03/18/2017 03:00 PM House HEALTH & SOCIAL SERVICES

         HB 159-OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES                                                                     
                                                                                                                                
3:03:59 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  first order of business would                                                               
be 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."                                                                                 
                                                                                                                                
3:04:59 PM                                                                                                                    
                                                                                                                                
JAY  BUTLER, MD,  Chief Medical  Officer/  DPH Director,  Central                                                               
Office,  Division  of Public  Health,  Department  of Health  and                                                               
Social Services, stated  that there had been  a fourfold increase                                                               
in the number  of opioid associated deaths in the  past 20 years.                                                               
He declared that  this was an opioid epidemic,  pointing out that                                                               
no other cause  of death had increased so remarkably  over such a                                                               
short  period of  time.    He reported  that  there  was also  an                                                               
increase in  the rates of Hepatitis  C, as well as  other burdens                                                               
on  the  health care  system  associated  with increased  use  of                                                               
opioids, both  legal and illicit.   He said that there  were many                                                               
things that had  to be done, which would  require a multi-faceted                                                               
approach.   He  declared that  it  was necessary  to address  the                                                               
needs  of people  who were  currently struggling  with addiction,                                                               
and to prevent addiction through  more evidence based prescribing                                                               
practices,  control  the flood  of  prescription  opioids in  the                                                               
community,  and  address the  access  to  treatment and  the  de-                                                               
stigmatization  by improving  provider  knowledge.   He  reported                                                               
that there had been an  increase in illicit opioid use, beginning                                                               
with  heroin in  the  past  five years,  and  more recently  with                                                               
fentanyl and other  synthetic opioids.  He noted  that 80 percent                                                               
of   heroin   users   started  opioid   use   with   prescription                                                               
painkillers.     He  said  that   HB  [159]  aligned   with  many                                                               
prescribing  guidelines delivered  to  the  legislature from  the                                                               
health care  boards through Senate  Bill 74  in 2016, as  well as                                                               
the Centers  for Disease Control  and Prevention  pain management                                                               
guidelines, and  the Surgeon General's report  on alcohol, drugs,                                                               
and health.   He added  that recent statements from  the American                                                               
Medical Association and the American  Dental Association, as well                                                               
as   recommendations   for   evidence   based   improvement   and                                                               
prescription drug  monitoring from the PEW  Charitable Trust also                                                               
supported these guidelines.                                                                                                     
                                                                                                                                
DR.  BUTLER  offered  to  outline the  proposed  bill  for  three                                                               
particular areas: patients, providers,  and the prescription drug                                                               
monitoring program.   He  said that  proposed HB  [159] empowered                                                               
patients in  two ways, it  provided an  option for those  who did                                                               
not wish to be prescribed  opioids to communicate that preference                                                               
to the providers by way  of a voluntary revocable opioid advanced                                                               
directive  which could  be  placed  on the  medical  record.   He                                                               
shared that this had been  a request from the recovery community,                                                               
describing  the challenges  they faced  in interactions  with the                                                               
health care system  when a provider was unaware  that the patient                                                               
was  in recovery.   He  shared that  the second  way was  that it                                                               
allowed  patients to  request that  the pharmacist  dispense less                                                               
than the  total prescribed amount.   He said that a  partial fill                                                               
was  authorized under  federal law,  with  a goal  to affirm  the                                                               
rights of  the patient and the  authority of the pharmacist.   He                                                               
said  that a  portion  of the  continuing professional  education                                                               
that health care  providers must receive would  include a section                                                               
of  at least  two hours  designated  on pain  management and  the                                                               
basics of addiction  medicine.  He explained that  the renewal of                                                               
a  medical  license required  at  least  40 hours  of  continuing                                                               
medical education credit.  He  said that the second component for                                                               
providers  was a  setting of  dispensing limits  for the  initial                                                               
opioid prescription  to no more than  7 days.  He  added that the                                                               
proposed  bill did  allow exceptions,  when  in the  professional                                                               
judgment of  the provider, a  longer supply was necessary  due to                                                               
chronic  pain,  severe acute  pain,  cancer  pain, or  palliative                                                               
care, or  when a  longer supply  was necessary  due to  travel or                                                               
other logistical barriers.   The third component  was for changes                                                               
to  the  prescription  drug  monitoring   program,  a  data  base                                                               
accessible  to  prescribers and  dispensers,  in  order to  share                                                               
information about  controlled substances.   He declared  that the                                                               
data base was  secure and confidential, and  met the requirements                                                               
of  the  Health  Insurance  Portability  and  Accountability  Act                                                               
(HIPAA).   He added that  this database was not  openly available                                                               
to law enforcement without appropriate search warrant authority.                                                                
                                                                                                                                
DR. BUTLER  said that the  proposed bill authorized  the pharmacy                                                               
board  to   issue  routine   periodic  confidential   reports  to                                                               
prescribers to  provide feedback  on their  prescribing practices                                                               
relative to  those of their peers.   These "report cards"  were a                                                               
good  way  to  provide  feedback  for  providers  for  their  own                                                               
prescribing habits.  He said  that this had been proven effective                                                               
in   other  states   for  reducing   the   number  of   excessive                                                               
prescriptions with other  substances.  He stated  that the second                                                               
component  of the  changes to  the  prescription drug  monitoring                                                               
program  (PDMP) was  for clarification  to include  veterinarians                                                               
who  prescribe  opioids  to  register   and  use  the  monitoring                                                               
program.   He referenced recent media  reports regarding attempts                                                               
to get opioid medications from  veterinarians.  He explained that                                                               
the third  component was to make  the PDMP a more  useful tool by                                                               
providing that  pharmacists update  the data  on a  daily, rather                                                               
than  weekly, basis.   He  stated that  the proposed  bill had  a                                                               
zero-fiscal  note  from  the  Department  of  Health  and  Social                                                               
Services and the  Department of Corrections, and  a one-time cost                                                               
of $27,500 from the Department  of Commerce, Community & Economic                                                               
Development to  cover legal  costs to  amend the  regulations and                                                               
for printing.  He directed attention  to a letter of support from                                                               
the Alaska Dental Society.                                                                                                      
                                                                                                                                
REPRESENTATIVE  TARR asked  if  there had  been  a response  from                                                               
pharmacists regarding the more frequent updating of PDMP.                                                                       
                                                                                                                                
DR.  BUTLER said  that there  had been  this discussion  with the                                                               
pharmacists  and  that  DHSS shared  concern  for  any  increased                                                               
burden on the  smaller pharmacies. He explained  that there could                                                               
be a delay  for this requirement to take effect.   He pointed out                                                               
that  some  of  the  larger, more  automated  pharmacies  already                                                               
updated more frequently than currently required by law.                                                                         
                                                                                                                                
3:16:58 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ  asked about the  option for patients  to decline                                                               
the full prescription  amount, as it seemed  counter intuitive to                                                               
ask  permission to  accept less  medicine than  prescribed.   She                                                               
asked if that was not currently possible.                                                                                       
                                                                                                                                
DR. BUTLER  offered his belief that  "it depends on who  you ask"                                                               
and that federal  law had recently changed,  which clarified that                                                               
pharmacists  could  do a  partial  fill  at  the request  of  the                                                               
patient.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  KITO   pointed  out   that  there   were  certain                                                               
medications  which required  the  full regimen  to be  effective,                                                               
which could lead to some confusion.                                                                                             
                                                                                                                                
DR. BUTLER  acknowledged and  stated that  the law  specified for                                                               
federally designated  Schedule 2 controlled substances.   He said                                                               
that this  use for  full regimen may  have inadvertently  lead to                                                               
patient confusion with opioid prescriptions.                                                                                    
                                                                                                                                
3:19:16 PM                                                                                                                    
                                                                                                                                
DR. BUTLER paraphrased from the Sectional Analysis [Included in                                                                 
members' packets], which read:                                                                                                  
                                                                                                                                
     Sec.  1  Adds a  new  Chapter  55, Voluntary  Nonopioid                                                                    
     Directive   Act,   to   AS  13,   Decedents'   estates,                                                                    
     guardianships,  transfers,  trusts,   and  health  care                                                                    
     decisions,  that provides  an  option  for patients  to                                                                    
     execute  a  Voluntary  Nonopioid Directive  that  would                                                                    
     allow a  person in recovery  (or for other  reasons) to                                                                    
     make clear  the person's desire not  to be administered                                                                    
     an  opioid. A  person, guardian,  conservator or  other                                                                    
     appointed person  may revoke  a directive at  any time.                                                                    
     The person would  provide this confidential information                                                                    
     to  a  health  care  provider or  hospital  on  a  form                                                                    
     provided  by   the  Department  of  Health   of  Social                                                                    
     Services. The  department would  promulgate regulations                                                                    
     on  procedures,  confidentiality,  and  exemptions  for                                                                    
     emergency or substance  misuse treatment. Providers are                                                                    
     not  liable for  following  a directive.  Prescriptions                                                                    
     are  assumed to  be valid;  pharmacists are  not liable                                                                    
     for dispensing a  controlled substance in contradiction                                                                    
     to  a  directive.  The  directive  does  not  alter  an                                                                    
     advance  health care  directive, limit  opioid overdose                                                                    
     drugs,  or  limit  treatment  for  substance  abuse  or                                                                    
     opioid dependence.                                                                                                         
                                                                                                                                
     Sec. 2-25  Amend AS 08,  Business and  Professions, for                                                                    
     the  Boards   of  Dentistry,  Medicine,   Nursing,  and                                                                    
     Optometry to                                                                                                               
     • Require two  (2) hours of pain  management and opioid                                                                    
     misuse and addiction instruction;                                                                                          
     •  Disciplinary actions  for prescribing  or dispensing                                                                    
     an opioid  in excess of  the maximum dosage  allowed by                                                                    
     law or violated  a law related to  drugs, regardless of                                                                    
     any criminal action;                                                                                                       
     •   Set  the   maximum   dosage   for  initial   opioid                                                                    
     prescriptions  at a  seven-day  supply  unless, in  the                                                                    
     practitioner's professional  judgment, it  is necessary                                                                    
     for chronic pain  management or a patient  is unable to                                                                    
     access   a  practitioner   in   time   to  refill   the                                                                    
     prescription; and                                                                                                          
     •  Require, for  a minor  under  18 years  of age,  the                                                                    
     practitioner discuss  with the  parent or  guardian why                                                                    
     the prescription is necessary  and the risks associated                                                                    
     with opioid use.                                                                                                           
                                                                                                                                
     Sec. 26-27 Amend AS 08.80 for the Board of Pharmacy to                                                                     
     •  Register  with   the  Prescription  Drug  Monitoring                                                                    
     Database  (PDMP)   with  or  without  a   federal  Drug                                                                    
     Enforcement Administration registration number; and                                                                        
     •  Allow   pharmacists  to   dispense  less   than  the                                                                    
     prescribed amount  of a schedule  II or  III controlled                                                                    
     substance at a person's  request; the pharmacists would                                                                    
     inform   the    prescribing   practitioner    and   the                                                                    
     Prescription Drug Monitoring Database.                                                                                     
                                                                                                                                
     Sec. 28  Amends AS  08.98 for  the Board  of Veterinary                                                                    
     Medicine  to  •  Register with  the  Prescription  Drug                                                                    
     Monitoring Database  if the veterinarian has  a federal                                                                    
     Drug Enforcement Administration number; and                                                                                
     •  Identify  resources  and educational  materials  for                                                                    
     veterinarians to  identify clients  at risk  for opioid                                                                    
     misuse or diversion of prescribed opioids.                                                                                 
                                                                                                                                
     Sec. 29-36  Amend AS  17.30, Controlled  Substances, to                                                                    
     change   the  frequency   pharmacists  report   to  the                                                                    
     Prescription  Drug Monitoring  Database from  weekly to                                                                    
     daily;  remove the  prohibition on  sharing information                                                                    
     with  the federal  government. The  pharmacy board  may                                                                    
     provide  a  confidential  unsolicited  notification  in                                                                    
     summary form to a  practitioner's licensing board which                                                                    
     includes   the   basis   for  the   notification.   The                                                                    
     notification must  be provided  to the  practitioner as                                                                    
     well.                                                                                                                      
                                                                                                                                
     Sec.  37 Directs  the Department  of Health  and Social                                                                    
     Services   to  draft   regulations  to   implement  the                                                                    
     Voluntary Nonopioid Directive Act.                                                                                         
                                                                                                                                
     Sec. 38 Repeals  sunset dates in sections 52  and 73 of                                                                    
     Ch. 25, SLA 2016 (SB 74).                                                                                                  
                                                                                                                                
     Sec. 39-40 Set an  immediate effective date and provide                                                                    
     an effective date for regulations.                                                                                         
                                                                                                                                
3:28:24 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE EASTMAN asked for the type of information on the                                                                 
report cards and whether the confidentiality was discoverable in                                                                
any legal action.                                                                                                               
                                                                                                                                
DR. BUTLER explained that the report cards, as used in other                                                                    
states, would compare the usage over the previous 12 months with                                                                
other providers.   He replied  that he did  not know if  this was                                                               
discoverable in a legal situation.                                                                                              
                                                                                                                                
REPRESENTATIVE EASTMAN directed  attention to page 7,  [lines 8 -                                                               
9] of the  proposed bill, and questioned whether  there should be                                                               
sanctions  "regardless  of  whether  there has  been  a  criminal                                                               
action or patient harm."  He  expressed his concern, as there was                                                               
the possibility  of easily breaking one  of many, many laws.   He                                                               
asked  if  this  was  opening  up  the  providers  to  liability.                                                               
Although he  was unsure  of the  implications, he  suggested this                                                               
might require  the hiring of  extra staff to deal  with potential                                                               
technical violations,  or the  increasing of  insurance coverage.                                                               
He asked for the reason behind this language.                                                                                   
                                                                                                                                
DR. BUTLER offered  his understanding that this  language was not                                                               
new in this bill.                                                                                                               
                                                                                                                                
REPRESENTATIVE TARR  directed attention  to page 28,  Section 36,                                                               
of the proposed  bill, and stated that she was  supportive of the                                                               
idea  that providers  be  responsible,  benchmark their  practice                                                               
against  others,  and  adjust  their  own  prescribing  practices                                                               
accordingly.   She pointed out  that the language  was permissive                                                               
and not  required, and  asked if  this should  be required.   She                                                               
declared  that  providers were  part  of  the solution,  as  they                                                               
recognized  that   there  were  alternative  options   for  their                                                               
patients to address health care needs.                                                                                          
                                                                                                                                
DR. BUTLER explained  that the primary goal of Section  36 of the                                                               
proposed bill was  to provide authority to the  Board of Pharmacy                                                               
to issue  the report cards, and  whether or not it  was a mandate                                                               
was  a matter  of ideology.   He  said that,  as the  issuance of                                                               
these  types of  report  cards was  not  currently allowed  under                                                               
Alaska law, the desire was to establish the authority to do so.                                                                 
                                                                                                                                
REPRESENTATIVE   TARR   asked  if   the   board   had  a   better                                                               
understanding for whether this would  be voluntary.  She asked if                                                               
these were the recommendations from the task force.                                                                             
                                                                                                                                
DR. BUTLER, in reference to  the Alaska Opioid Policy Task Force,                                                               
said that a number of its recommendations were used in the bill.                                                                
                                                                                                                                
3:35:28 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ said that the bill would be held over.