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Combatting Massachusetts's Opioid Epidemic

Reducing the Social Stigma of Addiction Through Increased Access to Voluntary Treatment Services and Expansion of Mandatory Clinician Education Programs

Published online by Cambridge University Press:  06 January 2021

Julie Pearlman
Julie Pearlman*
Affiliation:
Boston University School of Law, Political Science, University of Rochester
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Notes and Recent Case Developments
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American Journal of Law & Medicine , Volume 42 , Issue 4 , November 2016 , pp. 835 - 857
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Copyright © American Society of Law, Medicine and Ethics and Boston University 2016

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References

1 See Nora D. Volkow, America's Addiction to Opioids: Heroin and Prescription Drug Abuse, Nat'l Inst. on Drug Abuse (May 14, 2014), https://www.drugabuse.gov/about-nida/legislativeactivities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse [https://perma.cc/35KT-H5VP] [hereinafter America's Addiction to Opioids].

2 See Dep't Pub. Health, A Comprehensive Strategy to End Opioid Abuse in Massachusetts, Mass.gov (2016) http://www.mass.gov/eohhs/feature-story/end-opioid-abuse-in-mass.html [https://perma.cc/KT8Q-ECDN].

3 Id.

4 Rebecca Haffajee et al., What is a Public Health “Emergency?” 371 New Engl. J. Med. 986, 986 (2014) (questioning whether health issues such as substance abuse should even be considered public health emergencies).

5 Id.

6 America's Addiction to Opioids, supra note 1.

7 Recommendations of the Governor's Opioid Working Group 2 (June 11, 2015), http://www.mass.gov/eohhs/docs/dph/stop-addiction/recommendations-of-the-governors-opioid-working-group.pdf [https://perma.cc/G5AF-SUM5].

8 Steve LeBlanc, Gov. Baker: Opioid Bill Designed to “Disrupt the Status Quo,” Associated Press (Nov. 16, 2015, 5:51 PM), http://www.apnewsarchive.com/2015/Gov._Baker%3A_Opioid_bill_designed_to_%22disrupt_the_status_quo%22/id-d3756ecd1f3f491c8d38ab1dd0208cd3.

9 Courtney, Cunningham, Opioid Addiction Treatment: Evidence-Based Medicine, Policy, and Practice, 2 On-Point: Health Pol'y Brief 1, 1 (2015)Google Scholar.

10 Nora D. Volkow, What Science Tells us About Opioid Abuse and Addiction, Nat'l Inst. on Drug Abuse (Jan. 27, 2016), https://www.drugabuse.gov/about-nida/legislative-activities/testimony-tocongress/2016/what-science-tells-us-about-opioid-abuse-addiction [https://perma.cc/4ZZ8-GQ7B] (“Among those who need treatment for a substance use disorder, few receive it.”).

11 Id.

12 Cunningham, supra note 9, at 2.

13 See Joshua Miller, Facing Epidemic, Baker Seeks to Limit Opioid Prescriptions, Bos. Globe (Oct. 15, 2015), https://www.bostonglobe.com/metro/2015/10/15/baker-unveil-opioid-bill-looking-addresscrisis/JY30aFl1N5sQlHz4kKSRiL/story.html [https://perma.cc/25VJ-9BQ3].

14 See id. Baker's original proposal included an exception to the three-day limit for emergency situations. Gov. Charlie Baker, Governor Baker Files Landmark Substance Use Legislation, Mass.gov (Oct. 15, 2015), http://www.mass.gov/governor/press-office/press-releases/fy2016/governor-baker-files-landmark-substance-use-legislation.html [https://perma.cc/L9A8-LC7S]. In addition, the proposal permitted the Department of Public Health to determine when an additional exception was necessary. Id.

15 See Steve LeBlanc, Mass. House Approves Bill Aimed At Combating Opioid Overdoses, Associated Press (Jan. 14, 2016, 7:46 PM), http://www.apnewsarchive.com/2016/Massachusetts_House_approves_bill_aimed_at_opioid_overdoses/id-51d127c2454d4b2985776909e9ff8151 [https://perma.cc/V7TB-2K2Q].

16 See id.

17 See An Act Relative to Substance Use, Treatment, Education and Prevention, H. 4056, 189th Gen. Court § 21 (Mass. 2016); see also WBUR Newsroom, Baker Signs Compromise Opioid Bill into Law, Commonhealth (Mar. 14, 2016), http://www.wbur.org/commonhealth/2016/03/14/opioid-bill-becomes-law [https://perma.cc/APG5-UUP9]; infra Part III.

18 Miller, supra note 13.

19 See generally H. 4056.

20 See Nat'l Ctr. on Addiction & Substance Abuse at Columbia Univ., Addiction Medicine: Closing the Gap Between Science and Practice 4 (June 2012) http://www.centeronaddiction.org/addiction-research/reports/addiction-medicine [hereinafter Closing the Gap] (finding that the “profound gap between the science of addiction and current practice related to prevention and treatment is a result of decades of marginalizing addiction as a social problem rather than treating it as a medical condition”).

21 See America's Addiction to Opioids, supra note 1 (providing background information about the use of opioids as painkillers).

22 See Joanna, Shepherd, Combating the Prescription Painkiller Epidemic: A National Prescription Drug Reporting Program, 40 Am. J. L. & Med. 85, 87 (2014)Google Scholar.

23 Id.

24 America's Addiction to Opioids, supra note 1.

25 Id.

26 See id.

27 See Mass. Dep't of Pub. Health, Opioid Overdose Education and Naloxone Distribution, MDPH Naloxone Pilot Project Core Competencies 6, http://www.mass.gov/eohhs/docs/dph/substance-abuse/core-competencies-for-naloxone-pilot-participants.pdf [https://perma.cc/4DNU-LGRY].

28 Id.

29 See id.

30 See Ryan Kath, I-Team: On The Front Lines Of The Opioid Crisis In Mass.¸CBS (Feb. 10, 2016, 11:30 PM), http://boston.cbslocal.com/2016/02/10/i-team-opioid-crisis-plymouth-heroin-overdose-police/ [https://perma.cc/G327-BMUC].

31 Id. (“The opioid crisis is touching every corner of Massachusetts and claiming victims of all ages.”).

32 Shepherd, supra note 22, at 86.

33 Cunningham, supra note 9, at 1.

34 See generally Lynn, R. Webster et al., An Analysis of the Root Causes for Opioid-Related Overdose Deaths in the United States, 12 Pain Medicine 26, 27 (2011)Google Scholar (describing how “identifying risk factors among opioid overdose decedents has been difficult due, in part, to the widely varying methods employed by state death investigators to collect mortality data and to report on drug involvement in overdose”).

35 See generally id. (“The reasons for the deaths are multifactorial, encompassing prescriber behaviors, patient contributory factors, non-medical use patterns, and systemic failures.”).

36 See America's Addiction to Opioids, supra note 1 (arguing that “drastic increases in the number of prescriptions written” have “contributed to the severity of the current prescription drug abuse problem”).

37 Shepherd, supra note 22, at 86.

38 See id.

39 See Webster et al., supra note 34, at 29-30.

40 See generally Pia Malbran, What's a Pill Mill?, CBS News (May 31, 2007, 6:01 PM), http://www.cbsnews.com/news/whats-a-pill-mill/ [https://perma.cc/R2QZ-7JMF] (defining a “pill mill” as “a doctor, clinic or pharmacy that is prescribing or dispensing powerful narcotics inappropriately or for non-medical reasons”).

41 America's Addiction to Opioids, supra note 1.

42 See Emily Wasserman, Attorney General to Investigate Pharmaceutical Companies for Opioid Marketing Practices, FiercePharma (Sept. 30, 2015, 8:36 AM), http://www.fiercepharma.com/press-releases/attorney-general-investigate-pharmaceutical-companies-opioid-marketing-prac [https://perma.cc/PA43-CXQ2].

43 Id.

44 America's Addiction to Opioids, supra note 1.

45 See Theodore, J. Cicero et al., The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years, 71 JAMA Psychiatry 821, 822 (2014)Google Scholar.

46 See Cunningham, supra note 9, at 1 (four out of five heroin users started abusing prescription drugs first).

47 See generally id. (outlining the issues that practitioners and policy-makers face in crafting solutions to the opioid addiction problem).

48 America's Addiction to Opioids, supra note 1.

49 Miller, supra note 13.

50 Heather Goldin, Historic Opioid Bill is Signed Into Law, Sentinel & Enterprise (Mar. 15, 2016, 12:23 PM), http://www.sentinelandenterprise.com/news/ci_29640158/historic-opioid-bill-is-signed-into-law [https://perma.cc/NJ4J-MN66].

51 Data Brief: Confirmed Unintentional/Undetermined Opioid-related Overdose Deaths Among Massachusetts Residents – Demographic Data Highlights, Mass. Dep't of Pub. Health (Jan. 2016), http://www.mass.gov/eohhs/docs/dph/quality/drugcontrol/county-level-pmp/opioid-demographic-january-2016.pdf [https://perma.cc/7VEG-GUS7].

52 David Eldridge, Today's Opioid Epidemic: This is Not Your Father's Heroin Crisis, Inside Sources (Mar. 25, 2016), http://www.insidesources.com/the-opioid-epidemic-its-not-your-fathers-heroin-crisis/ [https://perma.cc/KK34-JY72] (discussing opioid addiction epidemics around the nation).

53 Id.

54 Haffajee et al., supra note 4, at 986.

55 Garret Quinn, Everything You Need to Know About the New Massachusetts Opioid Law, Boston Daily (Mar. 14, 2016), http://www.bostonmagazine.com/news/blog/2016/03/14/massachusetts-opioid-law/ [https://perma.cc/5LX2-Y4H3].

56 Cicero et al., supra note 45, at 824.

57 Id.

58 See, e.g., Celine Gounder, Opioids Are a Bipartisan Issue Because They've Become a Mainstream, White One, Guardian (June 9, 2016, 12:26 PM), https://www.theguardian.com/usnews/commentisfree/2016/jun/09/opioids-bipartisan-issue-now-white-people-use-epidemic [https://perma.cc/KHK5-V7ZP].

59 See Anne Case & Angus Deaton, Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century, 112 Proc. Nat'l Acad. Sci. U.S. 15,078, 15,078 (2015). See also Gina Kolata, Death Rates Rising for Middle-Aged White Americans, Study Finds, N.Y. Times (Nov. 2, 2015), http://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americansstudy-finds.html?_r=2.

60 Case & Deaton, supra note 59, at 15,078 (recognizing that other causes contributing to the increase in death rates for middle-aged white Americans include increased suicides, alcohol poisoning, and liver disease).

61 Katharine Q. Seelye, In Heroin Crisis, White Families Seek Gentler War on Drugs, N.Y. Times (Oct. 30, 2015), http://www.nytimes.com/2015/10/31/us/heroin-war-on-drugs-parents.html?_r=0.

62 Id.

63 Id.; see also infra Part IV(a).

64 See Gounder, supra note 58.

65 See Steven Ross Johnson, The Racial Divide in the Opioid Crisis, Mod. Healthcare (Feb. 24, 2016), http://www.modernhealthcare.com/article/20160224/NEWS/160229947 [https://perma.cc/Z2NL5EG7].

66 See id. (citing a 2008 JAMA study that found that “minorities were less likely to receive opioids for pain in an emergency department compared to whites”).

67 Gina Kolata & Sarah Cohen, Drug Overdoses Propel Rise In Mortality Rates of Young Whites, N.Y. Times, Jan. 15, 2016, http://www.nytimes.com/2016/01/17/science/drug-overdoses-propel-rise-in-mortality-rates-of-young-whites.html?_r=1.

68 Id.

69 See H. 4056.

70 Id.

71 See id. at § 21; see also Joshua Miller, Governor Baker Signs Opioid Bill, Bos. Globe (Mar. 14, 2016), https://www.bostonglobe.com/metro/2016/03/14/baker-due-sign-opioid-billmonday/EYWh7oJXvKCRguHErxrWhI/story.html; WCVB, What to Know About the New Opioid Law, WCVB Boston (Mar. 14, 2016) http://www.wcvb.com/news/what-to-know-about-the-new-opioid-law/38505794#comments.

72 See H. 4056 at § 24; see also Quinn, supra note 55.

73 See H. 4056 at §§ 8-9; see also Quinn, supra note 55.

74 See H. 4056 at § 1; see also Quinn, supra note 55.

75 See H. 4056 at § 27; see also Miller, supra note 71; WCVB, supra note 71.

76 See H. 4056 at § 15; see also Quinn, supra note 55.

77 See Commonwealth of Mass., Governor Baker Signs Landmark Opioid Legislation into Law (Mar. 14, 2016), http://www.mass.gov/governor/press-office/press-releases/fy2016/governorsignslandmarkopioid-legislation-into-law.html [https://perma.cc/Q3LT-5R4M].

78 Brian Fraga, The Opioid Crisis and the Media's Responsibility to Cover the Epidemic, Herald News (Mar. 17, 2016), http://www.heraldnews.com/article/20160317/BLOGS/160316156 [https://perma.cc/MAL7-UKQ7].

79 Gary, Franklin et al., A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned, 105 Am. J. Pub. Health 463, 463 (2015)Google Scholar.

80 See H. 4056.

81 Leo Beletsky et al., Expanding Coercive Treatment is the Wrong Solution for the Opioid Crisis, Health Affairs Blog (Feb. 11, 2016), http://healthaffairs.org/blog/2016/02/11/expanding-coercive-treatment-is-the-wrong-solution-for-the-opioid-crisis [https://perma.cc/HN2W-JVHD] (arguing that “data suggest that individuals who are forced into treatment are more likely to relapse upon discharge than those who voluntarily seek care”).

82 If a large part of the problem is that physicians are operating pill mills, then the problem does not stem from a lack of education; rather, some doctors are choosing to prescribe medications inappropriately in order to make money.

83 See infra Part IV(b).

84 See generally Daniel, P. Alford, Opioid Prescribing for Chronic Pain — Achieving the Right Balance through Education, 374 New Eng. J. Med. 301, 301-02 (2016)Google Scholar (“Education has the potential to both reduce overprescribing and ensure that patients in need retain access to opioids.”).

85 Nat'l Inst. on Drug Abuse, DrugFacts: Understanding Drug Abuse and Addiction (Aug. 2016), https://www.drugabuse.gov/publications/drugfacts/understanding-drug-abuse-addiction [https://perma.cc/F788-8XN9] [hereinafter Drug Facts].

86 Id.

87 See Drug Facts, supra note 85 (explaining that “drug addiction is a complex disease, and quitting usually takes more than good intentions or a strong will”).

88 See Closing the Gap, supra note 20, at 4 (explaining that the “profound gap between the science of addiction and current practice related to prevention and treatment is a result of decades of marginalizing addiction as a social problem rather than treating it as a medical condition”).

89 See Beletsky et al., supra note 81 (arguing that “by blurring the line between health care and incarceration, the proposed approach would also threaten provider-patient trust”).

90 See id.

91 Closing the Gap, supra note 20, at 4. In addition, “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” Id. at 2.

92 See Beletsky et al., supra note 81; see also Closing the Gap, supra note 20, at 2.

93 See Vikki, A. Entwistle et al., Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships, 25 J. Gen. Internal Med. 741, 745 (2010)Google Scholar (concluding that “[t]he idea that patients should be offered options and allowed to make voluntary choices about potentially life-changing health care interventions is important” because “[i]t undoubtedly discourages some inappropriate paternalism and protects some patients from unwanted intervention ….”).

94 Richard, M. Ryan et al., Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice, 39 The Counseling Psychologist 193, 193 (2011)Google Scholar; see also M. Douglas Anglin et al., The Effectiveness of Coerced Treatment for Drug-Abusing Offenders, UCLA Drug Abuse Res. Ctr. (Mar. 23-25, 1998), https://www.ncjrs.gov/ondcppubs/treat/consensus/anglin.pdf [https://perma.cc/2LFS-RUYM] (presenting “an abbreviated survey of the substance abuse treatment literature regarding the effectiveness of various levels of coercion”).

95 Ryan et al., supra note 94, at 194.

96 Stefanie, Klag et al., The Use of Legal Coercion in the Treatment of Substance Abusers: An Overview and Critical Analysis of Thirty Years of Research, 40 Substance Use & Misuse 1777, 1781 (2005)Google Scholar.

97 See D., Werb et al., The Effectiveness of Compulsory Drug Treatment: A Systematic Review, 28 Int'l J. Drug Pol'y 1, 1 (2016)Google Scholar.

98 Nazlee Maghsoudi, New Study Shows Compulsory Addiction Treatment is Less Effective than Voluntary Treatments for Long-Term Treatment of Drug Dependence, Int'l Ctr. for Sci. Drug Pol'y (Feb. 9, 2016), http://www.icsdp.org/compulsory_addiction_treatment [https://perma.cc/DUJ5-GDXX].

99 Id.

100 Werb et al., supra note 97, at 8.

101 See Fairbairn, et al., Compulsory Drug Detention and Injection Drug Use Cessation and Relapse in Bangkok, Thailand, 34 Drug & Alcohol Review 74, 74 (2014)CrossRefGoogle ScholarPubMed (finding “[c]ompulsory drug detention was associated with short-term cessation and relapse”).

102 See id. at 74.

103 See Michelle Samuels, Answer to Opioid Crisis: Treatment Instead of Jail, Boston Univ. School of Pub. Health (Mar. 17, 2016), http://www.bu.edu/sph/2016/03/17/looking-at-care-instead-of-jail-for-problem-close-to-home/ [https://perma.cc/JVF5-QGWH] (explaining that “from June 1 to February 15, 352 people have walked into the Gloucester police department asking for treatment”).

104 See generally Alford, supra note 84, at 301-02 (discussing the importance of clinical education in treating opioid abuse).

105 Id. at 302.

106 Id.

107 See James F. Childress, Paternalism in Health Care and Health Policy, in Principles of Health Care Ethics 223, 224 (2d. ed. 2007).

108 H. 3817, 189th Gen. Court § 11.

109 Klag et al., supra note 96, at 1778.

110 See Alan I. Leshner, Why Should We Treat Addicts Anyway? The Solution We Refuse to Use, Nat'l Inst. on Drug Abuse, http://archives.drugabuse.gov/Published_Articles/Solutions.html [https://perma.cc/3SM8-484X].

111 Id.

112 Larry Copeland, Substance Abuse Treatment Often Impossible to Find, Usa Today (Feb. 19, 2014), http://www.usatoday.com/story/news/nation/2014/12/19/mental-health-and-addiction/19861509/ [https://perma.cc/Z8K5-HVH5].

113 Id.

114 Leo, Beletsky et al., Fatal Re-Entry: Legal and Programmatic Opportunities to Curb Opioid Overdose Among Individuals Newly Released from Incarceration, 7 Ne. U. L.J. 149, 150 (2015)Google Scholar.

115 Id. at 156.

116 Michael, D. White et al., Co-Occurring Mental Illness and Substance Abuse in the Criminal Justice System: Some Implications for Local Jurisdictions, 86 Prison J. 301, 304 (2006)Google Scholar (“Few jails can boast of adequate resources or the necessary services for handling mentally ill inmates in their care and seek mainly to protect and stabilize such inmates while they are confined.”). See also Beletsky et al., supra note 114, at 151.

117 White et al., supra note 116, at 302.

118 Deborah Becker, The Opioid Treatment Business Is Booming, Commonhealth (Mar. 1, 2016), http://www.wbur.org/commonhealth/2016/03/01/opioid-treatment-business [https://perma.cc/TGR3-GLRA] (finding that the lack of availability in Massachusetts treatment facilities causes some addicts to seek help in Florida or even California).

119 Police Assisted Addiction and Recovery Initiative (2016), http://paariusa.org/about-us/ [https://perma.cc/64W3-H4DS].

120 Id.

121 Boston Univ. School of Pub. Health, Boston University's Dean's Seminar Series on Contemporary Issues in Public Health: Why Cops are Sending People With Addiction to Treatment Instead of Jail (Mar. 17, 2016), http://www.bu.edu/sph/2016/03/17/looking-at-care-instead-of-jail-for-problem-close-to-home/ [hereinafter Dean's Seminar].

122 Samuels, supra note 103.

123 Dean's Seminar, supra note 121.

124 Id.

125 See Police Assisted Addiction and Recovery Initiative, supra note 119.

126 See, e.g., Mass Gen. Laws ch. 94C § 34 (2016).

127 See Dean's Seminar, supra note 121.

128 See Samuels, supra note 103.

129 Id.

130 Id.

131 Dean's Seminar, supra note 121.

132 Id.

133 See Samuels, supra note 103 (“We're very anti-coercion, anti-incentive, for this disease.”).

134 See Kara Dansky, Jail Doesn't Help Addicts. Let's Stop Sending Them There, Aclu Center For Justice (Oct. 17, 2014), https://www.aclu.org/blog/jail-doesnt-help-addicts-lets-stop-sending-them-there [https://perma.cc/8E4P-Y345].

135 See id.

136 See id.

137 See Samuels, supra note 103.

138 Leadership Conference on Civil Rights And Education Fund, Race and Prosecutorial Discretion, in Justice on Trial: Racial Disparities in the American Criminal Justice System (2016), http://www.protectcivilrights.org/pdf/reports/justice.pdf (arguing that prosecutorial discretion is too broad and results in racially disproportionate outcomes).

139 Id. See also Bennett, L. Gershman, The New Prosecutors, 53 U. Pitt. L. Rev. 393, 448 (1992)Google Scholar (“[T]he American prosecutor, owing to a variety of social and political factors, has emerged as the most pervasive and dominant force in criminal justice. The prosecutor's substantive and procedural powers continue to expand, while the courts increasingly defer to the prosecutor's decisions.”).

140 See infra Part IV(c).

141 See Mass. Gen. Laws ch. 94C, § 34 (2015) (“No person knowingly or intentionally shall possess a controlled substance unless such substance was obtained directly, or pursuant to a valid prescription or order, from a practitioner while acting in the course of his professional practice, or except as otherwise authorized by the provisions of this chapter.”).

142 Dean's Seminar, supra note 121.

143 See id.

144 See Mass. Gen. Laws ch. 94C, § 34.

145 Dean's Seminar, supra note 121.

146 See id.

147 See Cunningham, supra note 9, at 2 (finding that “many of those suffering from opioid addiction do not access treatment”).

148 See Drug Facts, supra note 85 (finding that “[i]n reality, drug addiction is a complex disease, and quitting takes more than good intentions or a strong will.”); see also Closing the Gap, supra note 20, at 8.

149 See Dansky, supra note 135 (explaining that “addictions haven't been helped by a stint behind bars”).

150 Closing the Gap, supra note 20, at 8.

151 Recommendations of the Governor's Opioid Working Group, supra note 7, at 4.

152 Governor Baker Releases Fiscal Year 2017 Budget Proposal, Official Website of the Governor of Mass. (Jan. 27, 2016), http://www.mass.gov/governor/press-office/pressreleases/fy2016/gov-baker-releases-fiscal-year-2017-budget-proposal.html [https://perma.cc/WFJ4-GU4G]. Specifically, the funds will help create 150 adult treatment beds, $140 million towards rehabilitation services at the Department of Public Health and $13 million towards the Department of Mental Health. Id.

153 See Becker, supra note 118.

154 Id.

155 Id.

156 Daniel P. Dooley, Boston Patterns and Trends in Drug Abuse: 2013, Proceedings of the Community Epidemiology Work Group 1, 12 (2014), https://www.drugabuse.gov/sites/default/files/boston2014.pdf [https://perma.cc/22VU-ZATJ].

157 Id. at 7.

158 Id. at 3.

159 Vic DiGravio, Ideas to Combat Opioid Crisis, Worcester Telegram & Gazette (May 1, 2015), http://www.associationforbehavioralhealthcare.org/newsroom/abh-in-the-news/1442-ab-op-ed-column-concerning-the-opioid-crisis-in-massachusetts-worcester-telegram-a-gazette-5115.html [https://perma.cc/9Q6J-HGT6]. The author of this article is the president and CEO of the Association for Behavioral Healthcare in Massachusetts. Id..

160 Dean's Seminar, supra note 121.

161 Id.

162 Alford, supra note 84, at 301.

163 Id.

164 Id. at 302. (“Clinicians are thus left basing treatment decisions on a brief subjective assessment of whether there's enough benefit to justify continued opioid therapy or enough harm to justify discontinuing it.”).

165 The Am. Pain Soc'y in Conjunction with the Am. Acad. of Pain Med., Clinical Guideline for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain, 8, http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf [https://perma.cc/SVV3-SXYZ].

166 See Malbran, supra note 40.

167 CJ Arlotta, Study: Florida's Crackdown on ‘Pill Mills' Is Working, Forbes (Dec. 21, 2015, 4:23 PM), http://www.forbes.com/sites/cjarlotta/2015/12/21/study-floridas-crackdown-on-pill-mills-isworking/#75019a2c273e.

168 Id.

169 Id.

170 See generally Alford, supra note 84, at 302. (“When a clinician determines that discontinuing opioid treatment is appropriate, the patient may disagree and express anger.”)

171 See generally id. at 303 (arguing that patients deserve a medical profession that is knowledgeable about prescribing opioids).

172 See H. 4056 §§ 15, 62.

173 See Educating Clinicians Important in Safe Opioid Prescribing, Study Shows, Go Local Worcester (Aug. 27, 2015), http://www.golocalworcester.com/health/educating-clinicians-important-in-safe-opioid-prescribing-study-shows [https://perma.cc/2B3Q-ZZNJ] [hereinafter Educating Clinicians].

174 See Scope of Pain Live Conferences (2016), https://www.scopeofpain.com/in-person-training/.

175 Education Positively Impacts Safe Opioid Prescribing Among Clinicians, Boston Univ. School of Med. (Sept. 3, 2015), https://www.bumc.bu.edu/busm/2015/09/03/education-positively-impacts-safe-opioid-prescribing-among-clinicians/.

176 Id.

177 Educating Clinicians, supra note 174.

178 Education Positively Impacts Safe Opioid Prescribing Among Clinicians, supra note 176.

179 See Boston Medical Center Agreement, Resources, SCOPE of Pain (2016), https://www.scopeofpain.com/tools-resources/.

180 Id.

181 See generally SCOPE of Pain Live Conferences, supra note 175 (citing as one of the educational objectives the ability to “[e]mploy appropriate assessment, monitoring and documentation strategies to meet best practice standards ….”).

182 See Assistant Sec'y for Pub. Aff. (ASPA), About the Epidemic, HHS.gov (June 23, 2016), [https://perma.cc/UWN3-Z5Y3].

183 See Nora D. Volkow, What Science Tells Us About Opioid Abuse & Addiction, Nat'l Inst. on Drug Abuse (Jan. 17, 2016), https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction [https://perma.cc/NA2U-9VBC].

184 See Franklin et al., supra note 79, at 466.

185 See UW Pain Medicine Patient Care: UW TelePain, UW Med., http://depts.washington.edu/anesth/care/pain/telepain/ [https://perma.cc/D3FF-VXYW].

186 Franklin et al., supra note 79, at 465; see also Engrossed Substitute H.B. 2876, 61st Leg., 2010 Reg. Sess. (Wash. 2010).

187 See Commonwealth of Mass. - Bd. of Registration in Med., Notice on Prescribing Practices Policy and Guidelines, Policy 15-05 (Oct. 8, 2015), http://www.mass.gov/eohhs/docs/borim/policies-guidelines/policy-15-05.pdf. See generally Commonwealth of Massachusetts: Board of Registration in Medicine – Prescribing Practices Policy and Guidelines, Policy 15-05 (Adopted Oct. 8, 2015).

188 See SCOPE of Pain Live Conferences, supra note 175.

189 See generally Commonwealth of Mass. - Bd. of Registration in Med., Notice on Prescribing Practices Policy and Guidelines, Policy 15-05 (Oct. 8, 2015), http://www.mass.gov/eohhs/docs/borim/policies-guidelines/policy-15-05.pdf (requiring licensees who prescribe controlled substances to complete three credits in opioid education and pain management training on a biennial basis).

190 See generally David C. Dugdale, Ronald Epstein & Steven Z. Pantilat, Time and the Patient-Physician Relationship, 14 J. Gen. Internal Med. S34, S34 (1999) (“Being a physician always has been a busy job.”).

191 See Alford, supra note 84, at 303.

192 Section 34A of chapter 94C refers to MA's law on unlawful possession of particular controlled substances, including heroin and marihuana. Mass. Gen. Laws ch. 94C, §34A

193 H. 4056 § 1.

194 See generally Gloucester Police Dep't, Volunteer ANGEL Program (June 1, 2015), http://paariusa.org/wp-content/uploads/sites/46/2015/06/Angel-program-policy-Aug-7-2015.pdf [https://perma.cc/C8BS-9J8W] (providing the model for the guidelines above).

195 Mass. Gen. Laws ch. 123, § 35.

196 See generally Gloucester Police Dep't, supra note 195 (providing the model for the guideline above).

197 Mass. Gen. Laws ch. 123, § 35.

198 Governor's Message to the Senate and House of Representatives, H. 3817, 189th Gen. Court at 1.

199 See H. 4056.

200 Massachusetts agencies should look to Washington's pain management specialist requirements as a model. Washington's pain management specialist requirements are as follows:

Long-acting opioids, including methadone, should only be prescribed by a physician who is familiar with its risks and use, and who is prepared to conduct the necessary careful monitoring. Special attention should be given to patients who are initiating such treatment. The physician prescribing long-acting opioids or methadone should have a one-time (lifetime) completion of at least four hours of continuing education relating to this topic. Wash. Admin. Code § 246-919-858 (2012).

201 See H. 4056 § 22.

202 WBUR Newsroom, supra note 17.

203 Miller, supra note 71.

204 Cunningham, supra note 9, at 5.