Here’s the Early Favorite for 2023’s Saddest Piece of Legislative Testimony

Pictured above: Members of the House Human Services Committee, giving themselves a round of applause after unanimously passing H.222, a bill that would do quite a few good things on overdose prevention. The bill would make it easier for providers to prescribe buprenorphine without going through the cumbersome process of getting prior authorization* from the state Health Department; improve access to needle and syringe disposal programs and pay for it with a fee charged to prescription drug makers; make it easier to site recovery residences; give reasonable protection against lawsuits for those who administer overdose treatments; and set up some studies on how to best administer treatment and reduce opioid-related deaths.

*Stick a pin in that. We’ll circle back to it in time, and you won’t want to miss it.

All reasonable. And all acceptable to the entire panel. The “Yes” votes included Republicans Anne Donahue and James Gregoire and right-of-center independent Kelly Pajala.

Which brings us to this guy.

This is Dr. Michael Rapaport, Chief Medical Officer of the Department of Vermont Health Access, giving testimony on Thursday, March 16. He raised potential questions and anecdotal examples of possible bad outcomes from overdose prevention programs, specifically from the use of buprenorphine. He didn’t specifically oppose H.222, but he told his stories and spun scientific generalities to cast doubt on the bill.

That’s right, the mouthpiece for famously moderate Gov. Phil Scott was the most conservative voice in the room on H.222. But then, the governor does love himself some moral hazard when it comes to helping the less fortunate.

Funny thing: The panel completely ignored Rapaport’s testimony. He had zero impact on the bill. In fact, the committee went in the opposite direction in writing the final version of H.222. They made it stronger on the specific points Rapaport raised.

Which is just as well, since Rapaport’s testimony was highly anecdotal in nature and failed to present any evidence or scientific research to support his arguments. This came as a surprise to me, since Rapaport has been working in the field for many years. That work did, unfortunately, include almost four and a half years working for not one, but two private contractors that provide health care in correctional facilities. But still, the guy’s got experience, right?

Well, his experience seems to have blinkered his vision and left him out of step with best practices in overdose prevention — practices backed up by an impressive quantity of academic research. Instead, he leaned heavily on anecdote and personal experience in his testimony.

The goal of his remarks was to cast doubt on the safety of buprenorphine. The unspoken context of these remarks: Bupe is a costlier treatment because the manufacturers of suboxone give the state a price break. He hinted at this by referring to “fidiuciary responsibility” in Health Department policymaking.

In other words, they don’t want to admit it, but the preference for suboxone is entirely financial in nature. That’s why the state requires prior authorization for buped. If there’s a medical reason for doing so, Rapaport didn’t bother to bring it up.

Prior authorization doesn’t sound like a big deal, but in the world of opioid treatment you have to strike while the iron is hot. Even a small delay puts people at risk of overdosing or changing their minds about treatment.

Rapaport characterized buprenorphine as “a wonderful drug,” but added that it does raise “safety concerns” and “I think we have some obligations to make sure it’s done safely and appropriately.”

For example, “if it’s mixed with the wrong drugs or it gets into the wrong hands, particularly infants and toddlers, they can overdose and they can stop breathing.”

And this is a problem because people with substance use disorder are bad parents. “It’s a population that doesn’t always have the best safety strategies in place at home. …They don’t have the best parenting skills, they’re overwhelmed.”

As an example, he recalls a woman wrangling multiple kids. As she turned her attention to one child, another “grabbed her methadone and took a sip.”

This is the kind of patient-blaming you’d hope you wouldn’t get from a real-world practitioner. But I guess experience can cut both ways: It can open your eyes to the struggles and successes of people, or it can make you weary of your patients and see them as something less than human. Rapaport seems to approach clients with suspicion.

Besides all that, there’s the inconvenient fact that any medication can be abused or included in a toxic cocktail. Rapaport specifically acknowledged that suboxone is subject to the same kinds of misuse as buprenorphine. If there were any established differences that made bupe uniquely dangerous, he didn’t cite them.

Heck, he even referred to the risk of kids getting into the cannabis gummies. What that has to do with opioid treatment, I have no idea.

To its credit, the committee didn’t listen. In fact, the bill moves toward creating exeptions to the prior authorization requirement and orders studies of ways to further remove the obstacle.

It’s not the most courageous bill ever drafted, but H.222 is a solid step in the right direction. In a Legislature that too often reacts with timidity to substance use issues — and frequently overreacts to scare testimony — the committee’s unanimous approval of H.222 was a noteworthy achievement.

The bill still has a long way to go, and I wouldn’t be surprised at all if the governor gins up a reason to veto it. He is, after all, a big fan of moral hazard. Can’t let those druggies off the hook too easily, y’know.


2 thoughts on “Here’s the Early Favorite for 2023’s Saddest Piece of Legislative Testimony

  1. Tom Ziobrowski

    Hi John, I really look forward to your posts. This one on buprenorphine could use a clarification: Suboxone is the brand name for buprenorphine. They are the same medication.


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