A new bill requires insurers to cover naloxone provided at discharge from the hospital. (Faith Miller/Colorado Newsline)
Despite extensive budget cuts necessitated by COVID-19, Colorado legislators managed to avoid what one lawmaker said would have been a major setback for the state’s opioid response.
“What we were looking at initially was going back 10 years on this issue and completely decimating any progress that we’ve made,” says Sen. Brittany Pettersen (D-Lakewood). “Honestly, I can’t believe how much we were able to save.”
Initial cuts proposed by the Joint Budget Committee would have removed $43 million in funding for substance use disorder prevention and treatment, according to figures provided by the Colorado Consortium for Prescription Drug Abuse Prevention.
Treatment advocates salvaged more than half of that — $22 million — in the final budget, with some help from federal grants and COVID-19 relief funds.
Much of the legislation that originally included help for the opioid crisis had been developed in previous years by the Opioid and Other Substance Use Disorders Study Committee, which heard from stakeholders such as treatment providers, insurers and people in recovery from substance use.
“We are now expecting 75,000 additional deaths because of drug misuse and overdoses and suicide. … It was always urgent, and now it’s even more urgent, that we step up and address this at every level,” Pettersen, who chairs the committee, said at a virtual bill signing in July for some of the new legislation.
While Gov. Jared Polis vetoed a bill that would have required insurers to cover alternatives to opioids for pain management and extended prescribing limits on the highly addictive drugs, he signed major legislation that removed barriers for syringe access programs, improves coverage for substance use disorders, and ensures Medicaid enrollment for people released from jail or prison.
The legislation is especially important, advocates say, because the pandemic and associated economic downturn could lead many to turn to abusing prescriptions, alcohol or street drugs — burdening the already-overwhelmed treatment system and leading to a surge in overdose deaths, which hit an all-time high of nearly 71,000 in 2019 after a brief decline the previous year.
Read on for a summary of COVID-19-era victories and losses for legislators working to improve the state’s response to the national opioid crisis.
Greater access to clean syringes
One major win for advocates of harm reduction — a term that connotes reducing health risks associated with addiction, rather than implementing zero-tolerance policies — came with House Bill 20-1065.
Sponsored by Democratic Reps. Chris Kennedy of Lakewood and Leslie Herod of Denver, the bill requires insurers that cover the opioid reversal drug naloxone to reimburse hospitals when it’s provided to patients upon their release from an emergency department. The bill also contains explicit authorization for pharmacists to sell clean syringes.
A more controversial provision of the bill creates a new process through which the Colorado Department of Public Health and Environment can approve syringe access programs without the consent of local health departments.
Such programs provide people who inject drugs with clean syringes while providing them free naloxone, fentanyl test strips, education on how to inject safely, and resources for getting into treatment when they’re ready. Previously, such programs needed approval from local health departments — which sometimes reject them despite the fact that the federal Centers for Disease Control and Prevention provides funding to help pay for the programs.
“People end up with fewer infections, they go to the hospital less — people do a lot better if there are syringe access programs in their location,” says Dr. Robert Valuck, executive director of the Colorado Consortium for Drug Abuse Prevention. “Many parts of the country are really expanding them, other parts of the country are not. It’s a controversial topic.”
The El Paso County Board of Health, which has stood firm against allowing syringe access, voted unanimously in March to oppose the bill on the grounds that it “unnecessarily removes local control over issues of local public health concern.”
CDPHE will need to promulgate rules governing a new approval process for syringe access programs, Valuck says, so it could be months before any proposals are heard by the state.
Coverage for inpatient treatment and detox
When Pettersen’s mother was struggling with an opioid use disorder that nearly killed her, she said she discovered that Medicaid doesn’t pay for inpatient substance use treatment.
“I couldn’t believe that that wasn’t covered … and so we brought the (Medicaid) waiver process, which took two years before it would actually be implemented,” Pettersen said.
In 2018, legislators passed a bill that would have provided Medicaid coverage, pending federal approval of a new waiver, for substance use and detox treatment starting in the fiscal year that began July 1, 2020.
“It had to be kicked back six months just because of the enormous pressure that Medicaid’s under right now with all of the people who are new enrollees,” Pettersen said.
But the delay could have been much longer. The legislation would have cost $17.5 million for the fiscal year, and since it hadn’t been implemented by the time budget cuts were being considered in the spring, it was one of the first programs on the chopping block.
The Joint Budget Committee proposed delaying the program for an entire year, which, Pettersen said, probably would have meant additional years of delays. Now, it’ll be implemented in January, saving the state $9 million for the fiscal year.
Another bill takes a similar step for insurance plans under Colorado’s oversight, which cover about 30% of the population, Pettersen said.
Currently, though the Affordable Care Act mandates coverage for substance use treatment, it doesn’t specify what that means. The result is that many health plans only cover five days of inpatient treatment, which is “completely insufficient,” Pettersen said.
Senate Bill 20-7, sponsored by Pettersen and Sen. Faith Winter (D-Westminster) will change that.
It requires insurers to follow the American Society of Addiction Medicine criteria, which Pettersen has called the “gold standard” for substance use treatment.
After the Medicaid waiver takes effect in January and SB-7 mandates those new standards starting the following year, more than half of the state’s population “will no longer be told, ‘I’m sorry we have nowhere to send you,’ or, ‘I’m sorry you’re struggling, but no, we don’t cover that’” when they seek treatment for substance use disorders, she said.
SB-7 also streamlines the process for having someone involuntarily committed for substance use treatment, aligning state statutes for alcohol and drug use, and defines patient rights.
Besides that, the Consortium “fought like heck” against budget committee staff’s proposal to cut a $2.5 million medication-assisted treatment pilot program created through 2019 legislation, Valuck said.
The program — which was preserved with full funding — serves people in rural areas of the state with limited access to treatment that involves using medication, such as buprenorphine or methadone, to treat substance use disorders.
“(The bill) expanded treatment in the San Luis Valley and Pueblo and Routt counties, and then we brought in a few other areas, like Gunnison and Montrose,” Valuck said. “… We’re getting hundreds of new patients treated in those areas because of this funding.”
Substance use treatment in the criminal justice system
Another victory came with Polis’ July 13 signing of House Bill 20-1017, sponsored by Reps. Herod and Kennedy.
The bill “makes sure that people in our jails, community corrections and prisons have access to better treatment, so when they get out, they’re clean, and they can regain their dignity and their lives,” Polis said at the time.
Originally, HB-1017 would have required jails and prisons to provide medication-assisted treatment for opioid use disorder to inmates. The final version merely encourages the practice, but it also requires jails to provide people with Medicaid re-enrollment paperwork and file that paperwork with the county health department upon their release.
“Right now, in Colorado, our largest treatment facilities are our jails and our prisons. That should not stand,” Herod said at the bill signing.
While HB-1017 wouldn’t change that dynamic, “what it will do is put Coloradans on the right path to recovery, and ensure that there’s a continuity of care for those who need it,” she said.
Finally, the state Office of Behavioral Health designated some federal COVID-19 relief funding to a program for co-responder teams, a criminal justice diversion practice that pairs law enforcement officers with behavioral health workers to help de-escalate situations that stem from mental health concerns or substance use disorders.
Additional funding for medication-assisted treatment in jails, which would have been cut under budget staff’s proposal, is expected to be replaced by a State Opioid Response grant that OBH applied for from the federal government.
“Making sure that when … we have those people in custody, that we are getting them the care that they need, is critical for saving lives,” Pettersen said.
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