Legislature(2017 - 2018)BELTZ 105 (TSBldg)

03/21/2017 01:30 PM LABOR & COMMERCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Governor's Appointees to State Boards & TELECONFERENCED
Commissions:
-- Above Item Removed from Agenda --
+ HB 48 ARCHITECTS,ENGINEERS,SURVEYORS: EXTEND BD TELECONFERENCED
Heard & Held
-- Public Testimony --
+ Bills Previously Heard/Scheduled: TELECONFERENCED
-- Public Testimony --
+= SB 79 OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES TELECONFERENCED
Heard & Held
Bill Postponed from 9:30 a.m. 3/21/17 Meeting
-- Public Testimony --
+= SB 71 COMMERCIAL FISHING LOANS TELECONFERENCED
Moved SB 71 Out of Committee
        SB 79-OPIOIDS; PRESCRIPTIONS; DATABASE; LICENSES                                                                    
                                                                                                                                
2:05:29 PM                                                                                                                    
CHAIR   COSTELLO  reconvened   the  meeting   and  announced   the                                                              
consideration  of SB 79.  She noted  it is  the second hearing  on                                                              
the bill.  The intention is  to look at  a sectional  analysis and                                                              
take  members' questions.  She noted  a letter  from Ms.  Chambers                                                              
pertaining to the bill.                                                                                                         
                                                                                                                                
2:06:35 PM                                                                                                                    
SARA  CHAMBERS,  Operations  Manager,  Division  of  Corporations,                                                              
Businesses,  and Professional Licensing,  Department of  Commerce,                                                              
Community  and Economic  Development (DCCED),  explained that  the                                                              
letter is in response  to a concern by Senator Hughes  that when a                                                              
person receives  a prescription that  meets a threshold  the Board                                                              
of Pharmacy  has set as a  policy call - visiting  five pharmacies                                                              
or five prescribers  within three months - it gives  a red flag to                                                              
the  prescriber.  In  the  Prescription  Drug  Monitoring  Program                                                              
(PDMP), at  the behest of  the Board of  Pharmacy, there is  a red                                                              
flag alert to potential problems.                                                                                               
                                                                                                                                
2:07:41 PM                                                                                                                    
CHAIR  COSTELLO noted  the letter  does not indicate  the  type of                                                              
prescriptions.                                                                                                                  
                                                                                                                                
MS.  CHAMBERS  offered  her  understanding  that it  is  only  for                                                              
scheduled drugs.                                                                                                                
                                                                                                                                
CHAIR COSTELLO  used an example  of someone with cancer  who would                                                              
use those drugs frequently and thus be targeted.                                                                                
                                                                                                                                
MS. CHAMBERS  said it is  only an alert  and does not  require any                                                              
action. It  is for the prescriber  to determine a  legitimate need                                                              
or not for the drugs.                                                                                                           
                                                                                                                                
2:09:50 PM                                                                                                                    
CHAIR  HUGHES voiced  concern about  all the  requirements put  on                                                              
pharmacists and  providers. She wondered if the  Prescription Drug                                                              
Monitoring Program  (PDMP) could be monitored by  one office, such                                                              
as  the  chief  medical  officer,   instead  of  by  providers  or                                                              
pharmacists, in order to target over-prescribers.                                                                               
                                                                                                                                
2:12:27 PM                                                                                                                  
JAY  BUTLER,  Chief  Medical Officer,  Department  of  Health  and                                                              
Social  Services (DHSS),  stated that  the question  about how  to                                                              
get information  back to  providers in the  most effective  way to                                                              
influence  prescribing   practices  is   at  the  center   of  the                                                              
discussion. The  current practice  of tracking doctor  shoppers is                                                              
not the  solution. The approach  in SB 79  is intended to  be non-                                                              
punitive  and educational,  such  as providing  a  report card  to                                                              
providers and  then comparing  that amount to  the average  of all                                                              
providers in the state.                                                                                                         
                                                                                                                                
He stated  that the  prescribing  rates today  are not lower  than                                                              
they  were  ten  years  ago.  He  maintained  that  the  level  of                                                              
prescribing is  not acceptable. He  said that prescription  use of                                                              
opioids  is one  of the  major  risk factors  for  heroin use.  He                                                              
referred  to  the  Centers  for  Disease  Control  and  Prevention                                                              
report  on risk factors  of long-term  opioid  use. One factor  is                                                              
having  a prescription  for longer  than  10 days.  The Annals  of                                                              
Surgery  study  found   that  72  percent  of   all  opioid  pills                                                              
prescribed  are not  taken. For  the most  common procedures,  the                                                              
majority  of patients  could  be managed  by  a one  to three  day                                                              
supply of pain medication.                                                                                                      
                                                                                                                                
2:17:06 PM                                                                                                                    
CHAIR  HUGHES asked  Dr. Butler  if he  has data  that shows  that                                                              
more doctors are prescribing more opioids in 2017 than in 2007.                                                                 
                                                                                                                                
DR. BUTLER  said Alaska data  is extrapolated from  national data;                                                              
it  indicates that  more  than half  of  opioid prescriptions  are                                                              
written by  primary care  providers. He  pointed to the  marketing                                                              
of opioids  to primary care  physicians in  the late 90s.  He said                                                              
he does not have the authority to look at PDMP data.                                                                            
                                                                                                                                
2:19:32 PM                                                                                                                    
CHAIR  HUGHES  questioned  whether  overprescribing  is  happening                                                              
generally or  by a few doctors.  She asked if it would  be helpful                                                              
if he could tell who is overprescribing.                                                                                        
                                                                                                                                
2:21:34 PM                                                                                                                    
DR. BUTLER said  if someone has the authority to  look at the PDMP                                                              
it would  be helpful.  He challenged  the concept  that "it's  the                                                              
bad actors" who  are overprescribing. He said he  does not believe                                                              
there are  many over-prescribers who  intend to do harm;  it's due                                                              
to a lack of knowledge.                                                                                                         
                                                                                                                                
2:23:47 PM                                                                                                                    
CHAIR  HUGHES   said  the   bill  is  here   partly  due   to  the                                                              
requirements of  the Board  of Pharmacy, but  she did not  want to                                                              
overburden the pharmacists.  Other states have allowed  the DEA to                                                              
monitor  the PDMP  and  find out  if it  is  prevalent across  the                                                              
board.  She asked  if he  could  find out  information from  other                                                              
states.                                                                                                                         
                                                                                                                                
DR.  BUTLER   said  they   already  have   that  information   and                                                              
recommendations  for   best  practices,  such  as   from  the  Pew                                                              
Charitable  Trust.   He  said  he   respects  the   concern  about                                                              
confidentiality  and patient  privacy that  has led  Alaska to  be                                                              
very careful  with  PDMP data. Some  of the  lessons learned  from                                                              
other states has gone into the drafting of the bill.                                                                            
                                                                                                                                
2:25:46 PM                                                                                                                    
CHAIR  HUGHES said  she  would like  to  know:  the percentage  of                                                              
providers  in other  states that  are  over-prescribers; and  what                                                              
happens to someone who has been found to over prescribe.                                                                        
                                                                                                                                
2:26:35 PM                                                                                                                    
MS.   CHAMBERS  stressed   the   importance   of  first   defining                                                              
overprescribing.  The  bill  sets  the  limit  of  a  prescription                                                              
supply at  seven days. Overprescribing  used to be  considered the                                                              
number of prescriptions.                                                                                                        
                                                                                                                                
She  said there  are penalties  in the  bill for  overprescribing,                                                              
but without  a further definition  of overprescribing it  would be                                                              
hard to enforce.                                                                                                                
                                                                                                                                
2:28:11 PM                                                                                                                    
CHAIR  HUGHES  asked if  there  is  some  exception to  the  7-day                                                              
prescription  supply for those  who live in  rural areas  and have                                                              
trouble getting to a pharmacy.                                                                                                  
                                                                                                                                
MS. CHAMBERS  said the bill makes  exceptions for that  and allows                                                              
for  professional  discretion  when  prescribing,  and  there  are                                                              
electronic  prescription options.  These  provisions are  concepts                                                              
that  the  Joint  Committee on  Prescriptive  Guidelines  came  up                                                              
with.                                                                                                                           
                                                                                                                                
She  agreed that  lack  of awareness  about  overprescribing is  a                                                              
topic  the  State  Medical  Board  is aware  of.  They  said  more                                                              
education is also needed about alternatives to opioids.                                                                         
                                                                                                                                
2:31:35 PM                                                                                                                    
CHAIR COSTELLO  referred to the  data on deaths related  to heroin                                                              
and  synthetic  opioids  in  the   State  of  Alaska  Epidemiology                                                              
Bulletin dated November  7, 2016. Fifty percent  were in Anchorage                                                              
and  Mat-Su. She  asked about  the connection  between heroin  use                                                              
and opioid addiction.                                                                                                           
                                                                                                                                
2:32:33 PM                                                                                                                    
DR. BUTLER described  the opioid epidemic in terms  of three waves                                                              
of a  tsunami. The first  wave was the  increase in the  number of                                                              
overdose  deaths related  to prescription  opioids. That  wave has                                                              
not fully  receded. The  second wave appeared  in about  2010 when                                                              
heroin  became   cheaper  and  more  available.   The  third  wave                                                              
appeared two  years ago  and is driven  by fentanyl  and synthetic                                                              
opioids. That  wave differs  because there is  not an  increase in                                                              
prescriptions   for  fentanyl.   These   substances  are   readily                                                              
available and can be ordered on the internet.                                                                                   
                                                                                                                                
He noted  that half  of deaths  are in  Anchorage and  Mat-Su, but                                                              
that is also  where 40 percent of the state's  population resides.                                                              
The  problem is  spread throughout  the  United States,  including                                                              
small Alaskan villages.                                                                                                         
                                                                                                                                
2:35:52 PM                                                                                                                    
CHAIR   COSTELLO  referred   to   drug  representatives   in   the                                                              
pharmaceutical  industry that  lobby doctors.  She asked  if there                                                              
is any  information about "performance  targets" for  doctors. She                                                              
asked if  they have considered  the pharmaceutical  company's role                                                              
in this epidemic.                                                                                                               
                                                                                                                                
2:37:26 PM                                                                                                                    
DR.   BUTLER  said   it's  important   that  prescribers   receive                                                              
information from  sources other than pharmaceutical  companies. He                                                              
spoke of  fines to  drug companies  for not communicating  dangers                                                              
of opioid dependency to physicians.                                                                                             
                                                                                                                                
He said they  would like to go toward "academic  detailing," which                                                              
is  based on  the concept  of what  is evidence  based in  medical                                                              
literature. The  goal is to learn  from past experiences  and look                                                              
at alternatives for pain management.                                                                                            
                                                                                                                                
2:39:30 PM                                                                                                                    
SENATOR GARDNER said  she has a disabled veteran  constituent with                                                              
chronic pain who  thinks the bill will punish people  in pain. She                                                              
asked  for assurance  that  there is  a  provision that  addresses                                                              
this type of exception.                                                                                                         
                                                                                                                                
2:41:12 PM                                                                                                                    
DR.  BUTLER  said  it  is  left  to  the  provider's  professional                                                              
judgement  as to  whether  a larger  dispensing  is indicated.  He                                                              
said there are exceptions listed in the bill.                                                                                   
                                                                                                                                
2:42:40 PM                                                                                                                    
SENATOR GARDNER  talked about a partial prescription  as requested                                                              
by a patient.  She asked if patients  that are in charge  of their                                                              
own pain management use less.                                                                                                   
                                                                                                                                
DR. BUTLER said he believes that is true.                                                                                       
                                                                                                                                
SENATOR  GARDNER  voiced concern  about  the voiding  of  leftover                                                              
pain  medication  from  a  partial  prescription.  She  asked  Dr.                                                              
Butler if he would  support an amendment to allow  the rest of the                                                              
prescription to be used.                                                                                                        
                                                                                                                                
2:44:23 PM                                                                                                                    
DR. BUTLER  said yes.  The bill attempts  to allow pharmacists  to                                                              
fill  only part  of  the prescription  at  the patient's  request.                                                              
Federal law  already allows that  to happen while not  voiding the                                                              
second half of the prescription.                                                                                                
                                                                                                                                
2:45:32 PM                                                                                                                    
CHAIR  HUGHES   asked  how   much  illegal   street  activity   is                                                              
attributed to prescription drugs versus heroin.                                                                                 
                                                                                                                                
2:46:07 PM                                                                                                                    
CAPTAIN MIKE DUXBURY,  Alaska State Trooper, Department  of Public                                                              
Safety (DPS), said  it depends on the location. He  said pills are                                                              
cheaper  in  Anchorage than  in  Western  Alaska. He  provided  an                                                              
example of supply and demand depending on location.                                                                             
                                                                                                                                
He  emphasized how  hard  it is  for  doctors  and pharmacists  to                                                              
understand  the lengths  a  person  might go  to  get drugs.  Some                                                              
people travel to other towns for doctor and pharmacy shopping.                                                                  
                                                                                                                                
2:49:08 PM                                                                                                                    
CHAIR HUGHES  referred to page  7 - a  report on the  Prescription                                                              
Drug Monitoring  Program (PDMP). She  asked what would  trigger 18                                                              
warrants for law enforcement to have access to PDMP in 2016.                                                                    
                                                                                                                                
2:50:01 PM                                                                                                                    
CAPTAIN  DUXBURY said  they work  closely with  the Department  of                                                              
Law  to get  those warrants.  Probable cause  is what  is used  to                                                              
obtain a  search warrant. They  see a great  deal of  opioid abuse                                                              
where heroin becomes the next step.                                                                                             
                                                                                                                                
He  described the  drug  problem  as a  "balloon  theory". If  you                                                              
squeeze a  balloon in your hands  it will pop out  somewhere else.                                                              
The  bill  would  provide  a  gradual  reduction  of,  and  better                                                              
control  of, consumption.  He added  that heroin  addiction has  a                                                              
very high death rate due to contaminated drugs.                                                                                 
                                                                                                                                
CHAIR HUGHES asked  what would cause the DEA to  get involved. She                                                              
also inquired  if State Troopers have  the tools to go  after drug                                                              
dealers of prescription pills and heroin.                                                                                       
                                                                                                                                
2:53:35 PM                                                                                                                    
CAPTAIN DUXBURY  spoke of  a lack of  officers and the  difficulty                                                              
of going  after small players,  causing them  to have to  go after                                                              
the  big ones.  They  work closely  with the  DEA  because of  the                                                              
DEA's resources and expertise.                                                                                                  
                                                                                                                                
2:55:15 PM                                                                                                                    
SENATOR  GARDNER  asked about  the  7-day  limitation  and how  it                                                              
relates to  the 10-day  prescription, which  is considered  a risk                                                              
factor.                                                                                                                         
                                                                                                                                
DR.  BUTLER said  there  is no  magic  to the  length  of a  7-day                                                              
prescription. He  noted that CDC  recommends no more than  a 3-day                                                              
supply; more  than a 7-day  supply is rarely  needed. It is  up to                                                              
the professional's judgement.                                                                                                   
                                                                                                                                
2:56:18 PM                                                                                                                    
SENATOR GARDNER  observed that  there is a  zero fiscal  note from                                                              
the department, and  asked if there will be a  financial impact to                                                              
practitioners, pharmacists, and others.                                                                                         
                                                                                                                                
DR. BUTLER  said it would be a  burden, but the payoff  of patient                                                              
safety and reduced cost due to death and disability is good.                                                                    
                                                                                                                                
MS. CHAMBERS noted  a fiscal note for the Department  of Commerce,                                                              
Community   and  Economic   Development  (DCCED)   to  cover   the                                                              
regulations required  by the various  boards that are  affected by                                                              
the changes due to the bill.                                                                                                    
                                                                                                                                
SENATOR  GARDNER said  many  parts of  SB 74  have  not gone  into                                                              
effect,   including  requirements   for   those   who  write   the                                                              
prescriptions  to  look up  patient  history  in PDMP  first.  She                                                              
asked if  it makes sense to  hold off on changing  requirements of                                                              
pharmacists.                                                                                                                    
                                                                                                                                
2:58:26 PM                                                                                                                    
DR. BUTLER clarified  that the intention of Section  32 is to have                                                              
a seamless process  where the prescriber is mandated  to check the                                                              
database before  prescribing a Schedule  II or Schedule  III drug,                                                              
and  the pharmacist  would populate  the  database. He  summarized                                                              
that  the prescriber  is subject  to disciplinary  action for  not                                                              
reviewing  the database  prior  to prescribing;  it  is not  meant                                                              
that the pharmacist must review the database before dispensing.                                                                 
                                                                                                                                
3:00:20 PM                                                                                                                    
CHAIR COSTELLO said that is not clear in the bill.                                                                              
                                                                                                                                
3:00:38 PM                                                                                                                    
SENATOR GARDNER said  she understands that the  pharmacist is also                                                              
a  practitioner  because they  can  give immunizations,  but  that                                                              
isn't the bill's intent.                                                                                                        
                                                                                                                                
DR. BUTLER suggested the Department of Law address the question.                                                                
                                                                                                                                
3:01:29 PM                                                                                                                    
STACIE KRALY,  Chief Assistant  Attorney General, Civil  Division,                                                              
Human Services  Section, Department  of Law, explained  that under                                                              
the Prescription  Drug Monitoring  Program, the pharmacist  is not                                                              
considered  a prescriber.  Rather,  the pharmacist  populates  the                                                              
data within the PDMP.                                                                                                           
                                                                                                                                
SENATOR GARDNER commented  that it's all about the  context of the                                                              
language.                                                                                                                       
                                                                                                                                
CHAIR  COSTELLO  asked how  it  is  determined  whether or  not  a                                                              
prescriber reviewed the database.                                                                                               
                                                                                                                                
MS.  KRALEY explained  that  when a  practitioner  signs into  the                                                              
PDMP it's  apparent that they've  accessed the information.  Prior                                                              
to Senate  Bill 74  the PDMP  was a voluntary  program.  That bill                                                              
made the PDMP mandatory  and changed from a 30-day  lookup to a 7-                                                              
day  lookup. SB  79 mandates  a one-day  look up.  She noted  that                                                              
Senate Bill  74 also allowed  for a licensed  delegate, such  as a                                                              
licensed pharmacy  tech or  licensed R.N., to  have access  to the                                                              
PDMP.  She described  the  changes  that Senate  Bill  74 made  as                                                              
critical   and   acknowledged   that   is   was   still   in   the                                                              
implementation phase.                                                                                                           
                                                                                                                                
3:05:48 PM                                                                                                                    
SENATOR   GARDNER  asked   what   proportion   of  providers   and                                                              
pharmacists are currently registered with the PDMP.                                                                             
                                                                                                                                
MS.  CHAMBERS  responded that  she  does  not  have the  Board  of                                                              
Pharmacy's  PDMP report with  her. There  is no  data on  how many                                                              
would  be  required  to  register   and  they  are  not  currently                                                              
required to track that information.                                                                                             
                                                                                                                                
3:07:22 PM                                                                                                                    
SENATOR GARDNER  asked how prescribers  and patients will  be made                                                              
aware of the non-opioid directive.                                                                                              
                                                                                                                                
3:07:46 PM                                                                                                                    
DR.  BUTLER responded  that  DHSS would  do  public outreach.  The                                                              
directive could also  be included on the medical  record. The bill                                                              
would  provide  a  waiver  for civil  or  criminal  liability  for                                                              
failure to  prescribe or dispense  an opioid. The intention  is to                                                              
have the  directive be  a communications  tool and avoid  creation                                                              
of liability.                                                                                                                   
                                                                                                                                
3:08:56 PM                                                                                                                    
SENATOR  GARDNER  wondered  about   marketing  drugs  and  whether                                                              
advertising contributes to the problem.                                                                                         
                                                                                                                                
DR. BUTLER  shared a story from  two years ago that  affirmed that                                                              
it does.                                                                                                                        
                                                                                                                                
CHAIR  COSTELLO  asked  if  the department  could  help  with  the                                                              
educational aspect.                                                                                                             
                                                                                                                                
DR.  BUTLER  said yes.  There  is  a broad  range  of  educational                                                              
messages, including  changing expectations of the  patient and the                                                              
provider   of  what   will   happen   when  someone   requires   a                                                              
prescription for a pain medication.                                                                                             
                                                                                                                                
3:10:50 PM                                                                                                                    
CHAIR  HUGHES  noted  there  has  been  a  decline  in  antibiotic                                                              
prescriptions.  She   asked  if  states  were  involved   in  that                                                              
process.                                                                                                                        
                                                                                                                                
DR. BUTLER  said it varied by  state; some states  received grants                                                              
from the federal  government and some grants went  to universities                                                              
with  medical  schools.  One  of   the  most  effective  education                                                              
methods is direct counseling to providers.                                                                                      
                                                                                                                                
3:12:03 PM                                                                                                                    
SENATOR  MEYER asked  about people  getting  pain medication  from                                                              
veterinarians and whether that is a factor in addiction.                                                                        
                                                                                                                                
DR.  BUTLER  said  there  have  been  several  reports  of  people                                                              
getting opioids from a veterinarian.                                                                                            
                                                                                                                                
3:14:06 PM                                                                                                                    
SENATOR MEYER  said opioid addiction  is a nationwide  problem. He                                                              
asked if  Alaska is doing what  other states are doing  to address                                                              
it.                                                                                                                             
                                                                                                                                
DR.   BUTLER  said   SB  79   mirrors   the  2016   STEP  Act   in                                                              
Massachusetts. Other  states that provided information  were Utah,                                                              
Arizona, and  Ohio; they  use the  concept of non-punitive  report                                                              
cards to providers.                                                                                                             
                                                                                                                                
3:15:50 PM                                                                                                                    
CHAIR  COSTELLO opened  public testimony  on  SB 79.  She noted  a                                                              
letter from Delta Junction.                                                                                                     
                                                                                                                                
3:16:17 PM                                                                                                                    
SCOTT ADAMS, representing  himself, expressed concern  with SB 79.                                                              
He said he  has a problem with  the 7-day supply limit;  it should                                                              
be  defined  by  the doctor  and  contributing  circumstances.  He                                                              
described his situation  in a rural setting and  his prescriptions                                                              
cannot  be electronically  faxed.  He suggested  when people  have                                                              
chronic  pain  or cancer  there  should  be  an exception  to  the                                                              
supply limit.                                                                                                                   
                                                                                                                                
3:19:18 PM                                                                                                                    
CHAIR  COSTELLO  closed public  testimony  on  SB 79  and  thanked                                                              
those who testified.                                                                                                            
                                                                                                                                
She referred  to a  letter from  Delta Junction  and asked  why an                                                              
education campaign  couldn't be the  solution to the  opioid issue                                                              
rather  than   record  keeping.   SB  74   would  have   reporting                                                              
requirements.                                                                                                                   
                                                                                                                                
3:20:19 PM                                                                                                                    
DR.  BUTLER  stated that  clinical  guidelines  are not  making  a                                                              
difference soon  enough. A  single answer is  not the  solution; a                                                              
multiple  approach is  needed  to address  the  broader issues  of                                                              
substance abuse.                                                                                                                
                                                                                                                                
3:22:15 PM                                                                                                                    
SENATOR  GARDNER suggested  the  previous caller  could have  been                                                              
told about the exceptions in the bill.                                                                                          
                                                                                                                                
DR. BUTLER agreed with both of Mr. Adams' points.                                                                               
                                                                                                                                
CHAIR COSTELLO suggested comparing Senate Bill 74 and SB 79.                                                                    
                                                                                                                                
CHAIR HUGHES  asked for  a list  of special  provisions/exceptions                                                              
in the bill.                                                                                                                    
                                                                                                                                
CHAIR COSTELLO held SB 79 in committee.                                                                                         

Document Name Date/Time Subjects