Legislature(2017 - 2018)BELTZ 105 (TSBldg)
03/14/2017 01:30 PM LABOR & COMMERCE
Note: the audio and video recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
Download Mp3. <- Right click and save file as
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
SB 79-OPIOIDS; PRESCRIPTIONS; DATABASE; LICENSES 2:11:23 PM CHAIR COSTELLO announced the consideration of SB 79. She noted that the bill was introduced on behalf of Governor Walker. SB 79 helps address a major issue facing Alaska, an opioid epidemic. It is a national epidemic. She provided an example from the New York Times about a farmer who lost two children to opioids. She said this type of addiction can lead to heroin abuse and staggering problems across the country. Deaths related to opioid abuse have increased three-fold in the past seven years. She said SB 79 looks at a strategy in Alaska to prevent prescription pain killer abusers from becoming heroin users. In 2008 the legislature established a controlled substance database known as the Alaska Prescription Drug Monitoring Program. Last year the legislature identified ideas to help combat this issue through managing patient data. She shared another example of a parent in Juneau who lost a son in January. She maintained that the state has a moral obligation to address this issue because of the tremendous impact it is having on Alaska. She said this is the first hearing of SB 79. The intent is to hear from the sponsor, take members' questions, take public testimony, and then hold the bill for further consideration. 2:13:20 PM DR. JAY BUTLER, Chief Medical Officer, Department of Health and Social Services, commented that Chair Costello has nicely outlined the reason for hearing SB 79. He noted the increasing number of deaths due to opioid overdose, which has mirrored the increase in the rate of prescribing opioid pain relievers. Alaska is at a point where many people are dependent on or addicted to opioids and are more susceptible to heroin and fentanyl abuse. About 80 percent of those using heroin started their addiction by using prescription painkillers. DR. BUTLER spoke of an increase in rates of hepatitis C associated with drug use and more emergency room admissions. He emphasized that "all statistics are people with tears wiped away." He said that, today, most everyone has been touched by the opioid epidemic. 2:15:13 PM DR. BUTLER highlighted the need to address overdose, treatment of addiction, addiction as a chronic health condition, and prevention, including limiting legal and illegal opioids, involving law enforcement, curbing overprescribing, and addressing why people self-medicate. The bill is part of the larger response and is designed to encourage more evidence-based prescribing and limit the flood of opioid painkillers into communities. It intends to increase access to treatment and de- stigmatization by improving provider knowledge. SB 79 aligns with guidelines in SB 74 by healthcare boards, as well as with the Centers for Disease Control Pain Management Guidelines, the Surgeon General's Report on Alcohol Drugs and Health, and recent statements from the American Medical Association and the American Dental Association. 2:16:50 PM DR. BUTLER said SB 79 provides an option for patients who do not wish to be prescribed opioids to communicate their preference to their providers by way of a voluntary, revocable, opioid advance directive. This was a suggestion from the recovery community. It also allows patients to request from pharmacists, less than the total prescribed amount. He said SB 79 requires that five percent of providers' continuing education credits be committed to pain management and addiction. The bill sets limits on the initial opioid prescription to a seven-day supply. Exceptions can be made by providers in certain instances. SB 79 includes changes to the Prescription Drug Monitoring Program (PDMP), a centralized database where providers can go to look at a patient's prescription history. The bill authorizes the Pharmacy Board to issue routine, periodic, confidential reports to prescribers to provide feedback on their prescribing practices. He referred to a recent report in the New England Journal of Medicine that, using the Medicare Part D database, looked at prescribing habits of emergency room physicians. People who received opioids in the emergency department were more likely to have dependency a year later. There was a three- fold variation in the rate of prescribing opioids, which clearly demonstrated a lack of agreement among providers as to how to manage acute pain. He named states that have been effective in reducing the number of excessive prescriptions due to the non-punitive reports issued to providers. 2:20:20 PM DR. BUTLER spoke of two controversial aspects of the bill. One requires veterinarians who prescribe opioids to register and use the PDMP. The second controversial aspect is requiring daily updates of the PDMP to make it a more useful tool. 2:21:25 PM CHAIR COSTELLO noted that Public Safety Commissioner Walt Monegan is present and showing support for the bill. DR. BUTLER continued to say that 25 states have the requirement of daily updates of the PDMP. He stressed that the bill does not place blame. The goal is for everyone to be responsible for owning the problem and doing their part to address it. 2:22:52 PM CHAIR COSTELLO requested the sectional analysis. 2:23:13 PM DR. BUTLER presented the following sectional analysis for SB 79: 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. CHAIR COSTELLO asked if there are alternatives to opioids that doctors can use. DR. BUTLER said there are. He described the evolution over the past 20 years where opioids have become the first line of treatment for all pain. He noted the influence of market forces and the four-fold increase in prescribing and abuse, with no decrease in the level of pain. Physical dependency is also a factor. He shared that there are updated clinical guidelines for back pain by the American College of Physicians. Now, opioids are given as the third line of pain relief, starting with something like Tylenol and physical therapy. 2:26:11 PM CHAIR COSTELLO noted that the bill will be in committee again for further discussion. SENATOR HUGHES thanked Dr. Butler and expressed appreciation of the Governor's concern about the opioid crisis. She discussed liberal prescribing practices in the 90s and noted that today most doctors use opioids as a last resort. She asked how extensive overprescribing is today. DR. BUTLER opined that all providers use more opioids today than five years ago. He said overprescribing is spread across the profession nationally, but primary care providers prescribe more than half of all opioids. He pointed out that Oxycodone was heavily marketed to primary care providers. Heroin users switched to Oxycodone before 2010 because it was so prevalent and cheap. In the 90s there was a trend to be "pain free." He discussed the importance of pain and noted that it is subjective. It also can be debilitating and needs to be managed. SENATOR HUGHES asked Dr. Butler if he has access to the PDMP data to see who may be overprescribing. 2:31:23 PM DR. BUTLER said he does not. He explained that PDMP monitoring falls to the Pharmacy Board under SB 74, however, Public Health can access de-identified data for public health purposes. SENATOR HUGHES asked if law enforcement has access to the PDMP with a warrant from the DEA. DR. BUTLER said yes. 2:32:17 PM DR. BUTLER continued the sectional analysis of SB 79: 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. He provided an example of a 15-year-old who was prescribed Vicodin. He continued the sectional analysis of SB 79. 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. 2:35:21 PM 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. 2:37:29 PM CHAIR COSTELLO thanked Dr. Butler and opened public testimony on SB 79. 2:37:52 PM DANIEL NELSON, Director of Pharmacy, Tanana Chiefs Conference, presented concerns about SB 79. He agreed with the overall intention of the bill and noted a consensus amongst the entire medical community that opioid addiction is a huge problem. He addressed specific concerns in the bill. He pointed out that SB 74 from last year will not be implemented until July 17, 2017, and it contains several provisions that will significantly positively impact the inappropriate prescribing of opioids. It would make some things in SB 79 unnecessary. Also, there has been a lack of participation in drafting the bill by medical and pharmaceutical communities. Another concern is in Section 31 where there is a removal on the prohibition of sharing the PDMP information with the federal government, which would undermine public trust in PDMP. The requirement of daily updates to the PDMP is unnecessary and onerous. Finally, the voluntary non- opioid directive is unnecessary; no one is precluded from doing that now, and the partial filling of controlled substance prescriptions can be requested now. MR. NELSON stated support for the mandatory continuing education course. CHAIR COSTELLO noted Department of Health and Social Services Commissioner Davidson was present. 2:41:13 PM SENATOR GARDNER requested Mr. Nelson repeat the last sentence. MR. NELSON restated that the mandatory continuing education is beneficial. SENATOR STEVENS asked for clarification about partially filling a prescription at the patient's request. MR. NELSON explained that a pharmacist can fill a prescription using a lower quantity drug, at the patient's request. SENATOR STEVENS asked if pharmacists would be comfortable overriding a physician. MR. NELSON said only in that situation. 2:43:28 PM MICHAEL CARSON, Chair, Mat-Su Opiate Task Force, stated that the Task Force supports limiting opioid prescriptions to seven days and imposing stricter rules tied to the PDMP. He thanked Chair Costello for her introduction and confirmed that fatal overdoses have tripled in the state due to the increase of heroin abuse; fentanyl mixed with heroin is a factor. He said 80 percent of heroin users started with opioids. He concluded that the goal is to turn off the prescription spigot. 2:45:50 PM LEIF HOLM, Chair, Board of Pharmacy, voiced concerns with SB 79. He concurred with Mr. Nelson's testimony. He agreed it is necessary to find ways to combat the opioid epidemic. He maintained that the bill unfairly singles out pharmacists and looks to correct SB 74, which has yet to take effect. He stated that pharmacists have consistently spearheaded actions against the opioid epidemic, especially in finding funding sources for and using the PDMT. He questioned issues related to the partial- fill provision. He concluded that he opposes the bill in its current form. SENATOR GARDNER asked if partial fill and voiding the balance of a prescription is state law, and what needs to change to allow retention of the remaining prescription. MR. HOLM related that since July 2016 partial fills have been allowed without voiding the balance of a prescription. He stated support for that. SENATOR GARDNER asked how the bill could be written to ensure that a partial fill does not void the remaining amount. MR. HOLM suggested eliminating the phrase, "the remainder of the prescription is voided." 2:49:55 PM BARRY CHRISTENSEN, Co-Chair, Legislative Committee, Alaska Pharmacists Association, voiced concern with SB 79. He concurred with the previous testifiers, Mr. Holm and Mr. Nelson. He spoke of the poor timing, given the passage of SB 74. He shared the many contributions pharmacists have made to this issue and said many pharmacists feel that the Governor's press release put a negative spin on them. He voiced concern about patients being scared, due to tightening legislation, to refill medications for chronic pain management. He shared the risks related to patients suddenly quitting their pain meds. GERALD BROWN, Pharmacist, testified in opposition to parts of SB 79. He said many items in SB 79 are similar to those in SB 74. He suggested not holding the pharmacist in charge liable for failing to check the database, as written in Section 32. He pointed out the real control of abuse is when "the pen hits the paper." He commented on revisiting page 2 of the bill. CHAIR COSTELLO noted the people available to answer questions and invited them back the next time the bill is heard. She said she is keeping public testimony open. 2:55:25 PM SCOTT WATTS, Pharmacist, testified in opposition to parts of SB 79. He voiced appreciation for what the bill is trying to accomplish. He suggested that more input from pharmacy associations would help correct some of the problems in the bill. He said that daily monitoring of the database can be done electronically at his pharmacy if the bill passes, however, it may be more difficult for some pharmacies. He suggested having some implementation time for that. He pointed out that prescribers can check the PDMP database in their offices in advance. He said pharmacists don't always have the time to check the PDMP database, and they have better avenues to see about prescribing data and usage. He did not want to see daily checking of the database being a requirement. They are willing to maintain and enter the data in PDMP. He said he liked the ability to decrease the number of pills in the prescription. 2:57:39 PM SENATOR GARDNER asked if the database is confidential and requires logging in every time. MR. WATTS said correct. Pharmacists are waiting for SB 74, which allows for an agent to monitor the database. SENATOR HUGHES asked if there could be software to interface with PDMP to flag problems. MR. WATTS said there has been talk of that, but it is expensive. SENATOR COSTELLO held SB 79 in committee with public testimony open.