Legislature(2017 - 2018)HOUSE FINANCE 519

04/27/2017 01:30 PM FINANCE

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Audio Topic
03:44:49 PM Start
03:45:07 PM HB159
04:14:01 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Delayed to Ten Minutes Following Session --
+= HB 159 OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES TELECONFERENCED
Heard & Held
+= HB 25 INSURANCE COVERAGE FOR CONTRACEPTIVES TELECONFERENCED
Scheduled but Not Heard
+ Bills Previously Heard/Scheduled TELECONFERENCED
                  HOUSE FINANCE COMMITTEE                                                                                       
                      April 27, 2017                                                                                            
                         3:44 p.m.                                                                                              
                                                                                                                                
                                                                                                                                
3:44:49 PM                                                                                                                    
                                                                                                                                
CALL TO ORDER                                                                                                                 
                                                                                                                                
Co-Chair Foster called the House Finance Committee meeting                                                                      
to order at 3:44 p.m.                                                                                                           
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Neal Foster, Co-Chair                                                                                            
Representative Paul Seaton, Co-Chair                                                                                            
Representative Les Gara, Vice-Chair                                                                                             
Representative Jason Grenn                                                                                                      
Representative David Guttenberg                                                                                                 
Representative Scott Kawasaki                                                                                                   
Representative Dan Ortiz                                                                                                        
Representative Lance Pruitt                                                                                                     
Representative Steve Thompson                                                                                                   
Representative Cathy Tilton                                                                                                     
Representative Tammie Wilson                                                                                                    
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
None                                                                                                                            
                                                                                                                                
ALSO PRESENT                                                                                                                  
                                                                                                                                
Dr. Jay Butler, Chief Medical Officer and Director of                                                                           
Public Health, Department of Health and Social Services                                                                         
                                                                                                                                
SUMMARY                                                                                                                       
                                                                                                                                
HB 25     INSURANCE COVERAGE FOR CONTRACEPTIVES                                                                                 
                                                                                                                                
          HB 25 was SCHEDULED but not HEARD.                                                                                    
                                                                                                                                
HB 159    OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES                                                                               
                                                                                                                                
          HB 159 was HEARD and HELD in committee for                                                                            
          further consideration.                                                                                                
                                                                                                                                
3:45:07 PM                                                                                                                    
                                                                                                                                
Co-Chair Foster reviewed the meeting agenda.                                                                                    
                                                                                                                                
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.                                                                                                                            
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
4:14:01 PM                                                                                                                    
                                                                                                                                
The meeting was adjourned at 4:14 p.m.                                                                                          

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