Legislature(2017 - 2018)ADAMS ROOM 519
04/02/2018 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| HB268 | |
| HB221 | |
| HB400 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 268 | TELECONFERENCED | |
| + | HB 221 | TELECONFERENCED | |
| + | HB 400 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE BILL NO. 268
"An Act relating to the prescription of opioids;
relating to the Department of Health and Social
Services; 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; and
relating to the practice of optometry."
3:01:13 PM
REPRESENTATIVE LES GARA, SPONSOR, introduced himself.
CLAIRE GROSS, STAFF, REPRESENTATIVE GARA, introduced
herself.
Representative Gara explained that the difference between
the proposed Committee substitute (CS) and the original
bill was the transfer of requirements that were consistent
with the Center for Disease Control (CDC) guidelines for
informing patients about the dangers of opioid addiction
and reasonable drug alternatives. The change moved from the
legislature prescribing rules to allowing the board to
adopt their own regulations that were consistent with CDC
guidelines. The bill proposed to provide nine months for
the boards to adopt regulations.
Co-Chair Seaton MOVED to ADOPT proposed committee
substitute for SSHB 268, Work Draft 30-LS1081\E (Radford,
3/30/18).
There being NO OBJECTION, it was so ordered.
Representative Gara began the PowerPoint presentation: "HB
268 - Opioid Prescription Warnings." He referenced HB 159
[legislation pertaining to the prescription of opioids
passed in 2017], a bill sponsored by the governor. The
legislature since had learned about the addictive nature of
opioids, that 80 percent of those using heroin started on a
pain-killing drug, and that the longer a person used an
opioid the more likely one was to become addicted. He
relayed that the death rate from prescribed opioid overdose
in Alaska was about twice the national level. There was
still a gap between prescribers either being informed or
informing their patients of the dangers of opioids. He
shared that a number of states were adopting similar bills.
3:05:00 PM
Representative Gara moved to slide 2: "The Nationwide
Opioid Epidemic." Representative Gara continued discussing
the bill. He detailed that roughly 91 people died per day
from opioid overdoses.
Representative Gara scrolled to slide 3: "The Alaskan
Opioid Epidemic." He reported that heroin-associated deaths
in Alaska were 50 percent higher than the national average,
and there was a link between opioid addiction and heroin
use.
Representative Gara moved to slide 4: "Extended Opioid Use
Raises Risk of Addiction." The chart on the slide showed
that the longer a person was on an opioid prescription, the
more likely they would become addicted.
Representative Gara advanced to slide 5: "Link Between
Opioid Abuse and Heroin Addiction." He specified that
roughly 80 percent of those using heroine started out
misusing prescription opioids such as hydrocodone.
Representative Gara turned to slide 6: "HB 268":
Is a patient information bill which seeks to provide
new regulations for prescribing:
Dentists
Doctors
Podiatrists
Osteopaths
Nurses
Optometrists
Representative Gara reported that the bill was a patient
information bill. He considered that if patients were
informed about the dangers and addictive qualities of
opioids, it would be possible to find less dangerous
alternative treatments.
Representative Gara discussed the language from the bill on
slide 7: "HB 268 con't":
Requires the state Board of Dental examiners, the
State Medical Board, the Board of Nursing, and the
Board of Examiners in Optometry to adopt
regulations....
Representative Gara advanced to slide 8: "HB 268
Regulations":
Requiring prescribers to:
"Advise patients, using oral and written information,
before prescribing an opioid, of the potential dangers
of opioid addiction, and alternatives to the opioid
prescription the provider considers reasonable"
Representative Gara qualified that the bill would not
interfere with the provider-patient relationship. The
intent was to make the bill as simple as possible so that
it was useful for providers. The bill aimed to give boards
leeway to make exceptions to the requirement. The
requirement would generally apply to outpatients, and
providers could exempt classes of patients. He discussed
prescriptions of opioids for cancer patients and suggested
some thought that cancer patients did not need the same
information on the dangers of opioids. He thought a board
might determine that it was not sensible to have to provide
information in certain circumstances such as for Hospice
care patients. He discussed extenuating circumstances and
asserted that boards should have leeway.
Representative Gara discussed slide 9: "HB 268
Regulations":
The boards may:
"Determine which classes of patients may be reasonably
exempted from the information requirement and may
allow an exemption from the requirement for violations
the board considers to be unintentional, periodic
accidental violations, and for good cause, including
when a licensee needs to attend to the perceived
immediate health care of another patient."
Representative Gara scrolled to slide 10: "HB 268 DHSS":
HB 268 also requires that the Department of Health and
Social Services
"Post on the department's Internet website, and
provide access to a printable version of, a written
statement, which may include graphics, that provides
easily understandable information on opioids,
including the potentially addictive and harmful
qualities of opioids."
This written statement will assist prescribers in
complying with the patient information regulations
adopted by the state boards under this bill
3:09:30 PM
Representative Gara reviewed slide 11: "Making HB 268
Effective Without Hurting Doctor-Patient Relationship":
No civil liability for violating bill requirements
Prescribers given broad leeway to make honest mistakes
Representative Gara expressed that he did not want there to
be interference in the doctor-patient relationship by the
threat of lawsuits. He reiterated that the intent was to
give boards the ability to allow practitioners the leeway
to make honest mistakes.
Representative Gara explained how the idea for the
legislation was brought to his attention on slide 12: "CDC
Checklist for Prescribing Opioids: Bill Implements CDC
Opioid Crisis Voluntary Recommendations":
Bill Implements CDC Opioid Crisis Voluntary
Recommendations
The CDC recommends that prescribers discuss the risks,
benefits, and alternatives to opioid medication with
their patients when they prescribe ... and much more.
Representative Gara thought that many providers were
providing the opioid information, but many were not.
Representative Gara showed slide 13: "CDC Checklist for
Prescribing Opioids: Checklist for prescribing opioids for
chronic pain." He noted that the CDC guidelines were much
more comprehensive than what was proposed in the bill; and
boards could adopt more if desired.
Representative Gara reported on slide 14: "Why Inform
Patients?" He read the bubbles from the slide:
We know of no other medication routinely used for a
nonfatal condition that kills patients so frequently?"
Only about 5 percent of patients being prescribed
opioid painkillers are receiving them for chronic
pain. But that small group accounts for nearly three-
quarters of opioid prescriptions. 1
More than 70 percent of patients who die of opioid-
related overdoses became addicted while being treated
for chronic pain. 1
The CDC found that "many patients lack information
about opioids and identified concerns that some
clinicians miss opportunities to effectively
communicate about safety."
1.The Washington Post, CDC Warns Doctors About
the Dangers of Prescribing Opioid Painkillers,
(March 15 2016)
2.Dowell D, Haegerich TM, Chou R. CDC Guideline
for Prescribing Opioids for Chronic Pain United
States, 2016. MMWR RecommRep 2016;65(No. RR-1):1
49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
Representative Gara lamented that expanded opioid
information was not being communicated to patients in a
uniform way. The bill proposed to require providers to get
training to understand the dangers of opioids and
addiction.
Representative Gara looked at slide 15: "CDC Guidelines":
This first national guidance on the subject is
nonbinding, and doctors cannot be punished for failing
to comply.
...the head of the Centers for Disease Control and
Prevention, which issued the guidelines, said the
effort was critical to bringing about "a culture shift
for patients and doctors."
"Starting a patient on opiates is a momentous
decision, and it should only be done if the patient
and doctor have a full understanding of the
substantial risks involved."
--CDC Director Tom Frieden
Source: The Washington Post, CDC Warns Doctors About
the Dangers of Prescribing Opioid Painkillers, (March
15 2016)
Representative Gara stated that while there was not
conclusive proof, it was known that not all doctors were
providing the opioid information, and therefore the CDC had
issued the guidelines.
3:13:13 PM
Representative Gara advanced to slide 16: "Recognition that
Prescribers Don't Always Inform Patients about the Dangers
of Opioids." He read a portion of the slide:
This problem of overprescribing opioidsand, according
to other research, failing to warn patients about the
risks of dependence and overdoseisn't unique to
emergency doctors. Physicians in other specialties,
like internal medicine and primary care, prescribe
even more opioids, Barnett says. "The whole medical
community has a responsibility for this."
--TIME Health, How Doctors Are Fueling the Opioid
Epidemic (Feb 17, 2017)
Representative Gara relayed that other states had followed
the same approach as proposed in the bill. It was found
that emergency room doctors understood the need for greater
information as they witnessed the ill effects of opioids.
He referenced similar legislation in the states of Michigan
and Maine. He felt that the medical community was still
catching up to the body of information about opioids.
Representative Gara wanted to go through the presentation
quickly, and to provide additional information. There had
been progress with the bill. The Dental Society (a
prescribing authority) had testified as to the necessity of
the bill. Optometrists had a board and had not communicated
a position on the bill. Nurse practitioners had a board. A
board covering doctors and osteopaths had initially
objected to the bill and had referenced informed consent
from patients for any treatment from a physician. Most
recently the board for physicians had advised it was
considering regulations to comply with CDC guidelines. The
regulations of doctors would not govern dentists,
optometrists, and advanced nurse practitioners; who would
be governed by the bill. He considered that when the
physicians and osteopaths came onboard it would solve over
90 percent of the problem.
Representative Gara thought the bill was a matter of life
and death. He stated that the bill had addressed the opioid
issue in as non-intrusive a way as possible for medical
practitioners by giving them help and leeway to formulate
exceptions to the rules. He made himself available for
questions.
Co-Chair Foster relayed the available testifiers on the
bill.
3:17:34 PM
Co-Chair Seaton referred to slide 4 and asked about the
probability of using opioids for one year versus three
years. He wondered if it meant that only half as many were
continuing to use.
Representative Gara responded that the 1-year probability
was maintaining and overusing opioids for one year. The
number of people that used for 3 years was smaller. A
number of people that used for one year did not continue
for three years. The information was provided by the CDC
and was in the governor's packet from 2016.
Representative Wilson asked whether each board had a chance
to look at the bill and determine the outcomes.
Representative Gara responded that the Medical Board had
originally opposed the bill but was now coming onboard with
the legislation. He had no other information from the
Department of Commerce, Community and Economic Development
(DCCED) that other boards had adopted the regulations.
Representative Wilson asked if the boards had the chance to
discuss the legislation. She wondered if the bill had been
on any of their agendas, so it could be a full discussion.
Representative Gara responded that he had communicated with
boards through DCCED and had only heard a response from the
Medical Board. He stated there were some practitioners that
were supportive, and some that were not. For those who were
already providing the information would not be impacted. He
thought boards should be aware of the bill, which was pre-
filed. The current version of the bill was more relaxed in
terms of adoption of regulations.
3:21:30 PM
Representative Wilson asked how the bill would be policed.
She looked at page 3 of the "E" draft of the bill and
wondered how classes of patients would be reasonably
exempted. She asked about the term "good cause."
Representative Gara responded that "good cause" was a
commonly understood term, and a board could come up with
additional exemptions that it determined reasonable. He
used hospice patients and certain cancer patients as
reasonable examples of exemptions that would be under the
purview of boards. He reiterated the desire to leave boards
with leeway to make exceptions and interfere with the
patient-provider relationship as little as possible. He
stated that the term "reasonable" was also well defined in
law.
Representative Wilson asked about quantifying the
percentage of providers that did not provide expanded
opioid information.
Representative Gara argued that any providers not sharing
the information were too many. The CDC had decided that
enough providers were not providing information that it
necessitated the adoption of national guidelines, and a
number of states had addressed the issue as well. He
relayed that the head of the CDC had been very clear that
the evidence showed providers were not routinely giving out
the information.
Representative Wilson asked if the invited testifiers were
available.
Co-Chair Foster indicated that none of the invited
testifiers were not online.
Representative Gara argued that the bill was a policy call.
He continued that a number of practitioners had contacted
his office with support as well as opposition. He was
willing to listen to other medical board input and stated
that the Medical Board had already impacted the bill. He
was not interested in a response that included not wanting
to be regulated. He emphasized the need to mitigate the
deaths from opioid abuse and addiction.
3:26:41 PM
Representative Wilson agreed that the bill was a policy
call. However, she thought an invitation to testify should
be extended for boards. She questioned how to make a policy
call without input from medical boards.
Co-Chair Foster conveyed the names of others available to
testify on the bill.
Representative Gara responded that he had sat down with the
deputy director at DCCED that worked with boards. He had
authored letters requesting boards to comment and hoped for
a response by the time the bill moved to the other body. He
hoped the bill would not get held in committee. He believed
that having proactive legislation such as HB 268, would
result in boards examining the CDC guidelines and deciding
to make them mandatory.
Representative Wilson did not want to hold the bill in
committee. She wanted to understand what boards currently
required. She did not want to duplicate efforts that were
already in place.
3:29:17 PM
Co-Chair Seaton referred to slide 11 of the presentation.
He asked about the provision of no civil liability for
violation of bill requirements and wondered if it applied
to providers or boards.
Representative Gara informed that the former bill was a
requirement enforced in statute. The current bill simply
asked boards to adopt regulations, and the boards would
decide on punishment and the adoption of rules. There was
no civil liability attached to the bill.
Co-Chair Seaton wanted to make sure that the terms would
not prevent the boards from having sanctions on providers.
He discussed statistics associated with Medicare Part B
prescriptions. There were large areas of the state where
9.5 percent of all prescriptions for seniors were for
opioids; which was more than twice the national average. He
was very concerned that the problem was much greater than
was known. He agreed with the bill. He thought it was much
better for boards to be more involved in the process.
3:33:19 PM
Representative Guttenberg had no doubt that therapeutic and
behavioral health providers recognized that there was a
huge opioid epidemic. He did not believe that the medical
community thought it was their problem. He asked where the
doctors considered the problem came from, when a
significant part of the problem came from prescribing and
over-prescribing. He asked if doctors understood their role
in the matter.
Representative Gara thought many doctors and prescribers
had a good idea of the problem. However, he thought it was
true for every profession that some people did stronger
work than others. He was impressed with an emergency room
physician from Mat-Su that understood the problem and had
recommended passing a bill with a sunset. He chose to leave
the regulation to the boards instead. He referenced the
opioid addiction training required by HB 159, which had a
deadline in the following two months.
3:37:02 PM
Representative Guttenberg was concerned with the fact that
the boards had not come up with a policy to address the
problem.
Co-Chair Foster OPENED Public Testimony.
Co-Chair Foster CLOSED Public Testimony.
Co-Chair Seaton was confused regarding the effective dates
of the bill. He referred to page 7 of the bill. He read
from Section 7 and Section 8. He asked if there was some
contradiction in the language. He wondered if the dates for
implementing regulation was a long enough time period. He
thought it was important to raise the question earlier
rather than later.
Representative Gara stated he would provide greater detail
at the next hearing of the bill. He offered that the
department could put the information up on a website for
doctors to access. He wanted the bill to provide boards the
time to give public notice and perhaps retract and redo
regulations. The regulations would not have to be in place
until February 1, 2019.
Co-Chair Foster indicated that amendments were due on
Wednesday, April 4th at 5:00pm.
HB 268 was HEARD and HELD in committee for further
consideration.