Legislature(2017 - 2018)BELTZ 105 (TSBldg)

04/14/2017 09:00 AM LABOR & COMMERCE

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09:35:02 AM Start
09:36:38 AM SB79
10:43:40 AM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Delayed to 9:30 a.m. --
+ Bills Previously Heard/Scheduled: TELECONFERENCED
Moved CSSB 79(L&C) Out of Committee
         SB  79-OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES                                                                     
CHAIR COSTELLO announced  the consideration of SB  79. She stated                                                               
that  her aide  would present  the proposed  committee substitute                                                               
(CS) and Dr. Butler would provide his view of the changes.                                                                      
9:36:38 AM                                                                                                                    
SENATOR  STEVENS moved  to adopt  the work  draft CS  for SB  79,                                                               
labeled 30-GS1021\J, as the working document.                                                                                   
CHAIR COSTELLO objected for an explanation of the changes.                                                                      
9:36:52 AM                                                                                                                    
WESTON   EILER,  Aide,   Senate  Labor   and  Commerce   Standing                                                               
Committee,   Alaska  State   Legislature,   explained  that   the                                                               
administration  brought the  changes forward  in response  to the                                                               
concerns  articulated by  the  Alaska  pharmacist community.  The                                                               
concerns  relate  to  the administrative  burden  this  bill  and                                                               
Senate Bill 74  places on members of the  profession. He directed                                                               
members'  attention to  the red  line  version of  the bill  that                                                               
helps lay out the changes to the original version A.                                                                            
MR. EILER described the following changes:                                                                                      
     Page  2, Section  1. The  new Chapter  55 in  AS 13  is                                                                    
     moved  [to   page  26,  Section  31,   of  version  J].                                                                    
     Conforming  changes to  AS 08.64.250  and AS  08.64.312                                                                    
     are found  on page 12  of the red line  version. [These                                                                    
     are  found  on pages  10-11,  Sections  12 and  13,  of                                                                    
     version J.]                                                                                                                
     Page 16 of the red  line version changes the definition                                                                    
     of adult from  "a person" to "an  individual." [This is                                                                    
     found in  Section 15, page  14, lines 20-21  of version                                                                    
     Page 17 of  the red line version has  new text amending                                                                    
     AS 08.68.100(a),  as amended  by sec.  10, ch.  25, SLA                                                                    
     2016.  This pertains  to  advanced practice  registered                                                                    
     nurses.   Regulations   for    an   advanced   practice                                                                    
     registered  nurse  who  holds   a  valid  federal  Drug                                                                    
     Enforcement  Administration  registration  number  must                                                                    
     address training in pain management  and opioid use and                                                                    
     addiction. New  text is also added  to address concerns                                                                    
     raised during  public testimony. On page  18, paragraph                                                                    
     (10) requires  applicants under this chapter  to submit                                                                    
     fingerprints  and fees  required by  the Department  of                                                                    
     Public  Safety. This  is intended  to address  concerns                                                                    
     about  the connection  between  opioids  used for  pain                                                                    
     management and  drug abuse. [This  is found  in Section                                                                    
     18, pages 15-16, of version J.]                                                                                            
     Pages 21-22, Section  23, of the red  line version adds                                                                    
     new text  to [AS 08.72.140] relating  to qualifications                                                                    
     for  licensure  as   an  optometrist.  The  regulations                                                                    
     governing    these     professionals    must    include                                                                    
     qualifications  for licensees  holding a  valid federal                                                                    
     DEA registration  number that address training  in pain                                                                    
     management and  opioid use  and addiction.  [Section 23                                                                    
     is found on pages 19-20 of version J.]                                                                                     
     Page 27,  Section 30,  of the  red line  version covers                                                                    
     grounds  for imposition  of disciplinary  sanctions for                                                                    
     abuse of  prescription opioids, including  animal care.                                                                    
     [Section 30, is found on pages 25-26 of version J].                                                                        
     The new  Chapter 55 appears  on pages 28-29 of  the red                                                                    
     line  version.   It  details  some  of   the  committee                                                                    
     concerns including  definitions. It also  includes some                                                                    
     of  the  amendments  brought   forward  by  the  Alaska                                                                    
     Hospital   community   including  prepack   and   other                                                                    
     prescription drugs issued from prescribers.                                                                                
MR.  EILER   summarized  that  the   CS  intends  to   cover  the                                                               
committee's   jurisdiction   over   licensing   pharmacists   and                                                               
prescribing   professions  licensed   under  the   Department  of                                                               
CHAIR COSTELLO asked Dr. Butler to express his understanding of                                                                 
the bill and the role he played in drafting the committee                                                                       
9:43:24 AM                                                                                                                    
JAY  BUTLER, Chief  Medical Officer,  Division of  Public Health,                                                               
Department  of  Health  and Social  Services  (DHSS),  Anchorage,                                                               
stated that SB 79 is part  of a multi-faceted response to address                                                               
the current opioid epidemic. The  bill specifically addresses the                                                               
flood  of legal  prescription opioids  in Alaska  communities and                                                               
improving patient safety.                                                                                                       
9:44:38 AM                                                                                                                    
SENATOR GARDNER joined the committee.                                                                                           
DR. BUTLER  said the  first three amendments  embodied in  the CS                                                               
relate to  concerns from the Alaska  Pharmacy Association. First,                                                               
Section 28  brings the  language pertaining  to partial  fills of                                                               
opioid   prescriptions   into    alignment   with   the   federal                                                               
Comprehensive  Addiction  and  Recovery  Act  (CARA).  It  allows                                                               
partial  fills without  requiring the  remaining quantity  of the                                                               
prescription to  be voided. Thus,  the requirement to  notify the                                                               
prescribing practitioner is moot.                                                                                               
Second, the  CS clarifies  the role  of the  prescribing provider                                                               
and the  pharmacist. The prescribing provider  is responsible for                                                               
checking  the  prescription  drug  monitoring  program  prior  to                                                               
writing  a  prescription  for  a  Schedule  II  or  Schedule  III                                                               
controlled   substance.  The   pharmacist   is  responsible   for                                                               
populating the  Prescription Drug Monitoring Program  (PDMP) when                                                               
they  dispense  prescriptions  for these  controlled  substances.                                                               
This aligns with  the intention of both this bill  and SB 74 that                                                               
passed last year.                                                                                                               
Third,  the  CS delays  implementing  the  requirement for  daily                                                               
updates of  the PDMP  until July  2018. The  CS also  expands the                                                               
liability waiver for  the advance directive to  include events of                                                               
an inadvertent administration of an  opioid to someone who has an                                                               
opioid  advance  directive. The  concern  was  that in  emergency                                                               
situations  it may  not always  be feasible  to follow  an opioid                                                               
advance directive.                                                                                                              
9:48:39 AM                                                                                                                    
CHAIR  COSTELLO  asked  what   the  Comprehensive  Addiction  and                                                               
Recovery Act  (CARA) does and  how the  CS brings state  law into                                                               
alignment with that federal Act.                                                                                                
DR.  BUTLER said  the language  in the  original bill  authorized                                                               
pharmacists to  partially fill a prescription,  but the remainder                                                               
of the prescription was voided.  The pharmacist was also required                                                               
to notify the  prescribing provider of that  voiding. Federal law                                                               
under  CARA  2016  allows  partial   fills  without  voiding  the                                                               
remainder of  the prescription. This removes  a potential barrier                                                               
to partial fill that the  original language may have created. The                                                               
administrative  burden  on  the  dispensing  pharmacist  is  also                                                               
decreased  because  they  would  no longer  have  to  notify  the                                                               
prescribing provider.                                                                                                           
CHAIR COSTELLO asked  him to talk about the  report that compares                                                               
the  rate  that  different  providers in  a  community  prescribe                                                               
opioids  and  the  importance  of knowing  the  scope  of  opioid                                                               
DR. BUTLER  explained that the provider  community introduced the                                                               
concept of providers receiving a  regularly scheduled report from                                                               
the  Department  of  Commerce   that  provides  feedback  on  the                                                               
quantity  of  opioids  they  prescribed  during  the  prior  year                                                               
relative  to  their peers.  The  reason  for  this is  that  some                                                               
providers  may not  realize how  much they  are prescribing.  The                                                               
intent  is  not  punitive  but to  help  providers  review  their                                                               
practices  and   perhaps  rethink  their  approach   to  treating                                                               
patients that experience pain.                                                                                                  
CHAIR COSTELLO asked him to  talk about the training requirements                                                               
in  the  bill  to  help educate  providers  about  the  different                                                               
options for pain management.                                                                                                    
DR.  BUTLER said  the bill  includes requirements  for continuing                                                               
professional  education  for  each  prescriber  group  under  the                                                               
different boards.  These include the  Medical Board the  Board of                                                               
Nursing,  the Board  of Veterinary  Examiners, and  the Board  of                                                               
Pharmacy. For example,  when he renews his  medical license every                                                               
two years he  must document that he received credit  for 40 hours                                                               
of  continuing medical  education.  SB 79  requires  that two  of                                                               
those hours be designated to  issues related to addiction or pain                                                               
management. He highlighted that  the topic of physical dependency                                                               
and addiction is broader than just opioids.                                                                                     
9:56:35 AM                                                                                                                    
CHAIR COSTELLO  noted that the  CS requires weekly  reporting for                                                               
hospital pharmacies.  She asked  him to  talk about  how hospital                                                               
pharmacies differ from a pharmacy she and her family might use.                                                                 
DR. BUTLER said it appears that  the way that opioid pain killers                                                               
have  been  used  in  the  outpatient  setting  is  an  important                                                               
determinant  in   the  creation   of  the  opioid   epidemic.  By                                                               
comparison,  hospital   pharmacists  and   emergency  departments                                                               
dispense small amounts  at a time and do not  account for a large                                                               
volume  of opioids  going  into  the community.  He  said the  CS                                                               
intends to bring  the requirements for updating  prepacks in line                                                               
with  what is  required  of prescribers  when  small volumes  are                                                               
dispensed and in  line with the way  that inpatient prescriptions                                                               
are managed.                                                                                                                    
CHAIR  COSTELLO  asked  how the  bill  affects  the  professional                                                               
requirements  for  pharmacists  working with  the  Department  of                                                               
Corrections (DOC).                                                                                                              
DR. BUTLER explained that an  inmate who receives care inside the                                                               
prison walls is considered an  inpatient and the same rules would                                                               
apply as  an inpatient in  a hospital. Data  does not need  to be                                                               
put into  the PDMP and  the PDMP doesn't  need to be  accessed in                                                               
advance of  dispensing. However,  if an  opioid is  prescribed at                                                               
the  time of  discharge from  the  prison system,  the rules  for                                                               
outpatient prescribing would apply  and the prescriber would need                                                               
to use the PDMP.                                                                                                                
10:00:58 AM                                                                                                                   
SENATOR  STEVENS asked  if a  physician can  prescribe a  partial                                                               
DR. BUTLER said it's unlikely  a prescriber would do that because                                                               
of the cost of prescribing repeated small prescriptions.                                                                        
SENATOR STEVENS read paragraph (9) on  page 28 and asked if there                                                               
can be  a disciplinary sanction if  someone simply overprescribes                                                               
a drug. He observed, "That's  replacing a physician's decision or                                                               
judgement with someone else's."                                                                                                 
DR. BUTLER  said the Medical Board  historically has investigated                                                               
disciplinary issues  based on patient complaints.  He deferred to                                                               
Ms. Chambers or the Medical Board for further comment.                                                                          
SENATOR STEVENS  expressed concern  about the potential  abuse of                                                               
disciplinary sanctions.  He asked Ms. Chamber  if overprescribing                                                               
a drug is grounds for disciplinary sanction.                                                                                    
10:04:20 AM                                                                                                                   
SARAH  CHAMBERS,  Deputy   Director,  Division  of  Corporations,                                                               
Business  and  Professional  Licensing, Department  of  Commerce,                                                               
Community  and Economic  Development  (DCCED), Juneau,  explained                                                               
that each of  the boards that governs  prescribers would initiate                                                               
disciplinary action if there was a  violation of law, but at this                                                               
point Alaska  law has  no prescription  limits for  opioids. Last                                                               
year  these   boards-except  the  veterinary   board-worked  with                                                               
legislative  committees  to  develop  reasonable  guidelines  for                                                               
prescribing,   but  those   are  not   codified  in   statute  or                                                               
Speaking  to Senator  Steven's concern  about  the potential  for                                                               
misuse of disciplinary  sanctions, she said the  PDMP is intended                                                               
to  be used  as a  tracking and  educational tool.  However, it's                                                               
possible that at some point in  the future the PDMP could be used                                                               
as  evidence if  there is  a complaint.  Any discipline  would be                                                               
done by the governing board.                                                                                                    
SENATOR STEVENS  said he likes the  idea of the partial  fill and                                                               
the  nonpunitive  approach  to  getting  data  to  doctors  about                                                               
prescribing habits.                                                                                                             
MS.  CHAMBERS said  what this  bill and  Governor Walker  hope to                                                               
achieve is to  continue to appropriately manage  the diversion of                                                               
prescription  medications. She  suggested that  Dr. Butler  could                                                               
speak to  a new program called  "Mind Your Meds" that  is focused                                                               
on how  to manage prescription  medications in the  home medicine                                                               
cabinet. "I  think this bill does  go a long way  to address some                                                               
of those things that I think we can control."                                                                                   
10:08:56 AM                                                                                                                   
SENATOR MEYER  expressed support  for the  CS and  agreement with                                                               
Senator Stevens'  concerns. He noted  that stakeholders  were not                                                               
present  today and  expressed  hope that  they  were involved  in                                                               
drafting the CS and that everyone agrees with this approach.                                                                    
CHAIR  COSTELLO  asked  Mr. Butler  to  address  Senator  Meyer's                                                               
DR. BUTLER stated  that part of the planning for  the bill was to                                                               
contact  various organizations  and health  professionals in  the                                                               
state. He said that pharmacists  were difficult to reach when the                                                               
CS  was  drafted, but  their  early  participation during  public                                                               
testimony was valuable.                                                                                                         
He said  he's heard that  the CME [continuing  medical education]                                                               
requirements  have raised  questions among  providers that  don't                                                               
prescribe  opioids, but  he believes  those  requirements may  be                                                               
misunderstood. They are part of  what is primarily an opioid bill                                                               
and the broader  issue in terms of addiction  and substance abuse                                                               
is important.                                                                                                                   
DR.  BUTLER  said too  many  in  the medical  profession  haven't                                                               
recognized the medical aspects of  substance abuse and addiction.                                                               
They aren't  aware of the number  of people who live  in recovery                                                               
and  that  this special  population  needs  appropriate care.  He                                                               
reported that  about 8  percent of the  U.S. population  meet the                                                               
formal definition of  some type of substance  abuse disorder, but                                                               
just  10  percent  have received  any  specific  treatment.  This                                                               
includes alcohol, opioid, and other drug abuse and addictions.                                                                  
SENATOR MEYER asked if those are national statistics.                                                                           
DR BUTLER said yes.                                                                                                             
SENATOR MEYER asked if Alaska statistics are similar.                                                                           
DR. BUTLER said he doesn't have  exact data but the recent report                                                               
on  the cost  of  substance misuse  and  addiction suggests  that                                                               
Alaska is  no better than  the rest  of the country  in addiction                                                               
rates. However, Alaska does have  a larger proportion of overdose                                                               
deaths related to opioids compared to the rest of the country.                                                                  
SENATOR MEYER said  he wondered if overprescribing  is as serious                                                               
a  problem in  Alaska  as  the Lower-48,  but  it doesn't  really                                                               
matter because even one is too many.                                                                                            
CHAIR COSTELLO commented that SB  74 will provide the information                                                               
members are  looking for.  She noted that  a recent  Twitter feed                                                               
reported that  144 people in the  U.S. die every day  from a drug                                                               
overdose. She  expressed support for  SB 79's focus  on education                                                               
and the fact that the  report to prescribers is confidential. The                                                               
idea is  to turn the focus  from a pain free  society using drugs                                                               
to one  that won't put patients  at risk of becoming  addicted to                                                               
prescription medications that are supposed to make them better.                                                                 
10:15:58 AM                                                                                                                   
SENATOR  STEVENS  questioned  the  zero  fiscal  notes.  "Can  we                                                               
honestly say  there is  a zero-fiscal  note here  or are  we just                                                               
kidding ourselves?"                                                                                                             
MS.  CHAMBERS said  DCCED is  receipt supported  so there  are no                                                               
general  funds associated  with the  bill. She  related that  the                                                               
department  has successfully  partnered  with  the Department  of                                                               
Health and  Social Services (DHSS)  to support  the legislature's                                                               
intent  language to  create the  PDMP  in 2008  and seek  federal                                                               
grant funding to  support education and the  functionality of the                                                               
PDMP. "If  there were any  expenses that  were to be  incurred on                                                               
the Commerce side, it would  all be expenditure authority and not                                                               
UGF, as we look at this bill."                                                                                                  
DR.  BUTLER  confirmed that  the  departments  have been  working                                                               
together  aggressively  seeking  grants  and  even  donations  to                                                               
support  this effort.  He  cited  the example  of  a donation  of                                                               
several  thousand  drug  disposal  bags  that  will  help  people                                                               
deactivate excess medications  at home making them  safe to throw                                                               
SENATOR STEVENS  said he  appreciates the  effort to  get grants,                                                               
but "whether  it costs money  or not we  need to move  ahead with                                                               
CHAIR  COSTELLO  highlighted for  the  record  that the  Medicaid                                                               
reform bills the  legislature has passed have  added positions to                                                               
DHSS,  and  a  recent  bill  adds a  position  to  the  Board  of                                                               
10:20:04 AM                                                                                                                   
SENATOR GARDNER raised the  question of confidentiality regarding                                                               
the  language on  pages  32-33 that  allows  federal, state,  and                                                               
local law enforcement authorities access to the database.                                                                       
DR. BUTLER suggested Department of Law address the question.                                                                    
10:21:19 AM                                                                                                                   
STACY KRALEY,  Chief Assistant Attorney General,  Civil Division,                                                               
Human  Services Section,  Department  of  Law, Juneau,  explained                                                               
that the  amendment is  a technical  correction. A  prior version                                                               
omitted a  reference to the  federal government.  The information                                                               
in the  Alaska Prescription Drug Monitoring  Program (PDMP) would                                                               
be provided  to those entities if  a valid court order  or search                                                               
warrant is  presented. The information  would not be  shared with                                                               
anything less than that.                                                                                                        
CHAIR COSTELLO solicited public testimony on SB 79.                                                                             
10:23:27 AM                                                                                                                   
JEANNIE   MONK,   Alaska   State  Hospital   and   Nursing   Home                                                               
Association, pointed out  that an amendment that  was supposed to                                                               
be included in  the CS-and was approved in  the House version-did                                                               
not end  up in  the bill.  It relates  to inpatient  pharmacy and                                                               
emergency department prescriptions.                                                                                             
10:24:08 AM                                                                                                                   
At ease                                                                                                                         
10:40:13 AM                                                                                                                   
CHAIR COSTELLO  reconvened the  meeting and  asked Ms.  Monk tell                                                               
the  committee   about  the  provision  that   was  inadvertently                                                               
10:40:35 AM                                                                                                                   
MS.  MONK   said  the  amendment  ASHNHA   requested  relates  to                                                               
outpatient dispensing  of a controlled substance  from a hospital                                                               
pharmacy or  emergency department.  She noted that  hospitals are                                                               
already exempt  from reporting when prescription  medications are                                                               
administered  to inpatients.  The  proposed  amendment exempts  a                                                               
hospital   pharmacy  or   emergency  department   from  reporting                                                               
requirements  when  they send  someone  home  with an  outpatient                                                               
supply of  24 hours or  less. The regular  reporting requirements                                                               
apply if the supply is more than 24 hours.                                                                                      
10:41:24 AM                                                                                                                   
SENATOR GARDNER  moved Conceptual Amendment  1 to version  J. Add                                                               
the language in  Section 41, subsection (u) of  CSHB 159, version                                                               
     Section 41                                                                                                                 
          (u) A practitioner or a pharmacist is not                                                                             
      required to comply with the requirements of (a) and                                                                       
     (b) of this section if a controlled substance is                                                                           
          (1) administered to a patient at                                                                                      
               (A) a health care facility; or                                                                                   
               (B) a correctional facility;                                                                                     
          (2) dispensed to a patient for an outpatient                                                                          
     supply of 24 hours or less at a hospital                                                                                   
               (A) inpatient pharmacy; or                                                                                       
               (B) emergency department.                                                                                        
10:42:33 AM                                                                                                                   
CHAIR  COSTELLO objected  to asked  if  the conceptual  amendment                                                               
includes any confirming language that may be needed.                                                                            
SENATOR GARDNER said yes.                                                                                                       
CHAIR COSTELLO  removed her objection and  Conceptual Amendment 1                                                               
was adopted. She  removed her objection to the CS  and version J,                                                               
as amended, was adopted.                                                                                                        
SENATOR MEYER asked if there was additional public testimony.                                                                   
10:43:08 AM                                                                                                                   
CHAIR COSTELLO  found no  further public testimony  on SB  79 and                                                               
closed it.                                                                                                                      
10:43:21 AM                                                                                                                   
SENATOR STEVENS moved to report SB 79, as amended, from                                                                         
committee with individual recommendations and attached fiscal                                                                   
CHAIR COSTELLO announced that without objection, CSSB 79(L&C)                                                                   
[30-GS1021\J, as amended] moved from the Senate Labor and                                                                       
Commerce Standing Committee.                                                                                                    

Document Name Date/Time Subjects
SB 79 - Red Line Ver. A to J.pdf SL&C 4/14/2017 9:00:00 AM
SB 79
SB 79 Ver. J.pdf SL&C 4/14/2017 9:00:00 AM
SB 79