Services, Youth & Families, and Public Safety & Judicial System.  Meeting schedules, agendas and minutes can be found online.

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 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.  

UPDATE OCTOBER 2019:

In a victory which may add momentum to efforts in Maryland, in October 2019 the first federal ruling on the legality of supervised injection sites found that Philadelphia’s proposed site does not violate federal law.

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.

SPECIAL COMMITTEES OF THE MARYLAND GENERAL ASSEMBLY RELATED TO SUBSTANCE USE:

Hearings may occur in the following special committees even before the General Assembly’s legislative session.   We will provide updates here.

 


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.