Legislature(2017 - 2018)HOUSE FINANCE 519
04/27/2017 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| HB159 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 159 | TELECONFERENCED | |
| += | HB 25 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE BILL NO. 159
"An Act relating to the prescription of opioids;
establishing the Voluntary Nonopioid Directive Act;
relating to the controlled substance prescription
database; relating to the practice of dentistry;
relating to the practice of medicine; relating to the
practice of podiatry; relating to the practice of
osteopathy; relating to the practice of nursing;
relating to the practice of optometry; relating to the
practice of veterinary medicine; related to the duties
of the Board of Pharmacy; and providing for an
effective date."
3:46:08 PM
DR. JAY BUTLER, CHIEF MEDICAL OFFICER AND DIRECTOR OF
PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES,
introduced the bill and read from prepared remarks:
I think everyone is aware that the opioid epidemic
continues. In 2016, over 90 of our fellow Alaskans
died of an opioid overdose. That's nearly three times
the number of Alaskans who died of AIDS at the peak of
the HIV epidemic. This represents nearly 1 in every 40
deaths that occurred in Alaska last year and often
times these deaths occur among our young people. Two-
thirds of these deaths involved a prescription opioid
painkiller and the majority of people who use heroin
or synthetic opioids report that they started and
became hooked using prescription opioids, often times
taken on the advice of a trusted healthcare provider
and a well-meaning healthcare provider.
But Alaska is responding through community coalitions
and even through state government. SB 91 passed by the
legislature and signed into law by Governor Walker on
March 21 [2016] authorized increased access to the
lifesaving drug naloxone and with federal funds it
made possible for us to be able to provide these
rescue kits. We've now distributed nearly 5,000 of
these around the state. I'm very pleased to say that
now in the public health centers, we have staff that
have received the trainer information so they could
also be able to distribute the kits locally to people
and save lives. We have a number of reports of people
who have been able to be revived using the kits. While
the kits can save a life, they really don't solve the
problem. They do not support people in recovery who
desperately want to continue to live in sobriety and
they don't address the underlying drivers that
increase the risk of opioid misuse and addiction. HB
159 adds to the state's multifaceted approach to
addressing the epidemic and it aligns with many of the
recommendations of the CDC (Centers for Disease
Control and Prevention) as well as the recent report
from the U.S. Surgeon General and a number of medical
professional societies and with some of the best
practices developed and adopted through the VA
[Veterans Affairs] system.
3:48:54 PM
Mr. Butler provided an overview of the legislation with
prepared remarks:
HB 159 can be viewed as addressing three areas. As a
mnemonic I think of it as the three "P"s: patients,
providers, and the prescription drug monitoring
program (PDMP). Regarding patients, there's two
aspects. First, the bill provides for an opioid
advanced directive as a communication tool between
patients and a provider that can be included in the
medical record. The directive makes it clear that a
patient does not wish to receive opioid medications.
The directive is purely voluntary and is revocable. As
a provider, I might not have thought this was
necessary, but as I've talked to a number of people in
recovery, as well as their families, they have
expressed concern that too many providers don't fully
understand the destructive effects of opioids for some
people. For some, they're the wrong drug at any time
at any dose.
The bill provides for a waiver of civil liability if
an opioid is withheld when a directive is in place and
also if an opioid is inadvertently administered when a
directive is in place. As might occur during an
emergency situation. The second aspect for patients:
the bill provides in state statute the authority for a
patient to be able to request a partial fill of an
opioid prescription if they wish to receive a smaller
number of pills and it reinforces the authority of the
pharmacist to be able to honor the partial fill
request without immediately voiding the remaining
portion of the prescriptions. This matches with a
federal authority under the Comprehensive Addiction
and Recovery Act of 2016. The bill does two things
relating to providers to advance patient safety and
improve care for persons with addiction or who are in
recovery. First, an analysis of data that was released
earlier this year shows that persons who receive
larger first time supplies of opioids are more likely
to be chronic opioid users and at greater risk of
dependency and addiction a year later. This risk
increases particularly for first time prescriptions
that are more than about 5 to 7 days in length.
3:51:11 PM
Mr. Butler continued to read from prepared remarks:
Recently we reviewed the Alaska Medicaid claims from
last year and found that roughly half of all first
time opioid prescriptions were for supplies of 15 days
or longer. Even if the drugs are not used they can
become a source of diversion and misuse in the
community. Another review published this month in the
Annals of Surgery showed that nearly three-fourths of
all the opioids prescribed to patients being
discharged from a hospital at the time of surgery go
unused. Therefore, HB 159 proposes that first time
prescriptions for acute pain be limited to no more
than a 7-day supply to define a safer standard of
care. This aligns with the CDC recommendations for
pain management, which recommends in general a 3-day
or less supply be prescribed, but points out that more
than 7 days is really an unusual indication.
Recognizing that opioids are appropriate for treatment
of some conditions, the limit is waived for severe
acute pain, chronic pain, cancer pain, palliative
care, or situations where travel logistics would make
it difficult to potentially get a refill or to see a
provider.
The reason for dispensing more than a 7-day supply
would be documented in the medical record. There's no
intention of limiting the access to care, but this
does provide a stop-check for the provider to consider
how much of the medication is really needed for a
given patient and have it documented in the medical
record.
Mr. Butler shared that he continued to hear stories from
Alaskans and provided detail about one case that had caught
his attention about a month back related to a school nurse
who had described how one of her students had undergone a
fairly minor orthopedic procedure. The student had come to
school the next day and as was required turned in his
prescription medications and had 120 Vicodin. He stressed
that there really was no indication for that. He hoped the
bill would encourage providers to stop and consider whether
a patient really needed that many pills. He continued to
read from prepared remarks:
The second provision for providers is the bill
authorizes the professional boards to require part of
the currently required continuing education credit be
designated to education in pain management or basics
of addiction medicine. For example, as a physician
every time I renew my medical license every other year
I have to provide documentation that I have received
40 hours of continuing medical education credit and
the bill would require that at least 2 of those hours
be dedicated to either pain management or addiction
medicine. It's important to recognize that even though
this is part of an opioid bill, the challenges with
substance misuse and addiction are much larger.
There's a similar number of Alaskans who have a
substance use disorder as the number of Alaskans who
have diabetes. It's important that all providers
understand the basic fundamentals of both of these
common chronic conditions, yet many more understand
diabetes than are aware of the special needs of
persons in recovery or how to approach the patient
who's struggling with addiction or a substance use
disorder.
3:54:50 PM
Mr. Butler continued to read from prepared remarks:
The science of treating substance use dependency and
addiction is evolving fast and this had been an area
of medicine that too many of us have ignored, and I'll
be among the first to say that I certainly ignored it
for a number of years, despite the fact that as an
infectious disease provider I was taking care of a
number of self-injection drug users. There's plenty of
good, free online continuing medical education [CME]
courses available. For example, the American Medical
Association has produced a fabulous CME module that's
entitled "A Primer on Opioid Mortality and Morbidity:
What Every Prescriber Needs to Know."
Mr. Butler added that the CME module did not only apply to
what every physician needs to know, what every ER doctor
needs to know, what "the other guy" needs to know, but what
every prescriber needs to know. He continued to address
prepared remarks:
The CDC has also produced a number of materials in
collaboration with the UW [University of Washington]
pain clinic that is also available online and includes
some of the questions that I hear from providers that
are most challenging. Such as - what do I do with the
patient who has chronic pain and has been on opioids
for years, it's not controlling the pain, they want
increasing doses, and I really worry about this
patient's safety?
Some of the CME modules even provide specialty
maintenance of certification credit, making the
training a two-for. They were really, I believe,
underused. We'd stress again that many of the options
that are available are free.
The third "p" is the Prescription Drug Monitoring
Program. As I said to this committee last year, the
PDMP is not a panacea, but it can be a useful clinical
tool. Although, it's a tool that only does the job if
it's actually used. I have to admit I'm not a natural
fan to PDMP, it's another step in the process of
patient care, but I've been impressed as I've talked
to some of my colleagues who've begun to use it - that
they have learned things that they did not know about
how to best take care of their patients. There's also
emerging data showing that in states that have had the
required mandate to use the PDMP, there's been about a
10 percent decline in Medicaid expenditures related to
opioid medications.
3:57:21 PM
Mr. Butler spoke to the three aspects of the PDMP with
prepared remarks:
It authorizes the Department of Commerce, Community
and Economic Development to issue regular, unsolicited
reports to prescribers, sometimes called report cards.
These would be issued to all providers registered in
the PDMP and it would simply provide a non-punitive
feedback source for each provider on his or her
prescribing practices for opioids and how that
compares to that of their peers. In talking with
colleagues and thinking about what are some of the
things that we need to do to address opioids, this is
a concept that was actually suggested to me by some
providers as a way to use the PDMP as an educational
tool and a self-check. Not unlike what's been done in
some healthcare organizations to provide feedback on
prescribing of antimicrobial drugs to be able to limit
unnecessary use of those drugs that can lead to
antimicrobial resistance. Roughly ten states have
instituted similar programs.
The second aspect of the PDMP - the PDMP depends on
timely data. Under SB 74 the reporting interval for
pharmacies went from monthly to weekly. HB 159
proposes to further increase the reporting interval to
daily as is already done in 25 other states. We do
recognize that this is an administrative burden for
some of our valued rural pharmacies who may not be as
automated and are still preparing for the advanced
weekly updates. The draft you have of HB 159 has an
implementation date in mid-2018 for advancement to the
daily updates to be able to give pharmacies time to be
able to get up to speed.
Finally, HB 159 clarifies a point that was discussed
during the SB 74 hearings last year and clearly
defines the role of veterinarians with active DEA
numbers and who have legal authority to prescribe
opioids, requiring them to register in the PDMP. While
I do not know how prevalent the problem is, perhaps
you've heard some of the reports from the Lower 48 of
people who've actually injured animals as a way to go
to the veterinarian and try to obtain opioid
medications for personal use or for diversion. The
goal of this portion of the bill is to help vets from
becoming the go-to for opioids to be misused or
diverted.
In closing, addressing the opioid epidemic in Alaska
is going to take all of us. I'm not here to blame
anybody and I think it's important that we don't go
down that road - we all have to own the problem and
address it. Congressman Hal Rogers from Kentucky,
Chair of the House Appropriations Committee is a
lawmaker that really has struggled with this and said
it well when he said "no silver bullet exists to stem
the tide of prescription drug abuse in America, the
lack of an easy solution requires all of us to treat
the opioid crisis as a nonpartisan issue and adopt an
all-hands-on-deck approach." I believe HB 159 is part
of Alaska's call for all-hands-on-deck to help support
our fellow Alaskans living in recovery and reduce the
number of persons who become newly dependent on these
medications, while protecting the care of those who
truly need them.
4:00:51 PM
Co-Chair Seaton referred to CDC recommendations distributed
by his office (copy on file). He was concerned about the
seven-day time limit language in the bill. He explained
that the CDC specified that three days or less was often
sufficient for acute pain and that more than seven days
would rarely be needed. He wondered how Dr. Butler would
feel about intent language in the legislation detailing
that although there was a seven-day maximum that it should
not be considered a standard and that prescribers should
err on the side of the lower limit if it appeared
sufficient.
Mr. Butler believed the idea was very reasonable because it
would not define the limitation prescriptively, but it
would reiterate the intent of the bill to keep the dose low
and the amount of pills as small as possible to meet the
clinical needs. The language would also provide the
flexibility for the professional judgement of the provider.
Representative Wilson thought it appeared government was
trying to play doctor with the legislation. She surmised
prescriptions of 120 pills at a time should already be
against the rules and that a bill should not be needed. She
thought the bill insinuated that controlling the amounts a
doctor could prescribe would solve the whole issue and that
the only place people were getting the drug was from
doctors. She asked if her understanding was accurate.
Mr. Butler answered "no, absolutely not." He did not
believe it was government's role to dictate how medicine is
practiced. However, he believed there was a role for
government to define some parameters, which sometimes may
require definition in statute to have the ability to
address the challenge of the large numbers of pills that
were sometimes dispensed. He referred to the current
medical, nursing, and pharmacy boards that issued licenses
and oversaw the quality of care. He detailed there were
times the state needed to help redefine and direct the
standard of care. He noted that medicine was certainly
practiced differently than it had been 100 years earlier.
Additionally, "where we are in 2017 is a little different
place than we were in 1997." He continued that there
clearly needed to be some sort of check, particularly when
it came to pain management. From about 1995 to 2010 the
nation started prescribing four-fold the number of opioids,
which had been accompanied by a four-fold increase in
overdose deaths; however, there was no evidence there had
been a decline in chronic pain. The nation had been "doing
something with the goal of an outcome that we didn't
achieve, with clearly adverse effects."
4:05:12 PM
Representative Wilson did not have a problem with a
standard of care. Her issue was with government identifying
the standard of care. She specified that physicians
attended school for a significant amount of time and were
required to have a certain number of continuing education.
She surmised the bill was trying to control doctors who
were prescribing too much; however, it would also regulate
doctors already using best practices. She wondered why the
medical board would not set the regulations and do its own
monitoring. She thought the board already had the tools to
handle the issue if a physician was overprescribing.
Mr. Butler responded by quoting a colleague who had
objected vociferously to some of the measures in SB 74
[Medicaid reform legislation passed in 2016] that "it seems
like just putting out clinical guidelines isn't changing
things fast enough." He underscored that the bill would not
make everything go away, but it was part of the way to
address the problem. He believed there were two aspects in
the practice of medicine where "we're not doing everything
we should." The first was addressing how pain is managed
and understanding that opioids are like a third level. He
referred to the recent guidelines from the American College
of Physicians and explained there was much more emphasis on
nonsteroidal anti-inflammatories, but also some alternative
pain management strategies including massage and physical
therapy. However, too often opioids were the first thing
that were used.
Representative Wilson did not understand why government was
managing doctors and why doctors were not managing
themselves. She wondered if the committee would hear expert
testimony from physicians about how practices had changed.
She did not think it was so simple that the problem would
be solved if government merely told doctors what to do or
how to prescribe.
Co-Chair Foster replied that his office would work with
Representative Wilson's office on her request.
4:08:29 PM
Vice-Chair Gara wanted to get at least a partial solution
out as soon as possible. He agreed that he did not see a
full solution in the legislation; however, he did not want
to slow down a partial solution just because no one had a
full solution at present. He shared he had experienced pain
from broken ribs and back surgery, but in his "limited pain
experiences" he had never wanted more than three days'
worth of a pain prescription. He wondered why there would
not be a three-day limit for certain types of pain and the
requirement for a doctor to explain in a patient's chart
the reason for needing to prescribe more than the three-day
limit (five to seven days).
Mr. Butler responded that he was unsure where the "sweet
spot" was. He believed the idea was to provide as much
opportunity for the professional judgement of the provider
to be able to determine the appropriate amount and to
define some guidelines and guardrails (that did not
currently exist) because some very large amounts of opioids
were sometimes dispensed. Additionally, the goal was to
call attention to the seven-day limit by requiring
documentation in the record. He had often heard physicians
prescribe something "just in case you need it." He believed
the strategy was probably not a good indication for
opioids, particularly if a prescription included 30 to 50
tablets. He shared that he had been surprised to find a
prescription of that amount in his medicine cabinet when
his daughter had recently had some dental work done.
Vice-Chair Gara agreed that the doctor would know best. He
reasoned discretion would still be given to the doctor if
there was a three-day limit with the option for a physician
to provide an explanation that a patient needed more. He
asked what happened when an individual did not live in a
location with a drugstore in rural Alaska. He asked how the
patient would receive a renewal in time if needed.
Mr. Butler answered that it was an aspect of the bill that
was fairly unique compared to the language in some other
states and compared to language in Senator John McCain's
bill introduced in the U.S. Senate. He detailed that HB 159
specifically called out the situation of the rural resident
who may have logistical or travel challenges being able to
get to a pharmacy as a valid waiver to the seven-day limit.
Co-Chair Foster requested to hear from Mr. Butler via
teleconference during the next HB 159 bill hearing.
HB 159 was HEARD and HELD in committee for further
consideration.
Co-Chair Foster addressed the schedule for the following
day.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB25_Support_042417.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 25 |
| HB25_Oppose_042417.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 25 |
| HB159 SB 79 Supporting Document LOS from ASHNHA.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 159 SB 79 |
| HB159_Amend_042417.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 159 |
| HB 25 - Amendments 4.27.17.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 25 |
| HB 159 -Background -CDC Guideline for Prescribing Opioids for chronic pain_2016.pdf |
HFIN 4/27/2017 1:30:00 PM |
HB 159 |