A seven-day limit on opioid prescriptions for acute pain.
Sixty-six million dollars to add more residential treatment beds.
Allowing more trained professionals to administer overdose-reversal medication.
An end to prior insurance authorization for people seeking immediate inpatient treatment for opioid addiction as well as for medication to treat withdrawal symptoms.
These are among the features of legislation that Gov. Andrew M. Cuomo signed into law Wednesday at Evergreen Commons on Georgia Street in Buffalo to tackle the opioid crisis.
Overdoses and deaths from heroin and prescription painkillers have reached epidemic proportions here and across the country. Fatal opioid-related overdoses more than doubled from 2014 to 2015 in Erie County, from 127 deaths in 2014 to 256 in 2015. As of this month, there were 211 suspected or confirmed cases of fatal opioid overdoses.
For the men and women who are fighting opioids – and those living the nightmare of addiction – the new law is a step in the right direction. But will it work? See what people on the front lines have to say.
From front lines of crisis, seven voices
Anne D. Constantino
President and CEO
Horizon Health Services
“What I like most about the legislation, is that it is common sense and can be implemented. It is a great next step in a continuing effort against this epidemic,” said Constantino, who manages one of the region’s largest providers of drug treatment and mental health services.
“The legislation improves access to treatment and medication, and for these patients, access and timing is everything,” she said.
The measure allocates funding to add 270 treatment beds and 2,335 outpatient opioid treatment slots across the state, an expansion that is badly needed, experts say.
But Constantino pointed to another aspect of the law that seems more mundane but is also important. It expands support services for addicts, including education and employment assistance, legal services, social services, transportation assistance, child care services, and support groups.
“Addiction treatment is really chronic disease management, and we need a robust treatment system with wraparound services. Addiction is an up-and-down battle,” said Constantino, who is a member of the governor’s Task Force to Combat the Heroin and Opioid Crisis.
Moving forward, Constantino said what’s needed is a change much larger and more complex than what one law can address – the social determinants of health.
“We have to look at addiction from a community perspective and deal with health and wellness in a more comprehensive way,” she said, referring to such issues as socioeconomic status, education, employment and the physical environment.
Horace A. Gioia
Parent of grown child in recovery
The legislation will work, Gioia said, because it recognizes the need to provide treatment when an addict finally makes the decision to seek treatment.
“I was impressed with the governor’s knowledge of the subject. You can’t force a child to get treatment. They have to decide on their own. But when they are ready, you have a short window and you can’t go looking for a facility and be told we are full, come back in 14 days,” Gioia said. “Trust me, only a parent would know just how critical and short that window is.”
Gioia says the expansion of treatment beds and easier access to treatment are positive steps in the new legislation.
He also says that reducing prescription supplies of opioids is another positive development in attacking the heroin-opioid epidemic.
“Most people are told to finish their prescription when they go to a doctor. So if you get a 30-day prescription for opioids, you can get addicted. That’s just logic to me. A limit of seven days would reduce the likelihood of creating an addiction,” he said.
Gioia also said that the legislation takes away the incentive for drug manufacturers to push for larger quantities to be prescribed by physicians.
Speaking as a father, he said, “Parents are at a loss. You don’t know where to go. This legislation gives parents hope. It provides meaningful remedies.”
Recovering opioid addict
Stephanie started using prescription opioids when she was 15 years old. “A friend had gotten them from a doctor and he said to me, ‘Here, these are awesome.’ ”
The now 25-year-old Hamburg woman recalled that she tried the OxyContin. “It was awesome at first,” she said.
For several years, she denied having an addiction, but when she started using heroin and other drugs, she realized that it had gotten out of hand.
Now in her fourth inpatient treatment program, Stephanie says the legislation recognizes how much of a role doctors play in getting individuals addicted to opioids.
Reducing the supply of prescription painkillers from to seven days, from 30, is important for several reasons, she said.
“With a seven-day supply, someone who is addicted to them can’t sell them or give them away,” she said. “It’s barely enough for them. Usually people with a 30-day script will take them all in a week or two.”
Fewer pills, she said, means less availability for others.
She welcomed the news that more treatment beds are being funded.
“I had to wait five weeks for a bed in long-term treatment,” Stephanie said of her current admission.
But unlike others, she says, she was fortunate to have spent the wait in a short-term inpatient program.
“If I had had to go home and wait, it definitely would have been a risk,” she said of the temptation to relapse. “Or I could have changed my mind completely about going into treatment.”
And while she supports the new law, Stephanie says, she also believes that more can be done for people when they finish long-term residential treatment.
What might that include? She and her counselor say there is a need for more after-care housing.
“That would give me more structure than having to live on my own. I would have to follow a schedule,” she said. “I was using for 10 years, and eight or nine months of treatment is nothing compared to all the years I used. It’s the process of changing your thinking.”
Founder of Save the Michaels Foundation
“Lots of people call this a heroin epidemic, but it is really about painkillers,” said Israel, whose son, Michael, took his life in 2011 while addicted to prescription opioids that had been prescribed to him following surgery for Crohn’s disease.
Israel is thrilled by the educational components of the new law.
It mandates that physicians complete three hours of education every three years on addiction, pain management and palliative care. It also requires pharmacists to provide material about the risk of addiction to patients prescribed opioids, including information about local treatment services.
“Doctors don’t mean to harm anyone, but overprescribing of opioids has gotten too many people into trouble,” he said.
Israel also praised legislators and others, including the state task force, for pushing for the insurance mandates in the law.
The legislation eliminates insurance prior authorization for inpatient treatment for substance abuse and emergency supplies of medications to manage withdrawal symptoms. It also requires insurers to use state-approved criteria to determine the level of care they will cover for substance abusers.
“This is a huge victory. It means people can use services when they are most in need,” Israel said. “It’s too late to do something for those of us who have lost kids in this epidemic, but it will help others.”
Dr. Thomas E. Schenk
Senior vice president, chief medical officer
BlueCross BlueShield of Western New York
In his opening remarks in Buffalo on Wednesday, Cuomo took a combative stance explaining why the new law eliminates prior authorization and other review requirements for certain addiction treatment services.
The new law takes on the insurance companies, the governor said.
For instance, the measure extends to 14 from seven days that someone can be kept in an inpatient facility without an insurance review. It also mandates an extension to 72 hours, from 48, for the time that an addict can be kept for emergency treatment without prior authorization from an insurer, and mandates that such opioid substitutes as Suboxone be made available under insurance plans.
But not all insurance companies are equal, according to Schenk, who said BlueCross BlueShield of Western New York has already eliminated prior authorization in such cases. The insurance mandates will likely mean more costly insurance premiums, but should save lives, he said.
Schenk also noted that the extension to 14 days for reviews will likely conflict with the shortage of treatment capacity in the community in ways that will have to be worked out.
Overall, he lauded the package, saying that it was lacking in a few areas but generally addressed a host of key concerns, including education of doctors, limits on first-time opioids from 30- to seven-day prescriptions, earlier identification of people at risk of addiction, and improved services for the continuing care and recovery of addicts.
Where should efforts be focused next?
Schenk said he would have like to see more support for community education that goes beyond billboards and commercials, and that reaches a broader population. He also favors improved services – such as recovery coaches – to help people make a transition back into normal life after addiction treatment.
And it may be overly hopeful, but he would like to see a less adversarial approach from Cuomo toward insurers, who cite a shortage of treatment beds and programs statewide as primary issue that must be dealt with.
“We need to be partners in this,” he said.
Dr. Nancy H. Nielsen
Senior associate dean for health policy
University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences
For Nielsen, the law zeroes in one of the key factors in the opioid epidemic: overprescribing of narcotic painkillers.
Primary care physicians, usually the first stop for common medical problems, are increasingly reluctant to prescribe opioids.
Chronic pain can be difficult to diagnose and treat, and the prosecution of physicians has had a chilling effect.
“Physicians need to be regularly educated. They – we – need to be more careful in prescribing these drugs,” said Nielsen, who formerly ran a private internal medicine practice and in 2008 served as president of the American Medical Association, the nation’s largest physician organization.
“Doctors often resist things that have nothing to do with what they do every day, and there always will be pushback when something is mandated,” she said. “But we are the prescribers.”
Nielsen said she sees a change occurring within the medical community as physicians, who for years have been pushed to treat pain more aggressively, see the need for a more balanced approach.
“We’re sensitized to what’s happening,” she said. “Doctors realize there is a crisis.”
Education of doctors must coincide with a change in the way physicians communicate pain treatment options with patients, Nielsen said.
“We need to realize that every level of discomfort doesn’t require an opioid,” she said. “Chronic pain patients will continue to need opioids, but we also need to address alternative ways to treat pain.”
Edward C. Niemann
Retired Buffalo police narcotics detective
Niemann witnessed people die from heroin and opioids while spending more than two decades on the city’s streets. He also went after those who sold the drugs.
He was there when the opioid epidemic first started in the mid- to late 1990s. Enhanced prescription painkillers had hit the market and were soon diverted to illegal use because of their intensity. Addicts stole them from family members who had legitimate prescriptions, he said. Even sadder were cases he encountered where individuals who had been prescribed them for pain ended up addicted.
“Many times we would hear from addicts telling us that ‘you go here to this doctor, if you want a prescription.’ We would contact the DEA to go after the doctor,” Niemann said, referring to the federal Drug Enforcement Administration.
So the newly enacted legislation represents another step in the right direction, he said, but more needs to be accomplished.
“Educating doctors is great, but you know what? The families are being ignored. They need to know what the signs are when one of their loved ones is becoming addicted to these pills,” Niemann said. “They should be afforded an opportunity for some place to go to enhance their knowledge of signs of the symptoms of addiction.”
Such insight could prove invaluable in saving lives, according to Niemann.
“Just the other day, a friend of mine’s daughter died on Grand Island,” he said in making a case for helping families understand addiction.
Of the legislation increasing treatment beds and removing insurance obstacles to treatment, Niemann said that those are meaningful changes.
“Throughout my career, we would ask addicts, ‘Would you like to go to Drug Court?’ and many times we wouldn’t even have to ask. They would say they want help,” he said. “But when they got to Drug Court, many times they were told they would have to wait for a bed to be open to start the program. Some of the time they started using again. These are tough drugs.”
How the new state law intends to deal with opiate epidemic
What is required by the newly signed New York State legislation aimed at tackling the crisis of heroin and opioid addiction:
- A seven-day limit on opioid prescriptions for acute pain. Chronic pain and extreme pain will be exempt from that limit.
- Insurance companies must provide up to 30 days of coverage for opioid prescriptions if necessary.
- Insurers will be required to provide coverage for care relating to addiction treatment and recovery without prior approval.
- Insurance companies will be required to cover medications prescribed to treat substance abuse.
- Insurers also will be required to provide coverage for access to a five-day emergency supply of certain medications.
- Patients will pay one co-payment for the amount of medication they received. Customers of managed care organizations will make a co-payment proportionate to the amount of medication they are given.
- Medication to reverse effects of a heroin or opioid overdose, such as naloxone (Narcan), must be covered by the patient’s insurance.
- Someone who is on the same insurance policy as someone suffering from an addiction, such as a parent or spouse, would be able to be prescribed medication to reverse an overdose.
- Facilities will be able to hold a patient for 72 hours following an overdose instead of 48.
- Prescribers will be required to complete three hours of educational coursework on addiction treatment and pain management every three years.
- Hospitals and pharmacies will be required to give substance abuse education materials to patients who receive medication or care for an addiction.