Legislature(2017 - 2018)BUTROVICH 205
03/13/2017 01:30 PM HEALTH & SOCIAL SERVICES
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SB 91-EXTEND DISASTER EMERGENCY: OPIOID EPIDEMIC 1:56:58 PM CHAIR WILSON announced the consideration of SB 91. 1:57:17 PM DR. JAY BUTLER, Chief Medical Officer, Department of Health and Social Services (DHSS), Juneau, Alaska, provided an overview of SB 91 as follows: In late 2016, DHSS competed for and was awarded a five-year grant by the Federal Substance Abuse and Mental Health Services Administration to support an opioid overdose prevention program that included the distribution of Naloxone, a drug that can be lifesaving when administered to someone who has stopped breathing due to an opioid overdose. The grant funds have been used to acquire the nasal spray form of the drug that is part of a rescue kit distributed through Alaska Project HOPE, "HOPE" standing for, "harm reduction overdose prevention and education." We worked with law enforcement in terms of how they might be able to best carry the kits to best administer them if needed during an emergency situation. Project HOPE has prioritized partnerships with staff of organizations that do not have medical direction, meaning that they would have someone who could issue a prescription for the drug and those who are most likely to be present when an overdose occurs such as for certain first responders and persons involved in recovery support. To provide the kits under a standing-medical order, the department explored a number of options. We were advised by the attorney general's office that the best option would be for the state-medical officer to issue a standing order and the authority for the standing order would require a disaster declaration. Governor Walker issued the declaration on February 14 with an anticipated legislative concurrent resolution that would extend the declaration for longer than the 30- day deration defined by Alaska statute. No state funds are required to support Project HOPE. Since the declaration, 12 organizations have already received the training including some that have received training-the-trainer training and are able to provide the kits and nearly 800 kits have been dispensed so far. This past Thursday we returned that the opinion of Legislative Legal is that a bill is required to extend the declaration and to continue the distribution of the kits under the standing order. 2:00:15 PM DR. BUTLER addressed the sectional analysis of SB 91 as follows: Section 1: Includes the findings of the extent of the public-health threat. Acknowledges and describes the governor's disaster declaration, and the need for legislation to extend the declaration. Section 2: Extends the February 14, 2017 disaster declaration for 1 year to February 14, 2018. Section 3: Makes the effective date retroactive to March 15, 2017 when the current disaster declaration expires. SENATOR MICCICHE asserted that he is an active supporter of dealing the state's opioid crisis. He asked for an explanation of the emergency declaration's criteria under federal law. He inquired if the emergency declaration was actually appropriate. 2:01:36 PM STACY KRALY, Chief Assistant Attorney General, Alaska Department of Law, Juneau, Alaska, addressed the emergency declaration from SB 91 as follows: This is a state emergency declaration, not a federal declaration. Under current state statute there is a mechanism under the public-health authorizations under Title 18 and also under the Military and Veterans Affair statutory authorizations under Title 26 that provides for the issuance of a declaration of an emergency. If you look in particular under AS 18.15.390 which are the powers of the department in a public-health disaster, the department can work with the Department of Military and Veterans Affairs to initiate a public- health emergency under the auspices and authorities that Military and Veterans Affairs as under AS 26.23.020; so they kind of work in conjunction with each other generally and under emergency declaration are done for flooding, that's the most recent one that happened, ice jams and flooding and that sort of thing so there would be an emergency declaration through the Department of Veterans and Military Affairs that would provide the department authorization to provide certain services and funding in many cases to address this emergency, an earthquake or something like that. What has also happened though is that the Legislature through the public health statutes, like I said under Title 18, has given the department the authority to use the mechanisms of a disaster declaration for purposes of a public-health emergency and that is what we have done under this context; so they work together a little bit different. We use the same framework and format under the emergency declaration for the Veterans and Military Affairs, but it is used for a public health emergency which is what we've done in this context. SENATOR MICCICHE asked if the federal grants that are funding the program requires a disaster declaration. 2:04:19 PM MS. KRALY answered no. She continued as follows: What we were very clear in the emergency declaration when we crafted it for the governor's office is that there were going to be no additional funds that were going to be administered generally when an emergency happens like I was explaining previously; say the flood, there's a need for an expenditure, some financial outlay by the Legislature to help address the emergency. This grant was applied for and was received long before this declaration was received, so there's no addition fiscal outlay or request being made as a result of this declaration. CHAIR WILSON stated the following: Our offices looked into this a little bit and working with the department and the state as well and first we want to thank the governor for raising awareness to this issue. We all want here to save lives and we understand, but I do want to put this in perspective, if we will have a conversation to make sure we have clearness upon what is needed and what is being asked for. CHAIR WILSON asked if Alaska has already received the $4 million. DR. BUTLER answered yes. CHAIR WILSON asked him to verify that the declaration is not needed for the expenditure of the $4 million. DR. BUTLER answered correct. CHAIR WILSON summarized as follows: Really what is being asked for is that the medical director could have these special privileges to help dispense Naloxone throughout the Alaska communities and this would allow him to do that both allow this position to do that for the one year until the end date of this declaration. 2:06:11 PM DR. BUTLER answered correct. CHAIR WILSON asked if a bill could be drafted rather than an emergency declaration. DR. BUTLER answered that he supported any means in addressing opioid overdose prevention. CHAIR WILSON noted that Dr. Butler had the emergency declaration privilege within the 30 days. He asked if SB 91 extends the privilege for 30 days or would the bill be a stop-gap if the Legislature does not act within the 30-day timeframe. DR. BUTLER answered as follows: The current disaster declaration will expire on March 15, so if there is a gap period it means we would stop the dispensing of the kit until we can get a resolution for this issue. SENATOR VON IMHOF asked him to verify that the state received the federal Substance Abuse and Mental Health Services Administration (SAMHSA) grant of $4.1 million. DR. BUTLER answered correct. SENATOR VON IMHOF assumed that the program's success required as many caregivers as possible to have access to the kits in order to deliver Naloxone. DR. BUTLER specified that the persons who may be administering Naloxone did not have to be a health-care provider. 2:08:21 PM SENATOR VON IMHOF asked to confirm that Naloxone requires a doctor's approval of some sort in order to administer, something that is not always time efficient and not always possible in emergency situations. DR. BUTLER answered correct. SENATOR VON IMHOF stated that one way to circumvent the doctor's approval is by claiming an emergency disaster. She asked if circumventing approval by a doctor was the intent of the emergency disaster declaration. DR. BUTLER specified that the disaster declaration allows the standing order to be created to be able to provide that pre- existing prescriptive authority so that the kits could be available to people who are most likely to be present. SENATOR VON IMHOF asked him to verify that a blanket authority would be extended to the on-the-ground health-care providers that are in the emergency situation DR. BUTLER answered correct. SENATOR VON IMHOF replied that she understood the reasoning behind getting 800 kits out and distributed as quickly as possible without having the cumbersome aspect of having an individual doctor's approval each time. She stated that the question remained if an emergency declaration is required versus the statute process. She asked Dr. Butler if he would support extending the declaration 30 days to buy time for the committee to write up a statute for a 1-year authority period. 2:10:08 PM DR. BUTLER reiterated that he supported however the authority can be established to distribute the kits. He pointed out that the funding is for five years and asked if the prescriptive authority can be considered for a longer period. SENATOR GIESSEL quoted the statute that cited the declaration of disaster under AS 26.23.020 and commented as follows: "This emergency declaration allows the allocation of medicine or supplies to address the emergency;" it is only for 30 days, it is a standing order as Dr. Butler has pointed out. The medication in the overdose kit is a prescription medication, consequently he, as the state's medical officer, can write a blanket prescription allowing the training of personnel, of citizens in the proper use of these, it's a nasal spray, but it does require the prescription. To extend this only for 30 days does not really address the problem and the state medical director has provided us with some information about the size of this problem and it will take more than just another 30 days to address it properly. SENATOR BEGICH asked to confirm that the legislation would do what Senator Giessel referenced in statute. SENATOR GIESSEL answered yes. 2:12:54 PM CHAIR WILSON asked Dr. Butler to explain the numbers that are referenced in the bill on page 1, lines 9-13. DR. BUTLER confirmed that heroin-associated deaths more than quadrupled from 2009 to 2015, from 7 deaths to 38 deaths in 2015. CHAIR WILSON noted that in 2014 approximately 500 doses of Naloxone was given out. He asked Dr. Butler if he knew how many kits are planned to be administered for the first year. DR. BUTLER replied that the goal is to distribute 5,000 kits. 2:16:32 PM CHAIR WILSON noted constituency concerns that wide availability of Naloxone may have a negative impact on society as a "Get out of death for free card." He asked if there is concern that the $4 million will just be used for Naloxone rather than putting funds further upstream to get to people before they use opioids. DR. BUTLER specified that Naloxone can save a life, but does not cure the addiction. He concurred that Naloxone is not the only approach to address the opioid epidemic. He set forth that access to treatment and the stigma often associated with addiction must also be addressed. He added that how pain is being managed with opioids is another area that must be assessed. 2:20:51 PM SENATOR MICCICHE asked how other states are dealing with the opioid epidemic. DR. BUTLER replied that like Alaska, other states are also taking a multi-faceted approach that includes allowing the state medical officer to issue a standing order, address drug monitoring programs, continued medical education to providers on pain management and addiction, and limiting the number of opioid pills that can be dispensed. SENATOR MICCICHE asked if there is a "good samaritan" law that covers someone administering Naloxone. 2:24:06 PM MS. KRALY replied that she would take a look at the general "good samaritan" laws of the statutes and provide a more thorough answer of how those would apply. CHAIR WILSON asked if training certificates will be provided to show that a person was well trained for administering Naloxone. He opined that certification would apply to "good samaritan" laws that a person was trained within the authority of what they do. DR. BUTLER explained that the kits have pre-packaged Naloxone nasal spray to simplify administering the drug. He detailed that training is fairly simple and provided a step-by-step process for administering Naloxone. SENATOR MICCICHE asked if the state was in the right place "mechanically" in training for administering Naloxone. 2:28:05 PM ANDREW JONES, Section Chief, Emergency Programs: Health Emergency Response Operations, EMS and Trauma, Division of Public Health, Department of Health and Social Services, Anchorage, Alaska, announced his availability to address how the overdose kits are administered. CHAIR WILSON asked Mr. Jones to address Senator Micciche's inquiry on Naloxone. MR. JONES explained that Health Emergency Response Operations, Emergency Medical Services (EMS) and the Trauma System have a comprehensive and customized training program to meet the needs of Alaskans. He detailed that training is hands-on, one-on-one that is similar to CPR training. He noted that individuals that receive training get a card to show that they were trained. He revealed that training-on-training has an application process and the thorough training takes a few hours to complete. He explained that the intent of the program was to compliment SB 23 and one of the parts of the bill says, "An employer or volunteer of the overdose program with training can administer the lifesaving drug." He said the intent was for the state to create an umbrella-program with a goal to get the kits into the hands of the non-profits, the peer-recovery groups, the people who are in connection with individuals who are either going through recovery or may actually be using on a day-to-day basis. He addressed Senator Micciche regarding a disaster declaration and specified that the two things that are always analyzed and asked is: loss of life, and loss of property. He said the $4 million federal grant will assist with getting the medication out in an efficient and quick manner to save lives. 2:30:36 PM CHAIR WILSON asked if DHSS would come back in 2018 after the declaration is done and ask the Legislature to issue the medical director's position the same clearance to authorize dispensing. He asked if responding to the request would be best done through a bill process or continue a year-to-year process. DR. BUTLER opined that the most efficient response would be the bill process. SENATOR VON IMHOF said she was pleased the state received the $4 million SAMHSA grant; however, she posed that using a declaration of disaster emergency to implement the program opens the door to potential risk of open-ended funding in the future. She noted that legal opinion was sought and pointed out that there is a risk. She said as a person sitting on the Senate Finance Committee, she acknowledged the risk and asserted that she would like to explore an alternative option if the same thing can be accomplished. 2:33:27 PM DR. BUTLER reiterated that his objective is to maintain the program and save lives in whatever way that is optimal. MS. KRALY explained that the emergency declaration that was signed by Governor Walker was very narrowly crafted to specifically address the concerns that Senator von Imhof raised. She revealed that an emergency declaration was the quickest way to get the kits into Alaska's communities. 2:36:42 PM SENATOR GIESSEL noted that the Mat-Su has an opioid response team, a community group that has come together to address the issue in the Mat-Su Valley. She disclosed that Anchorage is forming a similar group. She asked Mr. Jones if he knows if a response team is formulating in Fairbanks. MR. JONES answered that a Fairbanks has a collation as well as numerous collations throughout the state. He said the intent is to provide tools and capabilities to empower communities for a long-term response. SENATOR GIESSEL asked Mr. Jones what Naloxone's side effects are and the result if the drug is mistakenly administered to someone that is not having an opioid overdose. MR. JONES answered that the side effects are minimal, unless the person is allergic specifically to Naloxone, a situation that has very few cases of occurrence in the U.S. He said most of the times what ends up happening if an individual is overdosing and it is not an opioid, the person probably will not wakeup and that's when CPR is administered. SENATOR GIESSEL asked Mr. Jones if he knew much about the state's "good samaritan" laws in reference to liability for Naloxone. 2:39:21 PM MR. JONES revealed that one of the statutes as a result of last year's legislation from SB 23 addressed liability and gross negligence. He explained that gross negligence would occur if a person had an overdose kit but did not administer Naloxone. He added that administering CPR is covered under the "good samaritan" law, as long as gross negligence is not applied. SENATOR GIESSEL asked Dr. Butler if he could elaborate on Naloxone's side effects and liability related to the "good samaritan" law. DR. BUTLER concurred with Mr. Jones that nothing will happen to a person that is administered Naloxone if the individual is not experiencing an opioid overdose. He detailed that the person will not wake up, but 9-1-1 should be called and CPR administered by someone that is trained. 2:41:17 PM CHAIR WILSON opened public testimony. 2:41:47 PM KARA NELSON, representing self, Juneau Recovery Community Organization, Juneau, Alaska, testified in support of SB 91. She said the opioid epidemic is an emergency and people are dying. She asserted that Naloxone is needed. She revealed that she has been trained in administering Naloxone and has done so in overdose situations. 2:44:55 PM MICHAEL CARSON, Vice President, MyHouse Mat-Su, Wasilla, Alaska, testified in support of SB 91. He noted that he is also the chairman of the Mat-Su Opioid Task Force. He detailed that MyHouse is one of the non-profits that would benefit from the wide distribution of Naloxone kits. He concurred that the state's heroine increase has, "Gone up through the roof." 2:48:27 PM MIKE COONS, representing self, Palmer, Alaska, testified in opposition of SB 91. He revealed that he was a paramedic for 22 years. He opined that distributing Naloxone will be a failure and may even add to increased deaths of opioids by enabling addicts. He said he objected to the use of federal funds to pay for the $4.1 million grant to the state for disaster relief. CHAIR WILSON clarified that the $4.1 million comes from a SAMHSA grant. MR. COONS replied that the grant still comes from taxpayer dollars. 2:51:27 PM JOHN GREEN, representing himself, Wasilla, Alaska, testified in support of SB 91. He revealed that his daughter died from a heroin addiction. He set forth that recovery resources should be made available in order to save lives. 2:54:12 PM CHAIR WILSON closed public testimony. He asked Dr. Butler about the "after effect." He remarked that the possible side effects from receiving Naloxone was overlooked. He asked Dr. Butler if an individual's state of mind and behavior is affected from Naloxone. DR. BUTLER replied that Naloxone does not cure addiction. He emphasized that addiction is a chronic health condition that requires management. He noted that the community coalitions play an important role in addiction recovery. CHAIR WILSON asked Dr. Butler to address the effects of what happens to a person right after receiving Naloxone. 2:56:55 PM DR. BUTLER replied that the effects are dependent on the situation. CHAIR WILSON inquired if there is a risk of the person being aggressive after being administered Naloxone. He asked if the effects from Naloxone and the risks are being covered in training. DR. BUTLER explained that the acute effects that are experienced by the person who receives the Naloxone is going to be driven somewhat by the dose and strength of the opioid. He added that the amount of Naloxone administered is important to get someone to start breathing again, but to avoid going into acute withdrawal. He pointed out that acute withdrawal is very unpleasant with the possibility for vomiting. SENATOR BEGICH noted that typically a "findings section" is not included in legislation and recommended that the section be eliminated from the bill. 2:59:59 PM CHAIR WILSON detailed that his intent is to introduce a committee substitute at the next committee meeting. He said he hoped to get the bill out of committee as soon as possible so that the work of DHSS is not hindered. He commented on the bill as follows: I don't think anyone here in the committee doesn't think that every life is valuable to be saved and we thank the administration for putting this forth and this plan together. I think that we've all had our own experiences with this issue one way or another, but we just want to make sure that we are looking at this as a whole. It is my viewpoint that we are addressing not just down-the-river, but we can go further upstream as possible. CHAIR WILSON held SB 91 in committee for future consideration.