Legislature(2017 - 2018)HOUSE FINANCE 519

05/11/2017 01:30 PM FINANCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+= HB 74 DRIVER'S LICENSE & ID CARDS & REAL ID ACT TELECONFERENCED
<Bill Hearing Canceled>
+= SB 97 PENSION OBLIGATION BONDS TELECONFERENCED
Scheduled but Not Heard
+= HB 6 JONESVILLE PUBLIC USE AREA TELECONFERENCED
Moved CSHB 6(RES) Out of Committee
*+ HJR 23 CONST AM: PERMANENT FUND; POMV; DIVIDEND; TELECONFERENCED
<Bill Hearing Canceled>
-- Public Testimony <Time Limit 2 Minutes> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
+= HB 159 OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES TELECONFERENCED
Moved CSHB 159(FIN) Out of Committee
                   HOUSE FINANCE COMMITTEE                                                                                      
                        May 11, 2017                                                                                            
                          1:33 p.m.                                                                                             
                                                                                                                                
1:33:54 PM                                                                                                                    
                                                                                                                                
CALL TO ORDER                                                                                                                 
                                                                                                                                
Co-Chair  Foster called  the House  Finance Committee  meeting                                                                  
to order at 1:33 p.m.                                                                                                           
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Neal Foster, Co-Chair                                                                                            
Representative Paul Seaton, Co-Chair                                                                                            
Representative Les Gara, Vice-Chair                                                                                             
Representative Jason Grenn                                                                                                      
Representative David Guttenberg                                                                                                 
Representative Scott Kawasaki                                                                                                   
Representative Dan Ortiz                                                                                                        
Representative Lance Pruitt                                                                                                     
Representative Steve Thompson                                                                                                   
Representative Cathy Tilton                                                                                                     
Representative Tammie Wilson                                                                                                    
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
None                                                                                                                            
                                                                                                                                
ALSO PRESENT                                                                                                                  
                                                                                                                                
Dr.  Jay  Butler,  Chief  Medical   Officer  and  Director  of                                                                  
Public  Health,  Department  of Health  and  Social  Services;                                                                  
Stacie  Kraly, Chief  Assistant Attorney  General,  Department                                                                  
of  Law;   Sara  Chambers,   Acting   Director,  Alcohol   and                                                                  
Marijuana  Control Office, Department  of Commerce,  Community                                                                  
and  Economic   Development;  Kara  Nelson,  Director,   Haven                                                                  
House,  Juneau;  Taneeka Hansen,  Staff,  Representative  Paul                                                                  
Seaton;  Linda Bruce,  Attorney, Legislative  Legal  Services;                                                                  
Valerie  Davidson,  Commissioner,  Department  of  Health  and                                                                  
Social  Services;  Representative   George  Raucher,  Sponsor;                                                                  
Darrel   Breeze,   Staff,   Representative   George   Raucher;                                                                  
Representative    Lora    Reinbold;     Representative    Andy                                                                  
Josephson.                                                                                                                      
                                                                                                                                
PRESENT VIA TELECONFERENCE                                                                                                    
                                                                                                                                
Michael  Karson,  Chair,  Matsu   Opioid  Task  Force,  Matsu;                                                                  
Carol  Carman,  Self,  Palmer;  Ryan  Brett,  AK  Mudslingers,                                                                  
Anchorage;  Patti Barber,  Self, Mat-Su;  Kenny Barber,  Self,                                                                  
Mat-Su;  Clark Cox,  Natural Resource  Manager, Department  of                                                                  
Natural Resources.                                                                                                              
                                                                                                                                
SUMMARY                                                                                                                       
                                                                                                                                
HB 6      JONESVILLE PUBLIC USE AREA                                                                                            
                                                                                                                                
          CSHB  6(RES) was  REPORTED out  of committee  with a                                                                  
          "do    pass"   recommendation    and   with    three                                                                  
          previously   published   zero   fiscal  notes,   FN1                                                                  
          (DNR),  FN  2 (DPS),  FN3 (DPS);  and  one new  zero                                                                  
          fiscal   note  from   the   Department  of   Natural                                                                  
          Resources.                                                                                                            
                                                                                                                                
HB 159    OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES                                                                               
                                                                                                                                
          CSHB  159(FIN was REPORTED  out of committee  with a                                                                  
          "do  pass" recommendation  and  with two  previously                                                                  
          published  fiscal notes,  one zero note:  FN2 (DHS);                                                                  
          and one fiscal impact note: FN3 (CED).                                                                                
                                                                                                                                
SB 97     PENSION OBLIGATION BONDS                                                                                              
                                                                                                                                
          SB 97 was SCHEDULED but not HEARD.                                                                                    
                                                                                                                                
Co-Chair Foster reviewed the agenda for the day.                                                                                
                                                                                                                                
HOUSE BILL NO. 159                                                                                                            
                                                                                                                                
     "An  Act   relating  to  the  prescription   of  opioids;                                                                  
     establishing  the  Voluntary   Nonopioid  Directive  Act;                                                                  
     relating   to  the  controlled   substance   prescription                                                                  
     database;   relating  to   the  practice  of   dentistry;                                                                  
     relating  to the practice  of medicine;  relating  to the                                                                  
     practice  of  podiatry;   relating  to  the  practice  of                                                                  
     osteopathy;   relating  to   the  practice  of   nursing;                                                                  
     relating  to the practice  of optometry; relating  to the                                                                  
     practice  of veterinary medicine;  related to  the duties                                                                  
     of  the   Board  of  Pharmacy;   and  providing   for  an                                                                  
     effective date."                                                                                                           
                                                                                                                                
1:35:18 PM                                                                                                                    
                                                                                                                                
DR.  JAY  BUTLER,  CHIEF  MEDICAL   OFFICER  AND  DIRECTOR  OF                                                                  
PUBLIC  HEALTH,  DEPARTMENT  OF HEALTH  AND  SOCIAL  SERVICES,                                                                  
provided  a broad  overview  of the  major  provisions in  the                                                                  
bill.  He  relayed  that  HB 159  was  an  omnibus  bill  that                                                                  
enhanced the  department's current  approach for treating  the                                                                  
opioid  epidemic  by primarily  focusing  on ways  to  support                                                                  
people in  recovery and reduce  the number of newly  addicted.                                                                  
The   bill    included   opportunities    to   avoid    opioid                                                                  
prescriptions   through  advanced  directives   documented  on                                                                  
patient's  medical   records  and  for  partial   refills.  He                                                                  
indicated  that the  bill offered  civil liability  protection                                                                  
for   providers  and   enforced   some  of   the   regulations                                                                  
contained   in  the   federal  Comprehensive   Addiction   and                                                                  
Recovery  Act  of 2016.  The  legislation  set a  standard  of                                                                  
care   limit  of   a   seven  day   supply   for  first   time                                                                  
prescriptions  for  an opioid.  The  policy was  aligned  with                                                                  
the  Center  for Disease  Control  (CDC),  other  professional                                                                  
agencies    and     organizations,    and    the     Veteran's                                                                  
Administration's  Opioid Safety  Initiative.  He related  that                                                                  
the initiative  made  "remarkable progress"  in reductions  in                                                                  
overdoses  and  addiction  of opioids  since  2013.  The  bill                                                                  
included  waivers  for  judicious   use  of  increased  opioid                                                                  
dispensing   at  the   discretion   of  a   professional   for                                                                  
situations  like  palliative  care,  acute  and  chronic  pain                                                                  
syndromes,  etc. Another  provision  in the  bill dedicated  a                                                                  
certain   portion   of   required   professional    continuing                                                                  
education  credits  for  pain  management   or  addiction.  He                                                                  
qualified   that  the  education   was  beneficial   even  for                                                                  
healthcare  providers who  did not  prescribe  opioids due  to                                                                  
the  "highly prevalent"  instances  of dealing  with  patients                                                                  
struggling   with  addictions   or  in   recovery.  The   bill                                                                  
"enhanced"  the   prescription  drug  database   and  required                                                                  
veterinarians  to register.  The bill  allowed the  Department                                                                  
of Commerce,  Community  and Economic  Development (DCCED)  to                                                                  
provide  feedback to  providers comparing  prescribing  habits                                                                  
of other  providers  and required  pharmacists  to update  the                                                                  
database  more  frequently.   He thought   that  the  database                                                                  
implemented   with  passage   of  SB   74  Medicaid   (Reform;                                                                  
Telemedicine;  Drug Database) [Chapter  25 SLA 16  06/21/2016)                                                                  
was a  useful tool only  with the  continued input of  quality                                                                  
data.                                                                                                                           
                                                                                                                                
1:40:21 PM                                                                                                                    
                                                                                                                                
Representative   Guttenberg   thanked  Dr.   Butler  and   the                                                                  
department  for  doing  a  "great job."  He  referred  to  the                                                                  
update  of the  prescription drug  database. He  asked him  to                                                                  
address  the issues  that  arose  with the  implementation  of                                                                  
the "Prescription  Drug Managers"  database established  in SB                                                                  
74  [Prescription   Drug   Monitoring   Program  (PDMP)]   and                                                                  
whether  the  database   was  being  regularly   updated.  Dr.                                                                  
Butler  responded that  the  monitoring program  updates  were                                                                  
in the process  of being increased  from monthly to  weekly as                                                                  
mandated  in  SB 74.  He  relayed  that  more than  25  states                                                                  
required  daily  updates and  the  standard was  considered  a                                                                  
best  practice. However,  the more  frequent  the updates  the                                                                  
more  burdensome the  requirement  was for  small  independent                                                                  
rural  pharmacies.   He  acknowledged   the  Alaska   Pharmacy                                                                  
Association's  help in  developing a strategy  to address  the                                                                  
issue  by delaying  the implementation  of  the daily  updates                                                                  
until mid-2018  to allow  a year for  pharmacies to adjust  to                                                                  
weekly  updates before  moving  forward.  The pharmacies  with                                                                  
highly automated  systems easily  complied with more  frequent                                                                  
updating  requirements  but wanted  to enable  all  pharmacies                                                                  
to comply.  He thought  Representative  Guttenberg had  raised                                                                  
a good  point of looking  at how the  epidemic grew  in Alaska                                                                  
and  how  the   Pharmacy  Benefit  Manager  (PBM)   influenced                                                                  
prescribing  practices  and  reimbursement   and  pointed  out                                                                  
that  the issue  provoked much  discussion  among the  medical                                                                  
community.  He  drew  attention   to  a  book  entitled  "Drug                                                                  
Dealer M. D." authored by Anna Lembke M. D.                                                                                     
                                                                                                                                
Representative   Ortiz  understood  that  pharmacies   had  an                                                                  
initial concern  about HB 159.  He asked whether the  concerns                                                                  
had  been addressed.  Dr. Butler  deferred  to the  Department                                                                  
of Law  (DOL) for  a response.  He added  that the issue  also                                                                  
related  to  provisions   in  SB  74  that  defined   who  was                                                                  
considered  a provider.  The intent  was  that the  prescriber                                                                  
checked  the  prescription  drug database  and  the  dispenser                                                                  
"populated" the database to ensure quality data.                                                                                
                                                                                                                                
1:46:41 PM                                                                                                                    
                                                                                                                                
STACIE  KRALY, CHIEF  ASSISTANT ATTORNEY  GENERAL,  DEPARTMENT                                                                  
OF LAW,  responded affirmatively.  She  explained that  within                                                                  
the  statutory framework  of  the prescription  drug  database                                                                  
was  a  definition  section  that  referred  to  a  definition                                                                  
contained  in Title  11 of  the criminal  code, which  applied                                                                  
the  Title   11  definition   unless  otherwise   specifically                                                                  
stated in  the SB 74 statute.  The pharmacists were  concerned                                                                  
over the  use of the word  "practitioner." She clarified  that                                                                  
AS 17.30.200  specifically identified  that the definition  in                                                                  
the  criminal code  only  applied if  not addressed  in  other                                                                  
statutes. She  emphasized that the  statutes in SB 74  and the                                                                  
amendments in  HB 159 were clearly  crafted. She believed  the                                                                  
definition  of practitioner  was very  concise and  delineated                                                                  
between  prescriber   and  pharmacist.   She  felt   that  the                                                                  
pharmacists concern was adequately addressed.                                                                                   
                                                                                                                                
Representative  Ortiz  asked Ms.  Kraly  to provide  the  page                                                                  
numbers of  the bill referring  to the definitions.  Ms. Kraly                                                                  
clarified   that  the   current   bill  did   not  amend   the                                                                  
definition  section  of  the  database.  She  delineated  that                                                                  
"under  the current  framework of  the  statutory scheme"  the                                                                  
concerns raised by pharmacists had been addressed.                                                                              
                                                                                                                                
1:49:41 PM                                                                                                                    
                                                                                                                                
Vice-Chair   Gara   referred  to   his   previous   discussion                                                                  
regarding  the adequacy of  a three day  supply as opposed  to                                                                  
the  seven day  supply in  the bill.  He  requested an  answer                                                                  
about the  prevalence in the  literature recommending  a three                                                                  
day  supply  as  adequate  for  pain and  why  the  seven  day                                                                  
supply was  chosen. Dr.  Butler responded  that the seven  day                                                                  
period  was based  on recent  studies pointing  to the  length                                                                  
of time  of a first  time prescription  and the likelihood  of                                                                  
chronic  use  for  a year  or  more.  He  indicated  that  the                                                                  
"flashpoint"  of an increase in  risk for abuse was  roughly 5                                                                  
to 7 days  for first time use.  He stated that 3 days  was the                                                                  
guideline  from  the CDC  and  that  supplies of  longer  than                                                                  
seven   days    was   rarely   necessary.   Vice-Chair    Gara                                                                  
ascertained  that the  bill allowed  for  a doctor's  override                                                                  
from the  7 day restriction due  to certain circumstances.  He                                                                  
wondered  why the  legislature  should  not pay  attention  to                                                                  
CDC's  recommendation  and establish  a  three  day limit  and                                                                  
allow a longer supply under the doctor's discretion.                                                                            
                                                                                                                                
1:53:01 PM                                                                                                                    
                                                                                                                                
Dr. Butler  indicated the  department was  not ignoring  the 3                                                                  
day CDC  guidelines.  He mentioned  that one  of the  analysis                                                                  
that  pointed to  a 5 to  7 day  supply as  an increased  risk                                                                  
for  prolonged use  came from  CDC  data. He  believed that  a                                                                  
"magic date"  did not  exist. He offered  that the issue  fell                                                                  
under  the   concept  of   "accountable  justification"   that                                                                  
described the  judicious use of  other drugs where  a stronger                                                                  
evidence   base  existed   for  how   to  change   prescribing                                                                  
behavior  to optimize  patient  safety. He  communicated  that                                                                  
the  concept was  not  proven with  opioids.  Vice-Chair  Gara                                                                  
provided  an example  of someone  responding well  to a  three                                                                  
day  supply. He  wondered  why  the bill  did  not impose  the                                                                  
limit  under the  number  of days  that carried  an  increased                                                                  
risk  of abuse  since  the  doctor could  prescribe  beyond  3                                                                  
days  at her  discretion  and the  science  supported it.  Dr.                                                                  
Butler  understood Vice-Chair  Gara's  point. The  issue of  3                                                                  
days versus  7 days  had to do  with analysis  of the  risk of                                                                  
addiction  and dependency  and the dramatic  increase  in risk                                                                  
that  occurred   in  5   to  7  days.   The  3  day   clinical                                                                  
recommendation  was "sound" but  flexibility for  professional                                                                  
judgement was important.                                                                                                        
                                                                                                                                
Co-Chair   Foster  acknowledged   Representative  Pruitt   had                                                                  
joined the meeting.                                                                                                             
                                                                                                                                
Vice-Chair Gara  wanted to protect  the individuals  that kept                                                                  
taking  the drug  subsequent to  pain relief  after the  third                                                                  
day.   Dr.   Butler   thought   Vice-Chair   Gara's   question                                                                  
addressed  the issue  of whether  opioids were  a "first  line                                                                  
drug."   He   remarked   that   the    legislation   did   not                                                                  
specifically  address the  issue but  was the  reason for  the                                                                  
continuing  education provision  dedicated to behavioral  pain                                                                  
management   and  treatment.   Over   the   last  ten   years,                                                                  
prescriptions  for  opioids  and  overdose   deaths  increased                                                                  
three  to  four  fold  without  a  corresponding   decline  in                                                                  
chronic pain.                                                                                                                   
                                                                                                                                
Representative    Ortiz    asked    whether    Dr.    Butler's                                                                  
professional  judgement was  that the seven  day language  was                                                                  
in  the best  interest  of  the state.  Dr.  Butler  responded                                                                  
that the  appropriate number of  days was a balancing  act. He                                                                  
believed  that  the risk  versus  benefit was  reasonable.  He                                                                  
commented that  some of the risk  was the under management  of                                                                  
pain and  a larger  administrative burden  but it limited  the                                                                  
risk  for  dependency.  He  reported  that the  state  of  New                                                                  
Jersey  had limited  the  number of  days  to 5  days and  was                                                                  
unaware of any state that adopted the three day limit.                                                                          
                                                                                                                                
1:59:18 PM                                                                                                                    
                                                                                                                                
Representative  Wilson felt that  only a medical doctor  could                                                                  
make educated  judgements  about prescribing  and she  was not                                                                  
a doctor.  She  wondered whether  it  was already  a crime  to                                                                  
prescribe  too  much  opioid  medication.  Dr.  Butler  agreed                                                                  
that  the   public  official's   role   was  not  to   dictate                                                                  
individual   patient  management   but  felt  that   advancing                                                                  
patient  safety  through  guidance  of how  medical  care  was                                                                  
addressed   was   acceptable.   He  noted   that   prescribing                                                                  
hundreds   of  opioid   pills  for   "fairly  minor   surgical                                                                  
procedures"  was not  a crime. Representative  Wilson  thought                                                                  
that  patient safety  should be  the number  one priority  for                                                                  
physicians.  She  wondered  whether addressing  the  issue  of                                                                  
over  prescribing  via  criminal  law was  a  better  approach                                                                  
than  laws limiting  prescriptions  made by  people without  a                                                                  
medical  education.  Dr.  Butler  thought   that  scrutinizing                                                                  
every  instance   of  large  opioid  prescriptions   would  be                                                                  
micromanagement  of the practice  of medicine. He  stated that                                                                  
some  people adequately  managed  pain through  prolonged  use                                                                  
of opioids  and he  did not  want to inhibit  access for  such                                                                  
use.  Conversely,  the  problem  of  over   prescribing  large                                                                  
quantities  of  opioids  was  identified  as  a  problem  that                                                                  
contributed  to the  epidemic. He  referred  to the  testimony                                                                  
of  a  young  man  that  had  ultimately  become  addicted  to                                                                  
opioids  and heroine  from  experimenting  with the  remainder                                                                  
of  a  previous  opioid  prescription.   He  voiced  that  the                                                                  
criminal  justice  system  controlled   the  illicit  flow  of                                                                  
opioids  into  communities  and additional  "stop  checks"  on                                                                  
the legal flow was needed as well.                                                                                              
                                                                                                                                
2:03:18 PM                                                                                                                    
                                                                                                                                
Representative  Wilson could  not understand  why a  physician                                                                  
would   over  prescribe   opioids.  She   believed  that   the                                                                  
legislature  was  doing  the   job  a  doctor  should  do  and                                                                  
assumed  the doctor was  incapable of  determining the  proper                                                                  
dosing amounts.  She wanted  to understand  how her  reasoning                                                                  
was  incorrect.   Dr.  Butler  offered  that   the  limit  was                                                                  
related  to  the   risk  analysis  and  recommendations   from                                                                  
professional  groups  like  the  CDC,  United  States  Surgeon                                                                  
General,  the American  College of  Physicians, and  Veteran's                                                                  
Administration.  He  thought  the  provision   was  "providing                                                                  
guardrails"     based     on     quantifiable     information.                                                                  
Representative  Wilson  could not  understand  why  physicians                                                                  
were  not limiting  prescriptions  "on their  own"  if it  was                                                                  
"not the  right thing  to do." Dr.  Butler explained  that the                                                                  
way  doctors prescribe  medications  and some  of the  drivers                                                                  
of the  system had  evolved over 25  years. The  reimbursement                                                                  
mechanisms  and medication  marketing  had  also been  drivers                                                                  
of over prescribing.  He exemplified  that the cost of  a pill                                                                  
was  lower than  some  of the  other  ways to  manage  chronic                                                                  
pain  and pain  syndromes. Representative  Wilson  appreciated                                                                  
what  the  bill   was  trying  to  do.  She  reiterated   that                                                                  
legislators  were not doctors and  were incapable of  making a                                                                  
determination about prescribing.                                                                                                
                                                                                                                                
2:07:21 PM                                                                                                                    
SARA  CHAMBERS,   ACTING  DIRECTOR,   ALCOHOL  AND   MARIJUANA                                                                  
CONTROL  OFFICE,   DEPARTMENT   OF  COMMERCE,  COMMUNITY   AND                                                                  
ECONOMIC  DEVELOPMENT,  was  impressed  with the  crafting  of                                                                  
the bill.  She pointed  out that although  the bill  contained                                                                  
recommendations,   doctors   were   given   flexibility.   She                                                                  
described  the 7  day limit  as the  "stop  and think  moment"                                                                  
when  a provider  could prescribe  over the  limit but  needed                                                                  
to  document  the   transaction.  Many  physicians   were  not                                                                  
properly  trained in prescribing  opioids  and unaware  of the                                                                  
recent advances  in pain  management. She  liked Dr.  Butler's                                                                  
comparison  to limiting  the  use of  antibiotics;  physicians                                                                  
no longer  just handed out antibiotics  due to the  resistance                                                                  
issues.  The   bill  offered   providers  an  opportunity   to                                                                  
receive  additional  education. She  expounded  that the  four                                                                  
prescribing  boards that  were affected  were  also given  the                                                                  
authority,  in  SB  74  and HB  159,  to  govern,  review  and                                                                  
discipline its  members if continued  over prescribing  was an                                                                  
issue.  She  reminded  the  committee  that  the  boards  were                                                                  
comprised   of  medical   professionals   qualified  to   make                                                                  
decisions affecting its profession.                                                                                             
                                                                                                                                
2:10:37 PM                                                                                                                    
                                                                                                                                
Representative   Guttenberg  thought  the  previous   question                                                                  
made  the   assumption  that  all   doctors  were   equal.  He                                                                  
remarked that  the issue was  multi-faceted. He surmised  that                                                                  
nothing  in the  bill  restricted  a doctor  from  prescribing                                                                  
over  7 days.  He  inquired  whether  the state  overrode  the                                                                  
doctor  patient relationship.  Dr.  Butler  affirmed that  the                                                                  
state  did not  override  the provider  patient  relationship.                                                                  
Representative   Guttenberg  asked  whether  the   legislature                                                                  
could  impose  a  strict  limit  on  prescribing   without  an                                                                  
exception  or   waiver.  Ms.  Chambers  responded   that  most                                                                  
states  had set recommended  guidelines.  The legislature  had                                                                  
the  opportunity  to  set  restrictive  legal  guidelines  for                                                                  
overprescribing.  She  detailed  that  in  HB  159  regulatory                                                                  
authority was  left up to the  discretion of the  professional                                                                  
judgements  of the  boards based  on acceptable  standards  of                                                                  
care. Representative  Guttenberg  was not  advocating for  any                                                                  
restrictive  limits.  He asked  about  the authority  held  by                                                                  
pharmacists  and  their  liability.   Ms.  Chambers  responded                                                                  
that currently  the Board of  Pharmacists set a threshold  for                                                                  
identifying   "doctor  shopping"   through  the  use   of  the                                                                  
prescription  drug manager.  The pharmacist  entered the  data                                                                  
into  the database  and the  practitioner  could review  prior                                                                  
to prescribing.  She  elaborated that  the reporting  filtered                                                                  
back to a  two-fold reporting process.  One route of  data was                                                                  
streamed  to  the  prescribing  board  through  the  Board  of                                                                  
Pharmacy;  the two boards  worked together  to see if  further                                                                  
investigation  was  needed.  The  other  element  offered  the                                                                  
prescriber  a report card  in comparison  to their peers.  The                                                                  
reporting  offered  the provider  the  opportunity  to  become                                                                  
self-aware through  viewing the  practice of their  peers. She                                                                  
described  the  Board of  Pharmacy's  role as  the  "delegated                                                                  
governor" of the entire process.                                                                                                
                                                                                                                                
2:16:20 PM                                                                                                                    
                                                                                                                                
Representative  Guttenberg   ascertained  that  the  physician                                                                  
had the  ability to "self-examine"  her prescribing  practices                                                                  
through  the  report  card.  He  wondered  who  else  had  the                                                                  
ability  to monitor the  database to  identify when  something                                                                  
was  wrong.  Ms. Chambers  responded  that  AS  17.30.200  (d)                                                                  
delineated  who   can  access  the  database   but  was  quite                                                                  
restricted.   She   reported  that   the   Prescription   Drug                                                                  
Monitoring  Program (PDMP)  manager  reviewed the  information                                                                  
at a  "higher level" to  identify trends  and worked  with the                                                                  
Control  Substances  Advisory  Committee,  the Task  Force  on                                                                  
Opioids,   Board  of   Pharmacy,  DHSS   experts,  and   other                                                                  
professional  groups to review  "trending." The analyzed  data                                                                  
helped shape  policy. In Alaska's  case, the data  was lacking                                                                  
until the SB 74 provisions went "live" in July, 2017.                                                                           
                                                                                                                                
Vice-Chair  Gara  referred  to a  remark  made by  Dr.  Butler                                                                  
about  the 5  day period  of  an initial  opioid  prescription                                                                  
and  asked  for further  clarification.  Dr.  Butler  answered                                                                  
that  a  CDC  study from  one  of  its  weekly  Morbidity  and                                                                  
Mortality Weekly  Report (MMWR  Weekly) included a  graph that                                                                  
depicted   the  length   of  time  from   an  initial   opioid                                                                  
prescription  an   individual  remained  on  opioids   a  year                                                                  
later.  He noted  that the  line was  not flat  and peaked  at                                                                  
the  five to  seven day  period and  again at  the thirty  day                                                                  
periods.  Vice-Chair  Gara asked  Dr.  Butler  to provide  the                                                                  
document.  He  clarified  that  the  risk  of  addiction  rose                                                                  
steeply  at  the   five  to  seven  day  period.   Dr.  Butler                                                                  
answered  in the affirmative  and agreed  to provide  the full                                                                  
report to Vice-Chair Gara.                                                                                                      
                                                                                                                                
2:20:32 PM                                                                                                                    
                                                                                                                                
Representative  Grenn asked  what  the goals  of the  proposed                                                                  
changes  in the  database were.  Ms. Chambers  indicated  that                                                                  
with  the passage  of SB  74 the  PDMP went  from a  voluntary                                                                  
basis  with low  participation  rates to  a mandatory  program                                                                  
for  all providers  with  prescribing authority.  She  related                                                                  
that in the  following months the  data would be analyzed  for                                                                  
trends  in   prescribing  by   occupation,  reports   on  what                                                                  
substances   were  being  prescribed   and  comparisons   that                                                                  
provided   more    information   on   further    trends.   The                                                                  
expectation  was  that  the knowledge  gained  from  the  data                                                                  
would instruct  further  policy and  procedural decisions  for                                                                  
the   professionals   as  well   as   legislators.   Mandatory                                                                  
reporting  to   the  legislature   was  a  provision   in  the                                                                  
legislation.                                                                                                                    
                                                                                                                                
2:23:51 PM                                                                                                                    
                                                                                                                                
Co-Chair  Seaton  appreciated the  legislation.  He  mentioned                                                                  
that  private  industry  did  a very  good  job  of  marketing                                                                  
their products  to prescribers.  The state  had an  antiquated                                                                  
education   system  regarding   pain   management  that   only                                                                  
considered  pain without looking  at addiction. He  remembered                                                                  
that  the   state  had   changed  the   criteria  for   rating                                                                  
hospitals  and  doctors  that  included   adequately  managing                                                                  
pain.  He  explained   that  the  criteria  resulted   in  the                                                                  
dispensing  of  many prescriptions  for  drugs  to ensure  the                                                                  
criteria was  met. He asked whether  the state had  removed or                                                                  
reformed  the pain management  criteria.  He wondered  whether                                                                  
the  legislature   needed  to  address  anything   further  to                                                                  
remove  the  incentive  for  a  facility  to  receive  a  good                                                                  
rating based  on dispensing medications  for pain.  Dr. Butler                                                                  
appreciated  the comments.  He  offered that  previously  pain                                                                  
was  undertreated  so  the emphasis  over  the  years,  became                                                                  
eliminating  pain rather  than managing  it. He reported  that                                                                  
he along  with  ten other  state health  officials composed  a                                                                  
letter to  the Joint  Commission and  the Center for  Medicare                                                                  
and Medicaid  Services (CMS)  pointing out the  "unintentional                                                                  
incentive"  of  opioid dispensing  from  the HCAHPS  (Hospital                                                                  
Consumer  Assessment  of  Healthcare  Providers  and  Systems)                                                                  
survey.  He   explained  that  the   HCAPS  was  a  survey  of                                                                  
patients'  perspectives of  hospital care  and physicians.  He                                                                  
added  that CMS  reimbursement was  based on  the HCAP  score.                                                                  
Initially,   the  two  entities   resisted  the   constructive                                                                  
dialogue  but   through  continued  communications   and  with                                                                  
assistance from  the American College  of Physicians  the HCAP                                                                  
score  was changed.  The  changes recognized  that  addressing                                                                  
pain was  a subjective experience  that encompassed  emotional                                                                  
and pathological states.                                                                                                        
                                                                                                                                
2:29:36 PM                                                                                                                    
                                                                                                                                
Co-Chair Foster OPENED Public Testimony.                                                                                        
                                                                                                                                
2:30:12 PM                                                                                                                    
                                                                                                                                
KARA  NELSON,  DIRECTOR,  HAVEN HOUSE,  JUNEAU,  supported  of                                                                  
the  legislation.  She particularly  favored  the  "non-opioid                                                                  
directive."  She spoke of  her own long-term  recovery  and of                                                                  
her  daughter  entering  treatment  only  2  days  prior.  She                                                                  
thought of  herself as  an expert in  recovery. She relayed  a                                                                  
story of  a woman who  had built a  strong recovery  framework                                                                  
that  was   undermined   by  a  prescription   from  a   tooth                                                                  
extraction.  The women  experienced  a temporary  relapse  and                                                                  
turned  to heroin. She  felt that  a lot  of addiction  had to                                                                  
do   with   pain  management   and   shared   that   was   the                                                                  
circumstance  regarding her  daughter. She  advocated for  the                                                                  
necessary  guidelines  contained  in the  bill  and  commented                                                                  
that  society was  moving in  the right  direction. She  spoke                                                                  
of  fighting  an  uphill  battle  everyday  through  addiction                                                                  
education and  the tools contained  in the bill to  combat the                                                                  
misconceptions  and mishandling of  the issue. She  thought it                                                                  
was  imperative  to  work aggressively  to  fight  the  opioid                                                                  
addiction.                                                                                                                      
                                                                                                                                
2:35:17 PM                                                                                                                    
                                                                                                                                
Representative  Ortiz asked  whether Ms.  Nelson was  familiar                                                                  
with  the  committee  discussion  regarding   the  appropriate                                                                  
number  of days  for  a  first time  opioid  prescription.  He                                                                  
asked  Ms. Nelson  for her  perspective.  Ms. Nelson  reported                                                                  
that  based on  her work experience  and  last year's  Surgeon                                                                  
General's  report  on  the  issue   Haven  House  changed  its                                                                  
policy  to a three  day limit.  She personally  supported  a 3                                                                  
day  policy.  She  advocated  for  the  continuing   education                                                                  
requirements  in the bill  as a crucial  tool in the  "battle"                                                                  
against addiction that she characterized as a "war."                                                                            
                                                                                                                                
Vice-Chair  Gara asked whether  she was  aware of doctors  who                                                                  
prescribed  "more than  others."  Ms. Nelson  answered in  the                                                                  
affirmative.   However,  she  noticed   that  the   "tide  was                                                                  
changing."  She  relayed that  her  work  as an  advocate  for                                                                  
addicts  often  included  attending   a doctor's   appointment                                                                  
with the  individual  and noted some  doctor's  misperceptions                                                                  
and lack of knowledge about addiction.                                                                                          
                                                                                                                                
2:38:34 PM                                                                                                                    
                                                                                                                                
MICHAEL  KARSON, CHAIR,  MATSU OPIOID TASK  FORCE, MATSU  (via                                                                  
teleconference),  spoke  in strong  support  of  the bill.  He                                                                  
reported a  drastic increase in  heroin overdoses and  use and                                                                  
cited statistics.  He reported  the number of overdose  deaths                                                                  
due to  fentanyl [a powerful synthetic  opioid analgesic]  and                                                                  
relayed that  the drug was 25  percent to 50 percent  stronger                                                                  
than  heroine.  Eighty percent  of  heroin users  began  using                                                                  
pain opioid  medication and 75  percent of the group  received                                                                  
the  drugs  from   friends,  grandparents,  and   parents.  He                                                                  
believed  that the  7 day  limit was  imperative and  informed                                                                  
the committee  that a  10 day  supply translated  to a  one in                                                                  
ten chance  of  long-term addiction  and a  50 percent  chance                                                                  
after  30 days.  He related  that  the state  of  Washington's                                                                  
PDMP  reduced  medical  costs by  $33  million  and  decreased                                                                  
opioid  related hospital  visits  by 24  percent. He  remarked                                                                  
on the deadly nature of addiction.                                                                                              
                                                                                                                                
Vice-Chair   Gara   asked   for   Mr.   Karson's   appropriate                                                                  
credentials  for   reference.  Mr.  Karson  replied   that  he                                                                  
worked  in  public   schools  for  35  years,   as  the  Vice-                                                                  
President  and addiction specialist  for My  House, a  drop in                                                                  
homeless  shelter,  and chaired  the  task  force.  Vice-Chair                                                                  
Gara thanked Mr. Karson for his work.                                                                                           
                                                                                                                                
Representative  Guttenberg  remarked  on  the bill's  goal  of                                                                  
plugging  a leaking  hole.  He asked  Mr. Karson  to  identify                                                                  
another issue  where a  difference could  be made. Mr.  Karson                                                                  
referred  the  committee  to an  Icelandic  study.  He  stated                                                                  
that  Iceland "knew  how to  reduce teenage  substance  abuse,                                                                  
but the  rest of  the world  was not  listening." He  reported                                                                  
that  teen tobacco,  marijuana,  and alcohol  use  was in  the                                                                  
single digits  and spoke to the  country's work in  "upstream"                                                                  
prevention."  He delineated  that  research  led officials  to                                                                  
discover that  youth under stress  took two paths:  one became                                                                  
risk takers  and other became  stimulant users. The  stimulant                                                                  
users  became sedative  users. The  solution  employed was  to                                                                  
match  the   behaviors  with   activities.  The  risk   takers                                                                  
engaged  in activities  like rock  climbing and  snowboarding.                                                                  
The sedative  users  engaged in  music, poetry,  and yoga.  He                                                                  
emphasized  that prevention  was imperative.  He  acknowledged                                                                  
Dr. Butler  for  his work  on pilot  projects like  "drug-take                                                                  
backs."  The bill  "turned  back the  spigot  on opioids"  but                                                                  
upstream  prevention  was  necessary.  He commented  that  the                                                                  
Icelandic  study revealed  that no one  was listening  to drug                                                                  
education.                                                                                                                      
                                                                                                                                
2:46:03 PM                                                                                                                    
Representative  Guttenberg noted  that Spain  or Portugal  had                                                                  
legalized all  drugs and had  successful results.  He wondered                                                                  
if Mr.  Karson was  familiar with  any of  the practices.  Mr.                                                                  
Karson  was  unaware of  the  situation  but referred  to  the                                                                  
method as  "harm reduction."  He used  needle exchanges  as an                                                                  
example.  The  contact  that  the  individual  user  had  with                                                                  
workers  at the  needle  exchange  was an  important  resource                                                                  
for  the user  seeking  treatment. He  noted  the belief  that                                                                  
"addiction    was     isolation    whereas     recovery    was                                                                  
relationships."  He referred  to other  harm recovery  methods                                                                  
such  as injection  sites or  public places  where Narcan  was                                                                  
immediately  available  in case  of  an overdose.  The  locked                                                                  
boxes of  Narcan located  on street  corners were unlocked  by                                                                  
a  call  to  911  for  immediate  use.  He  thought  that  the                                                                  
Iceland  study  was  the  best  resource  for  Alaska  due  to                                                                  
Iceland's Arctic location.                                                                                                      
                                                                                                                                
2:49:07 PM                                                                                                                    
                                                                                                                                
Co-Chair Foster CLOSED Public Testimony.                                                                                        
                                                                                                                                
2:49:17 PM                                                                                                                    
                                                                                                                                
Co-Chair Foster MOVED to ADOPT Amendment 1 (copy on file):                                                                      
                                                                                                                                
     Page 11, line 3:                                                                                                           
          Delete "for every 40 hours of education received"                                                                     
          Insert "in the two years preceding an application                                                                     
          for renewal of a license"                                                                                             
                                                                                                                                
Representative   Wilson   OBJECTED   for   the   purposes   of                                                                  
discussion.                                                                                                                     
                                                                                                                                
Co-Chair  Foster  explained  the  amendment.   The  department                                                                  
requested the  amendment that  corrected an inadvertent  error                                                                  
regarding  continuing medical education.  The original  intent                                                                  
of the bill  was to require physicians  to receive 2  hours of                                                                  
education  in pain  management and  opioid  use and  addiction                                                                  
in a 2  year licensing period.  The current language  mandated                                                                  
the 2  hours of  education for  every 40  hours of  continuing                                                                  
education  credit.  He  pointed  out that  some  doctors  were                                                                  
required  by  their professional  boards  to  take  up to  200                                                                  
hours of  continuing education  that resulted  in 10  hours of                                                                  
pain   management,  opioid   use  and   addiction   continuing                                                                  
education,  which was not  the intent  of the department.  The                                                                  
amendment reinstated  the continuing  education mandate  for 2                                                                  
hours in a 2 year licensing cycle.                                                                                              
Representative  Guttenberg  asked whether  two  hours for  the                                                                  
training  was enough.  Dr.  Butler  thought the  question  was                                                                  
challenging.    He   voiced   that    the   amount    balanced                                                                  
administrative  demands  and  benefits   and  avoided  placing                                                                  
"unintended   barriers"   to  seeking   continuing   education                                                                  
credits   beyond  the   amount  required   by  the  Board   of                                                                  
Medicine.  Representative  Guttenberg  wanted  to  ensure  the                                                                  
training was  useful and academic.  Dr. Butler responded  that                                                                  
the department  offered  suggestions of  free online  material                                                                  
that DHSS had reviewed.                                                                                                         
                                                                                                                                
Representative Wilson WITHDREW her OBJECTION.                                                                                   
                                                                                                                                
There being NO OBJECTION, it was so ordered.                                                                                    
                                                                                                                                
Amendment 1 was ADOPTED.                                                                                                        
                                                                                                                                
Co-Chair Seaton MOVED to ADOPT Amendment 2 (copy on file):                                                                      
                                                                                                                                
     Page I, following line 9:                                                                                                  
          Insert a new bill section to read:                                                                                    
     "* Section 1. The uncodified law of the State of                                                                           
     Alaska is amended by adding a new section to read:                                                                         
                                                                                                                                
          LEGISLATIVE   INTENT.  It  is  the   intent  of  the                                                                  
          legislature  that  the  seven-day supply  limit  for                                                                  
          an  initial opioid prescription  under secs.  5, 16,                                                                  
          and  22  of this  Act  may not  be considered  as  a                                                                  
          minimum  length of time  appropriate for  an initial                                                                  
          prescription.   The   United   States  Centers   for                                                                  
          Disease  Control  and  Prevention  guidelines  state                                                                  
          that   a  three-day   initial  prescription   of  an                                                                  
          opioid  is  sufficient   for  most  cases  of  acute                                                                  
          pain.   The  United   States  Centers  for   Disease                                                                  
          Control  and Prevention  reported  in its March  17,                                                                  
          2017,  weekly   report  that  the  likelihood  of  a                                                                  
          person's  chronic  opioid  use increases  with  each                                                                  
          additional  day  of medication  supplied  after  the                                                                  
          second   day.   Practitioners   should   use   their                                                                  
          professional judgement in each       case and not                                                                     
          interpret  the  seven-day limit  as  a direction  to                                                                  
          prescribe the full seven days."                                                                                       
                                                                                                                                
     Page 1, line 10:                                                                                                           
          Delete "Section 1"                                                                                                    
          Insert "Sec. 2"                                                                                                       
                                                                                                                                
      Renumber the following bill sections accordingly.                                                                         
                                                                                                                                
     Page 34, line  10:                                                                                                         
          Delete  "secs. 31 and 42"                                                                                             
          Insert  "secs. 32 and 43"                                                                                             
     Page 34, line  16:                                                                                                         
          Delete "sec. 34"                                                                                                      
          Insert "sec. 35"                                                                                                      
                                                                                                                                
     Page 34, line  17:                                                                                                         
          Delete "sec. 39"                                                                                                      
          Insert "sec. 40" 9                                                                                                    
                                                                                                                                
     Page 34, line  19:                                                                                                         
          Delete  "secs. 34 and 39"                                                                                             
          Insert  "secs. 35 and 40"                                                                                             
                                                                                                                                
     Page 34, line  24:                                                                                                         
          Delete  "secs. 1 and 2"                                                                                               
          Insert  "secs. 2 and 3"                                                                                               
                                                                                                                                
     Page 34, line  26:                                                                                                         
          Delete  "secs. l and 2"                                                                                               
          Insert  "secs. 2 and 3"                                                                                               
                                                                                                                                
     Page 34, line  28:                                                                                                         
          Delete "secs. 6 - 13"                                                                                                 
          Insert "secs. 7 - 14"                                                                                                 
                                                                                                                                
     Page 34, line  30:                                                                                                         
          Delete "secs. 6 - 13"                                                                                                 
          Insert "secs. 7 - 14"                                                                                                 
                                                                                                                                
     Page 35, line l:                                                                                                           
          Delete  "secs. 18 and 20"                                                                                             
          Insert  "secs. 19 and 21"                                                                                             
                                                                                                                                
     Page 35, line 3:                                                                                                           
          Delete  "secs. 18 and 20"                                                                                             
          Insert  "secs. 19 and 21"                                                                                             
                                                                                                                                
     Page 35, line 5:                                                                                                           
          Delete  "secs. 23 - 25"                                                                                               
          Insert  "secs. 24 - 26"                                                                                               
                                                                                                                                
     Page 35, line 7:                                                                                                           
          Delete  "secs. 23 - 25"                                                                                               
          Insert "secs. 24 - 26"                                                                                                
                                                                                                                                
     Page 35, line 8:                                                                                                           
          Delete  "Section 27"                                                                                                  
          Insert  "Section 28"                                                                                                  
     Page 35, line I 0:                                                                                                         
          Delete  "Section 32"                                                                                                  
          Insert  "Section 33"                                                                                                  
                                                                                                                                
     Page 35, line  12:                                                                                                         
          Delete  "Section 33"                                                                                                  
          Insert  "Section 34"                                                                                                  
                                                                                                                                
     Page 35, line  14:                                                                                                         
          Delete  "Section 35"                                                                                                  
          Insert  "Section 36"                                                                                                  
                                                                                                                                
     Page 35, line  16:                                                                                                         
          Delete  "Section 36"                                                                                                  
          Insert  "Section 37"                                                                                                  
                                                                                                                                
     Page 35, line  18:                                                                                                         
          Delete "Sections 37 and 38"                                                                                           
          Insert "Sections 38 and 39"                                                                                           
                                                                                                                                
     Page 35, line  20:                                                                                                         
          Delete  "Section 41"                                                                                                  
          Insert  "Section 42"                                                                                                  
                                                                                                                                
     Page 35, line  22:                                                                                                         
          Delete "Section 1, 2, 6 - 13, 18, 20, 23 - 25,                                                                        
          34, and 39"                                                                                                           
          Insert "Sections 2, 3, 7 - 14, 19, 21, 24 - 26,                                                                       
          35, and 40"                                                                                                           
                                                                                                                                
     Page 35, line  24:                                                                                                         
          Delete "Sections 31 and 42"                                                                                           
          Insert "Sections 32 and 43"                                                                                           
                                                                                                                                
     Page 35, line  25:                                                                                                         
          Delete "secs. 45 - 53"                                                                                                
          Insert "secs. 46 - 54"                                                                                                
                                                                                                                                
Representative Wilson OBJECTED for the purposes of                                                                              
discussion.                                                                                                                     
                                                                                                                                
Co-Chair  Seaton spoke  to his  amendment.  He explained  that                                                                  
the amendment  inserted  intent language  clarifying that  the                                                                  
seven  day limit  for initial  opioid prescription  should  be                                                                  
considered  a  minimum.  He cited  CDC  data  that  discovered                                                                  
that a 3  day supply alleviated  most cases of acute  pain and                                                                  
the  likelihood  of chronic  opioid  use increased  with  each                                                                  
additional  day. A  sharp  increase in  risk  occurred on  the                                                                  
5th  day,   with  a   second  prescription   or  refill,   700                                                                  
milligrams  of morphine equivalents,  or an  initial 10  or 30                                                                  
day supply.  He  wanted the  intent language  to clarify  that                                                                  
while the  provider maintained the  discretion to  prescribe a                                                                  
seven day  prescription, the full  amount was not  appropriate                                                                  
in every situation and definitely not a mandate.                                                                                
                                                                                                                                
Vice-Chair  Gara  supported  the amendment  and  reminded  the                                                                  
committee  that intent  language  was uncodified  law and  was                                                                  
not  included in  statute.  He  advocated for  a  "presumptive                                                                  
number"  set in statute,  which  was currently  7 days in  the                                                                  
bill and questioned whether it was the proper number.                                                                           
                                                                                                                                
2:56:24 PM                                                                                                                    
                                                                                                                                
Representative  Ortiz asked Dr.  Butler whether the  amendment                                                                  
"limited  the   overall  intent  of  the  bill."   Dr.  Butler                                                                  
thought  the  amendment  was  very  reasonable.  He  explained                                                                  
that the number  of days was not  intended to define  a length                                                                  
of a prescription  but to define  when a greater quantity  was                                                                  
justified   in  the  medical   record.  He  thought   Co-Chair                                                                  
Seaton's amendment was rational and he supported it.                                                                            
                                                                                                                                
Representative Wilson WITHDREW her OBJECTION.                                                                                   
                                                                                                                                
Vice-Chair  Gara  MOVED  to  AMEND  Amendment  2.  He  offered                                                                  
Conceptual  Amendment  1 to  delete  the  language  in line  3                                                                  
that read:                                                                                                                      
                                                                                                                                
     The uncodified law of the State of Alaska is amended                                                                       
     by adding a new section to read:                                                                                           
                                                                                                                                
Vice-Chair  Gara  explained that  he  wanted the  language  to                                                                  
remain in statute.                                                                                                              
                                                                                                                                
Co-Chair  Seaton  asked for  a  brief "at  ease"  in order  to                                                                  
consult with legal services.                                                                                                    
                                                                                                                                
Vice-Chair  Gara  WITHDREW  his   Conceptual  Amendment  1  to                                                                  
Amendment 2.                                                                                                                    
Vice-Chair Gara WITHDREW his OBJECTION.                                                                                         
                                                                                                                                
There being NO OBJECTION, it was so ordered.                                                                                    
                                                                                                                                
Amendment 2 was ADOPTED.                                                                                                        
Co-Chair Seaton MOVED to ADOPT Amendment 3 (copy on file):                                                                      
                                                                                                                                
     Page 8, line 27, following "Surgeons":                                                                                     
          Insert "or by the National Board of Osteopathic                                                                       
          Medical Examiners"                                                                                                    
                                                                                                                                
Representative   Wilson   OBJECTED   for   the   purposes   of                                                                  
discussion.                                                                                                                     
                                                                                                                                
Co-Chair  Seaton  reviewed  the amendment.  He  conveyed  that                                                                  
the  amendment  updated a  portion  of the  licensing  statute                                                                  
related  to Osteopathic  Physicians  by updating  the name  of                                                                  
the  national   examination  certification  board.   The  bill                                                                  
listed the  board's name  as the National  Board of  Examiners                                                                  
of Osteopathic  Physicians  and Surgeons.  However, the  board                                                                  
was  currently  known as  the National  Board  of  Osteopathic                                                                  
Medical  Examiners and  would be inserted  in the  legislation                                                                  
along with  the existing name.  He noted that some  osteopaths                                                                  
in  the  state  might  still  have  their  license  under  the                                                                  
previous name of the board.                                                                                                     
                                                                                                                                
Representative Wilson WITHDREW her OBJECTION.                                                                                   
                                                                                                                                
There being NO OBJECTION, it was so ordered.                                                                                    
                                                                                                                                
Amendment 3 was ADOPTED.                                                                                                        
                                                                                                                                
3:01:08 PM                                                                                                                    
                                                                                                                                
Co-Chair Seaton MOVED to ADOPT Amendment 4 (copy on file):                                                                      
                                                                                                                                
     Page 26, line 10, following "older":                                                                                       
          Insert   "or   an  emancipated   minor,   a   parent                                                                  
          or    legal   guardian    of   a   minor,    or   an                                                                  
          individual's  guardian  or other  person   appointed                                                                  
          by  the  individual    or  a  court  to  manage  the                                                                  
          individual's health care"                                                                                             
                                                                                                                                
     Page 26, line 12, following "individual":                                                                                  
          Insert "or the minor"                                                                                                 
                                                                                                                                
     Page 26, line 18, following "individual":                                                                                  
          Insert  "a parent or legal  guardian of a  minor, or                                                                  
          an    individual's   guardian   or    other   person                                                                  
          appointed  by the  individual or  a court to  manage                                                                  
          the individual's health care"                                                                                         
                                                                                                                                
     Page 26, lines 24 - 30:                                                                                                    
          Delete all material and insert:                                                                                       
                "(c) An individual who  is 18 years of  age or                                                                  
                older or an  emancipated minor,  a parent   or                                                                  
                legal   guardian   of    a   minor,    or   an                                                                  
                individual's   guardian   or    other   person                                                                  
                appointed by the  individual   or a court   to                                                                  
                manage the  individual's    health   care  may                                                                  
                revoke  a voluntary   nonopioid  directive  at                                                                  
               any time in writing or orally."                                                                                  
                                                                                                                                
     Page 26, line 31, following "individual":                                                                                  
          Insert,  "a parent  or  legal guardian  of a  minor,                                                                  
          or   an  individual's   guardian  or  other   person                                                                  
          appointed  by the  individual or  a court to  manage                                                                  
          the individual's health care"                                                                                         
                                                                                                                                
     Page 27, line 7:                                                                                                           
          Delete "who has executed"                                                                                             
          Insert "or a minor who has"                                                                                           
                                                                                                                                
     Page 27, line 11:                                                                                                          
          Delete "a controlled substance"                                                                                       
          Insert "an opioid"                                                                                                    
          Following "individual's":                                                                                             
                Insert "or a minor's"                                                                                           
                                                                                                                                
     Page 27, following line 24:                                                                                                
          Insert a new paragraph to read:                                                                                       
                "(2) "emancipated minor"  means a minor  whose                                                                  
                disabilities  have been  removed  for  general                                                                  
                purposes under AS 09.55.590;"                                                                                   
                                                                                                                                
     Renumber the following paragraphs accordingly.                                                                             
                                                                                                                                
     Page 27, following line 26:                                                                                                
          Insert a new paragraph to read:                                                                                       
                "(5)"minor" means an  individual who  is under                                                                  
                18 years of age and is unemancipated;"                                                                          
                                                                                                                                
     Renumber the following paragraphs accordingly.                                                                             
                                                                                                                                
Representative Wilson OBJECTED.                                                                                                 
                                                                                                                                
Co-Chair  Seaton presented  the amendment.  He purported  that                                                                  
the  amendment  was  related  to  the   opioid  directive  for                                                                  
minors.  The  amendment   allowed  parents  or   guardians  of                                                                  
minors to  issue an opioid directive  on behalf of  the child.                                                                  
Currently,  the  directive  only  applied  to  individuals  18                                                                  
years or  older, but  minors were also  prescribed opioids  or                                                                  
had  already  experienced  addiction.  He  explained  that  in                                                                  
emergency   situations  a   child  may   be  treated   without                                                                  
parental   consent  and   the  directive   would  notify   the                                                                  
practitioner   to  avoid  opioid   use.  He  added   that  the                                                                  
amendment  clarified  the role  of  legal guardians  for  non-                                                                  
minors.   Previously,   legal   guardians   could   revoke   a                                                                  
directive  but  not  execute  one.  The  department  concurred                                                                  
that a legal  guardian should be  able to execute  a directive                                                                  
therefore,  the  provision  was  included  in  the  amendment.                                                                  
Representative  Wilson cited page  27, line 24 of the  bill or                                                                  
page 2 of  the amendment and  asked whether the definition  of                                                                  
emancipated minor was new.                                                                                                      
                                                                                                                                
3:03:45 PM                                                                                                                    
                                                                                                                                
TANEEKA HANSEN,  STAFF, REPRESENTATIVE  PAUL SEATON,  informed                                                                  
the  committee  that staff  from  Legislative  Legal  Services                                                                  
would be able to answer the question.                                                                                           
                                                                                                                                
Representative   Wilson   stated   that  she   supported   the                                                                  
amendment  as long  as  the definition  of  emancipated  minor                                                                  
was not  altered. She requested  that the committee  waited to                                                                  
hear from legal services before voting on the amendment.                                                                        
                                                                                                                                
Ms.  Kraly  responded  that the  definition  was  not  changed                                                                  
from  current  statute.  She detailed  that  the  language  on                                                                  
page 2,  lines 13 through  14 of the  amendment referenced  AS                                                                  
09.55.590, which was the definition of emancipation.                                                                            
                                                                                                                                
Representative  Wilson  repeated  her question  regarding  the                                                                  
definition of emancipation of a minor.                                                                                          
                                                                                                                                
LINDA   BRUCE,    ATTORNEY,   LEGISLATIVE   LEGAL    SERVICES,                                                                  
confirmed   that  the   definition  was   not  changing.   She                                                                  
indicated  that  the  existing definition   was cited  in  the                                                                  
section.                                                                                                                        
                                                                                                                                
Representative Wilson WITHDREW her OBJECTION.                                                                                   
                                                                                                                                
There being NO OBJECTION, it was so ordered.                                                                                    
                                                                                                                                
Amendment 4 was ADOPTED.                                                                                                        
                                                                                                                                
3:07:03 PM                                                                                                                    
                                                                                                                                
Vice-Chair  Gara MOVED  to ADOPT  New Conceptual  Amendment  5                                                                  
(copy on file):                                                                                                                 
                                                                                                                                
     On page 5, lines 23,25,30,31 and page 6, lines 6 and 9                                                                     
     replace "seven-day" with "five-day."                                                                                       
     Make confirming language changes as needed.                                                                                
                                                                                                                                
Representative   Wilson   OBJECTED   for   the   purposes   of                                                                  
discussion.                                                                                                                     
                                                                                                                                
Vice-Chair  Gara spoke  to  his amendment.  He  cited the  CDC                                                                  
study  [Morbidity  and  Mortality  Weekly  Report,  March  17,                                                                  
2017  I Vol.  66, No.  10 US  Department of  Health and  Human                                                                  
Services/Centers  for  Disease   Control  and  Prevention]  of                                                                  
which  he distributed  one  page  [267]  (copy on  file)  that                                                                  
reported  the risk of  opioid addiction  rose sharply  after 5                                                                  
days of the  initial prescription  and that for most  people a                                                                  
3 day  supply was effective.  He noted  the bill's waiver  for                                                                  
an  initial  prescription  that was  longer  than  7 days.  He                                                                  
asserted  that the bill  should reflect  the science  that the                                                                  
addiction  risk grew  sharply after  5 days  and proposed  the                                                                  
change in  the amendment.  He emphasized  that the change  was                                                                  
appropriate  due to the waiver  for longer periods of  time in                                                                  
the bill.  He remarked  that the intent  of the amendment  was                                                                  
to include  all healthcare prescribers  that had  prescription                                                                  
authority.                                                                                                                      
                                                                                                                                
Representative  Thompson  asked  whether Amendment  5  altered                                                                  
the  intent   language   in  Amendment   2.  Vice-Chair   Gara                                                                  
answered that  the amendment would  mesh with Amendment  5 and                                                                  
state that  the intent was to  prescribe for less than  5 days                                                                  
unless  otherwise necessary.  He thought  the amendment  would                                                                  
remain the  same but mean fewer  than 5 instead of  fewer than                                                                  
7 days.                                                                                                                         
                                                                                                                                
3:10:44 PM                                                                                                                    
                                                                                                                                
Representative   Kawasaki    asked   whether   the   amendment                                                                  
included  all prescribers.  Vice-Chair Gara  responded in  the                                                                  
affirmative.  Representative Kawasaki  noted that the  CDC had                                                                  
recommendations  for  chronic  pain  and  separate  guidelines                                                                  
for  cancer or  palliative  care. He  observed  that the  bill                                                                  
referenced  the  limited  supply  for a  person  with  chronic                                                                  
pain  and wondered  whether how  that affected  a person  with                                                                  
cancer  or  palliative  care.  Vice-Chair  Gara  deferred  the                                                                  
question  to Dr.  Butler.  He recounted  that  the doctor  had                                                                  
the  authority   to  prescribe  for  longer  than   the  limit                                                                  
depending on the situation in either the bill or amendment.                                                                     
                                                                                                                                
Dr.   Butler   responded   that  the   waiver   provided   the                                                                  
protections  as defined  in the CDC  guidelines. He  commented                                                                  
that the  CDC guideline  was "a guideline  and not a  specific                                                                  
study."  He expounded  that a  summary of  the available  data                                                                  
in  2015  was used  to  develop  the  guideline  published  in                                                                  
early  2016. The  discussion  regarding 5  or 7  days was  not                                                                  
available in  2015. He concurred  with the CDC guideline  that                                                                  
pointed  to the 3  day supply as  being optimal  and that  a 7                                                                  
day  supply  was rarely  necessary.  He  referred  to the  CDC                                                                  
line graph  he referenced earlier  and characterized  the line                                                                  
as  a line  of  increasing  risk containing  "a  couple  bumps                                                                  
that were  steeper at 5 and 30  days" but did not  represent a                                                                  
"sudden quadrupling of the risk."                                                                                               
                                                                                                                                
3:14:32 PM                                                                                                                    
                                                                                                                                
Representative  Ortiz asked  whether Amendment  5 was  drafted                                                                  
without consultation  with DHSS.  Vice-Chair Gara answered  in                                                                  
the affirmative  and commented  that the  amendment was  based                                                                  
on the  department's  testimony  and the  CDC information.  He                                                                  
noted  that  he  spoke  with  the department.   Representative                                                                  
Ortiz  asked   Dr.  Butler  how   he  felt  about   Conceptual                                                                  
Amendment  5. Dr. Butler  understood  that the  administration                                                                  
did not  support  the amendment.  He felt  that the  amendment                                                                  
containing  the  intent  language  [Amendment  2]  struck  the                                                                  
balance between risks and benefits.                                                                                             
                                                                                                                                
Co-Chair Seaton  clarified that  Dr. Butler was talking  about                                                                  
a  line  graph,  which  was  not  handed   out  and  requested                                                                  
distribution  of  the document.  [MMWR  dated  March 17,  2017                                                                  
Vol.  66, No.  10  CDC page  267]  He  conveyed that  the  CDC                                                                  
guideline  reference  that  Dr.  Butler  previously  discussed                                                                  
was  from the  Morbidity and  Mortality  Weekly Report,  March                                                                  
15,  2016,  Vol. 65,  -  US  Department  of Health  and  Human                                                                  
Services/Centers  for  Disease  Control and  Prevention  (copy                                                                  
on file). He read from the March 17, 2017 handout:                                                                              
                                                                                                                                
     The probability of long-term opioid use increases most                                                                     
     sharply in the first days of therapy, particularly                                                                         
     after 5 days or 1 month of opioids have been                                                                               
     prescribed…                                                                                                                
                                                                                                                                
Co-Chair  Seaton   queried  why   the  committee  should   not                                                                  
embrace  the  most  recent  CDC  data   that  demonstrated  an                                                                  
increased   risk  after  5   days  of   use  and  adjust   the                                                                  
legislation.  Dr.  Butler   remarked  that  the  graph  was  a                                                                  
helpful  visual   aid  but  the  department  focused   on  the                                                                  
textural  interpretation  of  the report.  He  furthered  that                                                                  
the main  structural advantage of  retaining the 7  day supply                                                                  
was the  conceptual  ease for  the provider  keeping track  of                                                                  
calendar  days.  He speculated  that  5 days  was  a bit  more                                                                  
complicated.                                                                                                                    
                                                                                                                                
3:19:21 PM                                                                                                                  
                                                                                                                                
Vice-Chair  Gara asked  whether  the concern  over a  doctor's                                                                  
had the  ability to perform  simple math  was on balance  with                                                                  
the CDC  stated  guideline that  after 5  days addiction  grew                                                                  
sharply.  Dr.  Butler was  not  remarking  on the  ability  of                                                                  
providers  to   prescribe  for  5  days  versus   7  days.  He                                                                  
articulated  that he  wanted to  make the  guidelines as  easy                                                                  
as possible for busy providers.                                                                                                 
                                                                                                                                
Representative  Kawasaki  asked  whether  the  consequence  of                                                                  
prescribing  an  opioid past  the  7 day  limit  was that  the                                                                  
provider  was required to  document and  justify the  event in                                                                  
the   patient's   chart.   Dr.   Butler   responded   in   the                                                                  
affirmative.  Representative  Kawasaki  wondered  whether  the                                                                  
prescriber  would  feel  that  she  had  to  prescribe  lesser                                                                  
amounts to  avoid reporting.  Dr. Butler  thought he  raised a                                                                  
good  question and  was  not sure  whether  the reporting  was                                                                  
significant to a prescriber or not.                                                                                             
                                                                                                                                
3:23:11 PM                                                                                                                    
                                                                                                                                
Representative  Ortiz  understood  Vice-Chair  Gara's  concern                                                                  
but   was  not   comfortable   with  further   accessing   the                                                                  
relevance  of   the  issue.  He   felt  that  the   department                                                                  
thoroughly vetted the issue before the decision was made.                                                                       
                                                                                                                                
Co-Chair Seaton  referred to the  2 charts on the  CDC handout                                                                  
[MMWR, March  17, 2017   Vol. 66, No. 10 - CDC, page 267 (copy                                                                  
on file)]  he cited earlier  and asked  for an explanation  of                                                                  
the  second chart  the depicted  the number  of  prescriptions                                                                  
in the  first episode  of opioid use.  Dr. Butler referred  to                                                                  
the  first chart  that  depicted  the  days' supply  of  first                                                                  
opioid  prescription.   He  explained  that  the   solid  line                                                                  
denoted  the  1   year  probability  and  the   vertical  line                                                                  
denoted  the   probability  of   continuing  use  [1   to  100                                                                  
percent]  by the  number  of days'  supply  in the  horizontal                                                                  
axis. He  noted the steeper  upswing between  5 to 7  days and                                                                  
a  slight leveling  off  and did  not  feel the  increase  was                                                                  
much  more dramatic  at  5 days  than seven.  Co-Chair  Seaton                                                                  
interpreted  that  the  risk   at  five  days  was  roughly  7                                                                  
percent  and  7 to  8  days  was  over 15  percent  and  asked                                                                  
whether he  concurred. Dr.  Butler interpreted  the data  a 10                                                                  
percent risk at 5 days and 13 to 14 percent at 7 days.                                                                          
                                                                                                                                
Vice-Chair    Gara   was   "really    confused"   about    the                                                                  
department's  balancing of risks  and rewards. He  interpreted                                                                  
the data to  read a sharp rise  in the risk of addiction  from                                                                  
10  percent to  15 percent  from  5 to  6 days.  He cited  the                                                                  
text and read:                                                                                                                  
                                                                                                                                
     …increases most sharply in the first days of therapy                                                                       
     particularly after five days.                                                                                              
                                                                                                                                
Vice-Chair  Gara  voiced that  the  graph concurred  with  the                                                                  
narrative.  He reiterated  his skepticism  that the burden  of                                                                  
choosing  a limit based  on prescribing  around calendar  days                                                                  
was worth  the increased risk of  addiction. He felt  that the                                                                  
danger to  the public  was demonstrated  to be much higher  at                                                                  
7 days  and even higher  at 10 days,  roughly 20 percent.  Dr.                                                                  
Butler  did  not  intend  to  imply  that   Vice-Chair  Gara's                                                                  
interpretation  was "way off."  Vice-Chair Gara asked  whether                                                                  
Dr.  Butler  thought  the  5-day limit  was  bad  policy.  Dr.                                                                  
Butler replied  in the  negative and would  not object  to the                                                                  
amendment.                                                                                                                      
                                                                                                                                
3:30:20 PM                                                                                                                    
                                                                                                                                
VALERIE  DAVIDSON,  COMMISSIONER,  DEPARTMENT  OF  HEALTH  AND                                                                  
SOCIAL  SERVICES,  attempted  to  provide  more  clarity.  She                                                                  
relayed  that there  was nothing  in the  bill that  precluded                                                                  
the  provider from  writing  a prescription  for  less than  7                                                                  
days.  The  bill  required  the provider  to  justify  in  the                                                                  
medical  record why  the script  was written  for more than  7                                                                  
days.  She  shared   that  the  department  had   worked  with                                                                  
providers  to find  an amount  of time  that did  not pose  an                                                                  
administrative  burden and  7 days  was agreed  upon. She  was                                                                  
uncertain how providers would react to the amendment.                                                                           
                                                                                                                                
Representative  Wilson  thought the  issue  had been  properly                                                                  
vetted.   She  had   not  heard  objections   from   providers                                                                  
regarding  the current 7  day limit. She  did not support  the                                                                  
amendment.                                                                                                                      
                                                                                                                                
Co-Chair  Seaton  asked whether  a  doctor could  prescribe  a                                                                  
refill  for  an   initial  opioid  prescription.   Dr.  Butler                                                                  
answered  in the  affirmative and  added that  the refill  was                                                                  
possible due to the waiver.                                                                                                     
                                                                                                                                
Co-Chair Seaton  clarified that he  was asking about  a refill                                                                  
on  an initial  3  day or  5 day  prescription.  He  indicated                                                                  
that  the  objective  of  HB  159   was  to  halt  the  opioid                                                                  
epidemic  that was partially  caused by  over prescribing.  He                                                                  
reiterated his  inquiry regarding  whether a refill on  a 3 or                                                                  
5 day prescription  was allowed  under the bill. He  wanted to                                                                  
place  "downward   pressure  on  initial  prescriptions"   and                                                                  
strike a  balance between  need and the  5 and 7 day  options.                                                                  
He  deduced  that  if  a  refill  was  allowable,   without  a                                                                  
further  prescription,  the distinction  between the  5 and  7                                                                  
day was irrelevant.                                                                                                             
                                                                                                                                
3:36:18 PM                                                                                                                    
                                                                                                                                
Commissioner  Davidson  responded that  the way  the bill  was                                                                  
written   the   7   day   limit   applied   to   the   initial                                                                  
prescription.  She  added that  the  refill was  considered  a                                                                  
second  prescription  and fell  outside  of the  scope of  the                                                                  
seven  day limit.  The bill  allowed  a patient  to request  a                                                                  
partial fill  of a prescription.  She indicated that  the bill                                                                  
attempted to  "reset" the standard  practice of  automatically                                                                  
prescribing  much larger amounts  i.e., 30 days. She  restated                                                                  
that the  bill recognized  instances where  a longer  dose was                                                                  
necessary   by  providing   the   waiver   and  the   required                                                                  
justification.                                                                                                                  
                                                                                                                                
Vice-Chair  Gara  understood   that  a  doctor  could  already                                                                  
prescribe  less  but  the  bill  was  necessary  to  create  a                                                                  
standard.   Commissioner   Davidson    responded,   "That   is                                                                  
correct."  Vice-Chair  Gara  reasoned  that the  question  was                                                                  
what the standard  should be. He  noted that the CDC  data was                                                                  
released  subsequent  to  the bill's  introduction.  He  asked                                                                  
whether she  had spoken  to the providers  about the  spike in                                                                  
risk that occurred after 5 days.                                                                                                
                                                                                                                                
Dr.  Butler shared  that he  used the  same graph  in a  slide                                                                  
when he  spoke to providers  about the  bill. None had  spoken                                                                  
out about  the issue.  Vice-Chair Gara  cited statistics  that                                                                  
the state  experienced 90 deaths  due to opioid addiction  and                                                                  
two  thirds were  linked to  prescription  use. He  reiterated                                                                  
that the  risk for  abuse sharply increased  after five  days.                                                                  
He stressed  that even  though providers  did not weigh  in on                                                                  
the issue  the legislature  could make  the "policy call."  He                                                                  
asserted  that the  bill  needed to  include  a guideline  and                                                                  
that  the  guideline  should  be  5  days;  the  point  before                                                                  
prescription opioid abuse rose sharply.                                                                                         
                                                                                                                                
3:41:06 PM                                                                                                                    
                                                                                                                                
Representative Wilson MAINTAINED her OBJECTION.                                                                                 
                                                                                                                                
A roll call vote was taken on the motion.                                                                                       
                                                                                                                                
IN FAVOR: Gara, Grenn, Thompson, Seaton                                                                                         
OPPOSED: Wilson, Kawasaki, Ortiz, Pruitt, Tilton, Foster.                                                                       
                                                                                                                                
Representative Guttenberg was absent from the vote.                                                                             
                                                                                                                                
The MOTION to ADOPT Amendment 5 FAILED (4/6).                                                                                   
                                                                                                                                
Amendment 5 FAILED to be ADOPTED.                                                                                               
                                                                                                                                
Co-Chair Foster  asked Vice-Chair  Gara to discuss  the fiscal                                                                  
notes.                                                                                                                          
                                                                                                                                
Vice-Chair  Gara  had a  question  regarding Amendment  2.  He                                                                  
reiterated  that   the  amendment  provided  intent   language                                                                  
clarifying  that  the  provider  could  prescribe  an  initial                                                                  
opioid  prescription for  less than  seven days.  He asked  if                                                                  
the language,  "The uncodified law  of the State of  Alaska is                                                                  
amended  by adding  a new  section  to read:"  was deleted  on                                                                  
lines  3  and  4 would  the  intent  language  remain  in  the                                                                  
statue books.                                                                                                                   
                                                                                                                                
LINDA  BRUCE,  ATTORNEY,  LEGISLATIVE  LEGAL  SERVICES,  asked                                                                  
whether  he meant  that  by removing  the  uncodified  lead-in                                                                  
the language would be codified law.                                                                                             
                                                                                                                                
Vice-Chair   Gara  explained   that  he   wanted  the   intent                                                                  
language  to remain  in  statute. Ms.  Bruce  did not  believe                                                                  
that  as drafted  the  Amendment 2  language  would appear  in                                                                  
the   statute.   Vice-Chair   Gara   restated   his   question                                                                  
regarding  removing  the lead-in  language  and  adding a  new                                                                  
section  if Amendment  2 would  remain in  statute. Ms.  Bruce                                                                  
responded  in  the negative.  She  clarified  that  a  section                                                                  
number  was  necessary  and  substantive  language  needed  to                                                                  
replace the intent language.                                                                                                    
                                                                                                                                
3:45:42 PM                                                                                                                    
                                                                                                                                
Vice-Chair   Gara  reviewed   the  Department   of   Commerce,                                                                  
Community  and Economic  Development  fiscal note  FN 3  (CED)                                                                  
appropriated  to the Division  of Corporations Businesses  and                                                                  
Professional  Licensing in  the amount  of $27.5 thousand  for                                                                  
legal  and printing  costs  for  new regulations.  The  second                                                                  
fiscal note DHSS FN 2 (DHS) was zero.                                                                                           
                                                                                                                                
3:46:58 PM                                                                                                                    
AT EASE                                                                                                                         
                                                                                                                                
3:47:11 PM                                                                                                                    
RECONVENED                                                                                                                      
                                                                                                                                
Co-Chair Foster noted that Fiscal 1 was no longer relevant.                                                                     
                                                                                                                                
Co-Chair  Seaton   MOVED  to  report  CSHB  159(FIN)   out  of                                                                  
Committee    with   individual    recommendations   and    the                                                                  
accompanying fiscal notes.                                                                                                      
                                                                                                                                
Representative Wilson OBJECTED.                                                                                                 
                                                                                                                                
Representative   Wilson   felt   that  the   legislature   was                                                                  
attempting to  be doctors and the  bill was "beyond  the scope                                                                  
of  where  we  belong."  She  believed  that  overprescribing                                                                   
should  be  a   crime.  The  bill  only  contained   suggested                                                                  
guidelines    and    included    ways    to    maintain    the                                                                  
overprescribing  practices.  She believed  that the  decisions                                                                  
were better  left up  to the medical  professionals and  their                                                                  
boards and allow them to deal with the problem.                                                                                 
                                                                                                                                
3:49:59 PM                                                                                                                    
                                                                                                                                
Representative  Pruitt  disagreed   with  his  colleague  from                                                                  
North Pole.  He thought  that the medical  community  was slow                                                                  
to  respond   to  the  crisis.   He  felt  that  the   problem                                                                  
"ballooned"   rapidly.   He   believed   that   the   epidemic                                                                  
warranted   government    intervention   for    the   public's                                                                  
protection.  He  supported  the legislation  and  thanked  the                                                                  
sponsor for introducing the bill.                                                                                               
                                                                                                                                
Representative   Kawasaki  thanked   the  administration   for                                                                  
bringing  the  legislation  forward.  He  commented  that  the                                                                  
United  States  had 28  thousand  deaths due  to  prescription                                                                  
opioids  last year;  half  were  procured legally.  The  black                                                                  
market  for opioids  was still  a  major part  of the  problem                                                                  
but the legislation addressed part of the issue.                                                                                
                                                                                                                                
Representative  Grenn  appreciated  the  department's  efforts                                                                  
and felt  that the bill sent  a "strong message" of  awareness                                                                  
to  all parts  of  the  state.  He approved  of  Dr.  Butler's                                                                  
three  pronged approach:  working with  patients,  physicians,                                                                  
and prescribing.                                                                                                                
                                                                                                                                
Representative   Guttenberg    thought   the   issue   crossed                                                                  
multiple  lines.  He elucidated  that  the  medical  community                                                                  
was  self-regulating  and  was inattentive  to  "broad  public                                                                  
policy." The  pharmacists were  prescribing drugs and  filling                                                                  
prescriptions   and   the   pharmaceutical    companies   were                                                                  
manufacturing  and marketing  drugs under  their own  agendas.                                                                  
He  believed that  the  factors  made addressing  the  problem                                                                  
difficult.                                                                                                                      
                                                                                                                                
3:55:49 PM                                                                                                                    
                                                                                                                                
Co-Chair  Seaton  addressed the  previous  testifier,  Michael                                                                  
Karson's   comments.   He   believed   that  the   state   was                                                                  
"tinkering  around  the  edges  attempting  to  get  something                                                                  
under control."  He thought the  state had a problem  to solve                                                                  
when 85  percent of  addiction was  started with  prescription                                                                  
opioids  and  warned  that  the  bill was  only  part  of  the                                                                  
solution.  He  agreed with  Mr.  Karson's  comments  regarding                                                                  
prevention  and upstream  solutions  and felt  they offered  a                                                                  
"better"  solution. He  advocated for a  holistic approach  to                                                                  
the problem. He thanked all who worked on the bill.                                                                             
                                                                                                                                
Vice-Chair   Gara  agreed  with   all  of  Co-Chair   Seaton's                                                                  
comments  and  also  thanked  the  department.  He  maintained                                                                  
that  physicians   remaining  silent  during   a  power  point                                                                  
presentation  containing the  5 or 7 day  data was not  enough                                                                  
"evidence"  to  standby  the 7  day  period,  especially  when                                                                  
prescribers   opinions  were   not   directly  solicited.   He                                                                  
considered the  issue unresolved.  He urged the department  to                                                                  
revisit  the issue  with  providers  to determine  whether  it                                                                  
was worth choosing the 5 day limit "to save extra lives."                                                                       
                                                                                                                                
Representative Wilson MAINTAINED her OBJECTION.                                                                                 
                                                                                                                                
A roll call vote was taken on the motion.                                                                                       
                                                                                                                                
IN FAVOR: Gara,  Grenn, Guttenberg,  Kawasaki, Ortiz,  Pruitt,                                                                  
Thompson, Foster, Seaton                                                                                                        
OPPOSED: Tilton, Wilson                                                                                                         
                                                                                                                                
The MOTION PASSED (9/2).                                                                                                        
                                                                                                                                
CSHB  159(FIN)  was  REPORTED  out of  committee  with  a  "do                                                                  
pass"  recommendation   and  with  two  previously   published                                                                  
fiscal  notes,  one  zero  note: FN2  (DHS);  and  one  fiscal                                                                  
impact note: FN3 (CED).                                                                                                         
                                                                                                                                
3:59:14 PM                                                                                                                    
                                                                                                                                
Co-Chair  Foster indicated  that due to  time constraints  the                                                                  
committee would not hear SB 28 today.                                                                                           
                                                                                                                                
3:59:35 PM                                                                                                                    
AT EASE                                                                                                                         
                                                                                                                                
4:17:27 PM                                                                                                                    
RECONVENED                                                                                                                      
                                                                                                                                
HOUSE BILL NO. 6                                                                                                              
                                                                                                                                
     "An Act establishing the Jonesville Public Use Area."                                                                      
                                                                                                                                
4:17:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE   GEORGE   RAUCHER,    SPONSOR,   thanked   the                                                                  
committee   for   hearing   the   legislation.   He   provided                                                                  
information  about  the  legislation.  The  bill  provided  an                                                                  
opportunity  to make a  public use area  for the community  of                                                                  
Sutton  in conjunction  with  the  Matanuska/Susitna  Borough,                                                                  
Department  of Natural Resources  (DNR), Alaska Mental  Health                                                                  
Trust  Authority (AMHTA),  and  all of  the  user groups.  The                                                                  
bill  simply authorized  a public  use area  that allowed  the                                                                  
community to design a management plan in the future.                                                                            
                                                                                                                                
Co-Chair Foster OPENED public testimony.                                                                                        
                                                                                                                                
CAROL  CARMAN, SELF,  PALMER (via  teleconference),  testified                                                                  
in  support  of  the  legislation.  She  relayed   information                                                                  
about a  man who had  been shot and  killed in the  Jonesville                                                                  
mine area  about one year  earlier. She  shared that  the area                                                                  
was popular  with campers,  four wheelers,  and shooters.  The                                                                  
area lacked  management  and was littered  with trash,  unsafe                                                                  
with   frequent   shooting   incidences,   experienced   stray                                                                  
gunfire,  and out  of  control,  which created  safety  issues                                                                  
for residents  living in  the area.  She shared another  story                                                                  
about an  individual shooting into  a crowd around  a bonfire.                                                                  
The  area was  heavily  used. She  discussed  that the  police                                                                  
needed  to have  the  ability to  take  preventative  measures                                                                  
instead  of merely responding  to negative  events after  they                                                                  
took  place in  the area.  She remarked  that the  legislature                                                                  
passed  bill's dealing  with  honoring indigenous  people  and                                                                  
African  American  soldier's   efforts  to  build  the  Alaska                                                                  
Highway during  World War 2 and  opined that HB 6  was "passed                                                                  
over." She  urged the  committee and  legislature to  pass the                                                                  
legislation.                                                                                                                    
                                                                                                                                
4:23:47 PM                                                                                                                    
                                                                                                                                
RYAN BRETT,  AK MUDSLINGERS,  ANCHORAGE (via teleconference),                                                                   
spoke in  favor of  the legislation.  He provided  information                                                                  
about  the organization  and noted  that  the group  conducted                                                                  
an annual  Jim Creek/Knik River  area cleanup where  over 1000                                                                  
people participated.  He reported  a large decrease  in trash.                                                                  
He  shared  that the  same  issues  in the  Sutton  area  were                                                                  
present   in  the   Jim  Creek/Knik   River   area  prior   to                                                                  
management.  He  had  personally  seen  bonfires  and  out  of                                                                  
control  activities  in  the  unmanaged  area  in  Sutton.  He                                                                  
believed  the bill would  have a positive  impact on  the area                                                                  
and all  user groups.  He  spoke to  protecting the  community                                                                  
of Sutton.  He reported that  his organization was  conducting                                                                  
a  Jonesville  area  cleanup  in  June.  The  annual  cleanups                                                                  
provided more  exposure to the  issue. He asked the  committee                                                                  
to pass the bill.                                                                                                               
                                                                                                                                
Representative  Tilton  thanked  Mr.  Brett  for  coordinating                                                                  
the cleanups and for the way he ran the organization.                                                                           
                                                                                                                                
4:26:45 PM                                                                                                                    
                                                                                                                                
PATTI  BARBER, SELF,  MAT-SU (via  teleconference),  testified                                                                  
in support  of the legislation.  She stated that the  area was                                                                  
popular  and  needed direction  to  contain  the  uncontrolled                                                                  
use.  She  spoke  to  the  burned  out  vehicles,  trash,  and                                                                  
bullets  in  the  area. She  related  that  the  community  of                                                                  
Butte had  the same problems until  the Knik River  Public Use                                                                  
Area  was   established.  She   believed  that  creating   the                                                                  
Jonesville  Public Use  area would  educate  the public  about                                                                  
using  the  area  safety and  advocated  for  funding  in  the                                                                  
future.                                                                                                                         
                                                                                                                                
4:27:56 PM                                                                                                                    
                                                                                                                                
KENNY  BARBER, SELF,  MAT-SU  (via teleconference),  spoke  in                                                                  
support  of the bill.  He believed  it was  a positive  effort                                                                  
and hoped for financial support of the area in the future.                                                                      
                                                                                                                                
4:28:54 PM                                                                                                                    
                                                                                                                                
Co-Chair Foster CLOSED public testimony.                                                                                        
                                                                                                                                
Vice-Chair  Gara addressed  the  four zero  fiscal notes  from                                                                  
the  Department of  Natural  Resources, Department  of  Public                                                                  
Safety, and the Department of Fish and Game.                                                                                    
                                                                                                                                
Representative  Kawasaki asked  for  discussion regarding  the                                                                  
two fiscal notes from DPS.                                                                                                      
                                                                                                                                
4:31:20 PM                                                                                                                    
AT EASE                                                                                                                         
                                                                                                                                
4:31:33 PM                                                                                                                    
RECONVENED                                                                                                                      
                                                                                                                                
4:31:47 PM                                                                                                                    
                                                                                                                                
CLARK COX,  NATURAL  RESOURCE MANAGER,  DEPARTMENT OF  NATURAL                                                                  
RESOURCES   (via  teleconference),   introduced  himself   and                                                                  
asked Representative Kawasaki to repeat his question.                                                                           
                                                                                                                                
Representative  Kawasaki noted that  the DNR fiscal  note from                                                                  
the  Division  of  Mining,  Land  and   Water  discussed  that                                                                  
troopers  were unlikely  to provide enforcement  in the  area.                                                                  
Mr. Cox  explained  that the departments  gauged  HB 6 to  the                                                                  
Knik River  Public Use  area when creating  the fiscal  notes.                                                                  
The Knik  River area was  very successful  due to the  funding                                                                  
appropriated    when   the   area    was   established.    The                                                                  
appropriation  afforded   one  DNR  staffer  and  funding  for                                                                  
troopers  for enforcement. Representative  Kawasaki  indicated                                                                  
that   Mr.  Cox's   response   clarified   his  question.   He                                                                  
remembered  that  previously a  fiscal  note attached  to  the                                                                  
establishment  of the Knik River  Public Use Area  was roughly                                                                  
$400 thousand  in 2007. The major  portion of the  funding was                                                                  
for creation  of the management  plan. He asked how  DNR would                                                                  
prioritize  the  planning  work  for Jonesville  with  a  zero                                                                  
fiscal note.  Mr. Cox  answered that  the Knik River  planning                                                                  
took  several years  with  ample  funding and  the  Jonesville                                                                  
area  would  take  much  longer   with  a  zero  fiscal  note.                                                                  
Representative  Kawasaki cautioned  the Jonesville Public  Use                                                                  
Area's  supporters  that  without  funding  the  proposal  and                                                                  
management  plan  would take  a  long  time to  implement.  He                                                                  
noted  that troopers  and  a half-time  ranger  was  necessary                                                                  
for the Knik River area.                                                                                                        
                                                                                                                                
4:36:22 PM                                                                                                                    
                                                                                                                                
DARREL  BREEZE, STAFF,  REPRESENTATIVE  GEORGE RAUCHER,  noted                                                                  
the letter  in member's packet  from the commissioner  of DNR,                                                                  
Andrew  Mack  (copy  on  file)  and   pointed  to  the  second                                                                  
paragraph   that  stated   without   additional  funding   the                                                                  
process  was expected  to take  5 years. He  related that  the                                                                  
sponsor  acknowledged  that  the  plan  would  take  time.  He                                                                  
favored  taking  five  years  to  work   with  the  community,                                                                  
borough,  and users  to  develop a  management  plan that  met                                                                  
the needs of all of the users.                                                                                                  
                                                                                                                                
Representative   Wilson   asked   whether  the   sponsor   was                                                                  
expecting  the borough  to  play a  large role  in  developing                                                                  
the plan  to present  to DNR  and participate  in  fundraising                                                                  
efforts  unlike  the  development  of  the  Knik  River  area.                                                                  
Representative   Raucher  answered  in  the  affirmative.   He                                                                  
referred to Page 2, lines 10 through 11 of the bill:                                                                            
                                                                                                                                
     …the commissioner may designate incompatible uses and                                                                      
     shall adopt and may revise a management plan for the                                                                       
     Jonesville Public Use Area….                                                                                               
                                                                                                                                
Representative  Raucher   expounded  that  the  bill  did  not                                                                  
stipulate  that  DNR should  write  the management  plan.  The                                                                  
Matsu  Borough  was committed  to  developing  the public  use                                                                  
area and  was willing  to help write  the management  plan and                                                                  
help facilitate  the public process  among user groups.  There                                                                  
was  currently  a 30  page  plan developed  from  surveys  and                                                                  
previously meeting  and working  with user groups  every other                                                                  
week.  The same  process would  be used  to continue  building                                                                  
the comprehensive  plan  to present  to DNR  for their  review                                                                  
and approval.                                                                                                                   
                                                                                                                                
Representative   Wilson   thanked   the   representative   for                                                                  
working  with  local  government,   the  community,  and  user                                                                  
groups. She  thought that everyone  would understand  that the                                                                  
project would not happen overnight.                                                                                             
4:41:40 PM                                                                                                                    
                                                                                                                                
Co-Chair   Seaton  MOVED   to  report   CSHB  6(RES)   out  of                                                                  
Committee    with   individual    recommendations   and    the                                                                  
accompanying  fiscal notes. There  being NO OBJECTION,  it was                                                                  
so ordered.                                                                                                                     
                                                                                                                                
CSHB 6(RES)  was REPORTED  out of committee  with a "do  pass"                                                                  
recommendation  and  with  three  previously   published  zero                                                                  
fiscal notes,  FN1 (DNR), FN 2  (DPS), FN3 (DPS); and  one new                                                                  
zero fiscal note from the Department of Natural Resources.                                                                      
                                                                                                                                
Co-Chair  Foster   reviewed  the  agenda  for   the  following                                                                  
meeting.                                                                                                                        
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
4:43:41 PM                                                                                                                    
                                                                                                                                
The meeting was adjourned at 4:43 p.m.                                                                                          

Document Name Date/Time Subjects
HB 74 JBER Response 2017-04-26-084348.pdf HFIN 5/11/2017 1:30:00 PM
HB 74
HB 159 - Amendments 5.11.17.pdf HFIN 5/11/2017 1:30:00 PM
HB 159
SB 97 - Amendment.pdf HFIN 5/11/2017 1:30:00 PM
SB 97
SB 97 Retirement System Data LFD.pdf HFIN 5/11/2017 1:30:00 PM
SB 97
HB 159 Conceptual Amendment New 5 Gara.pdf HFIN 5/11/2017 1:30:00 PM
HB 159
HB 159 Backup for Amendment 5.pdf HFIN 5/11/2017 1:30:00 PM
HB 159
HB 159 CDC Data Opiod RX-Use.pdf HFIN 5/11/2017 1:30:00 PM
HB 159