Legislature(2017 - 2018)BELTZ 105 (TSBldg)
03/21/2017 01:30 PM LABOR & COMMERCE
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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.