Legislature(2017 - 2018)CAPITOL 106
04/17/2018 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| SB198 | |
| SB208 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | SB 198 | TELECONFERENCED | |
| + | SB 208 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
April 17, 2018
3:03 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Chair
Representative Tiffany Zulkosky, Vice Chair
Representative Sam Kito
Representative Geran Tarr
Representative Jennifer Johnston
MEMBERS ABSENT
Representative David Eastman
Representative Colleen Sullivan-Leonard
Representative Matt Claman (alternate)
Representative Dan Saddler (alternate)
COMMITTEE CALENDAR
SENATE BILL NO. 198
"An Act relating to a study of the effectiveness and cost of
providing long-acting reversible contraception to women with
substance abuse disorders."
- HEARD & HELD
SENATE BILL NO. 208
"An Act establishing the month of March as Sobriety Awareness
Month."
- MOVED SB 208 OUT OF COMMITTEE
PREVIOUS COMMITTEE ACTION
BILL: SB 198
SHORT TITLE: UAA LONG-ACTING CONTRACEPTION STUDY
SPONSOR(s): SENATOR(s) KELLY
02/19/18 (S) READ THE FIRST TIME - REFERRALS
02/19/18 (S) FIN
03/26/18 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/26/18 (S) Heard & Held
03/26/18 (S) MINUTE(FIN)
04/03/18 (S) FIN AT 1:30 PM SENATE FINANCE 532
04/03/18 (S) Moved SB 198 Out of Committee
04/03/18 (S) MINUTE(FIN)
04/04/18 (S) FIN RPT 4DP 1NR
04/04/18 (S) DP: MACKINNON, BISHOP, VON IMHOF,
STEVENS
04/04/18 (S) NR: HOFFMAN
04/09/18 (S) TRANSMITTED TO (H)
04/09/18 (S) VERSION: SB 198
04/11/18 (H) READ THE FIRST TIME - REFERRALS
04/11/18 (H) HSS, FIN
04/17/18 (H) HSS AT 3:00 PM CAPITOL 106
BILL: SB 208
SHORT TITLE: MARCH: SOBRIETY AWARENESS MONTH
SPONSOR(s): SENATOR(s) GARDNER
02/19/18 (S) READ THE FIRST TIME - REFERRALS
02/19/18 (S) HSS, STA
04/09/18 (S) HSS AT 1:30 PM BUTROVICH 205
04/09/18 (S) Moved SB 208 Out of Committee
04/09/18 (S) MINUTE(HSS)
04/10/18 (S) HSS RPT 4DP
04/10/18 (S) DP: WILSON, BEGICH, MICCICHE, GIESSEL
04/11/18 (S) STA REFERRAL WAIVED UC
04/12/18 (S) TRANSMITTED TO (H)
04/12/18 (S) VERSION: SB 208
04/12/18 (S) STA AT 3:30 PM BUTROVICH 205
04/12/18 (S) -- MEETING CANCELED --
04/13/18 (H) READ THE FIRST TIME - REFERRALS
04/13/18 (H) HSS
04/17/18 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
SENATOR PETE KELLY
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 198 as the sponsor of the
bill.
HEATHER CARPENTER, Staff
Senator Pete Kelly
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 198 on behalf of the bill
sponsor, Senator Kelly.
AMANDA SLAUNWHITE, Assistant Professor
Center for Alcohol and Addiction Studies
College of Health
University of Alaska Anchorage
Anchorage, Alaska
POSITION STATEMENT: Answered questions during discussion of SB
198.
JEFFREY JESSEE, Dean
College of Health
University of Alaska Anchorage
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of SB 198.
ART DELAUNE, Legislative Chair
Governor's Council on Disabilities and Special Education
Fairbanks, Alaska
POSITION STATEMENT: Testified in support of the proposed bill.
TREVOR STORRS, Executive Director
Alaska Children's Trust
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of SB 198.
JACOB TATUM, Staff
Senator Berta Gardner
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 208 on behalf of the bill
sponsor, Senator Gardner.
TIFFANY HALL, Executive Director
Recover Alaska
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of SP 208.
ACTION NARRATIVE
3:03:55 PM
CHAIR IVY SPOHNHOLZ called the House Health and Social Services
Standing Committee meeting to order at 3:03 p.m.
Representatives Spohnholz, Zulkosky, Johnston, and Kito were
present at the call to order. Representative Tarr arrived as
the meeting was in progress.
SB 198-UAA LONG-ACTING CONTRACEPTION STUDY
3:04:25 PM
CHAIR SPOHNHOLZ announced that the first order of business would
be SENATE BILL NO. 198, "An Act relating to a study of the
effectiveness and cost of providing long-acting reversible
contraception to women with substance abuse disorders."
3:05:12 PM
SENATOR PETE KELLY, Alaska State Legislature, shared some
background of his reasons for bringing the bill forward and
paraphrased the Sponsor Statement [included in members' packets]
[original punctuation provided], which read as follows:
The rising rate of maternal opioid use has resulted in
a drastic increase in children born with Neonatal
Abstinence Syndrome (NAS). In Alaska, the incidence of
children born with NAS has increased over 500% from
2004 to 2015. 1 In addition to the ongoing opioid
crisis, Alaska continues to report one of the highest
rates of fetal alcohol spectrum disorders (FASD) in
the nation. The true rate of FASD in the state is
likely to be significantly higher according to recent
national prevalence studies.
Through SB 198, the UAA Center for Alcohol and
Addiction Studies will evaluate the feasibility and
effectiveness of providing Long Acting Reversible
Contraception (LARC) to women involved in services
such as Alaska Regional Hospital's Neonatal Abstinence
Evaluation Support Treatment (NEST) program. The
population of women served by the NEST program
represent one of the highest risk groups in Alaska for
unintended pregnancy and prenatal drug/alcohol
exposure. The public health consequences of NAS and
FASD addressed by this program highlight the critical
importance of providing effective long-term
contraception options to women struggling with alcohol
and drug addiction challenges.
SB 198 is an important step in eradicating FASD and
NAS in Alaska. This study will provide critical data
on LARC as an effective tool in reducing the rates of
FASD and NAS. Furthermore, the anticipated outcomes
can inform future state spending related to LARC as a
public health strategy and its utility for reducing
pressure on state programs and budgets. Approximately
50% of infants with Neonatal Abstinence Syndrome
treated at Alaska Regional Hospital's NEST program
were immediately placed into the care of the Office of
Children's Services. 1 In Alaska, the Department of
Health and Social Services has estimated the average
cost of treating an infant with NAS is $88,869, which
is predominantly paid by Medicaid.2 According to the
Alaska Department of Health and Social Services, each
child born with FASD in Alaska will cost the State of
Alaska between $860,000 and $4.2 million dollars from
birth to age 18.
SB 198 is a foundational step towards turning the tide
on these staggering statistics.
3:13:17 PM
HEATHER CARPENTER, Staff, Senator Pete Kelly, Alaska State
Legislature, paraphrased from the Sectional Analysis, [Included
in members' packets] which read:
Section 1:
(A)Directs the University of Alaska Anchorage Center
for Alcohol and Addiction Studies to conduct a study
to evaluate the effectiveness of providing long-acting
reversible contraception (LARC) to women with
substance abuse disorders who are at high risk for
unintended pregnancies that may result in prenatal
drug or alcohol exposure.
The study shall be done in collaboration with
hospitals and health care providers in Alaska who
treat women with substance abuse disorders and:
(1) Establish an advisory council to assist with
designing and implementing the study,
(2) Evaluate best practices for treating women and
children when there is a high risk of neonatal
abstinence syndrome (NAS) or fetal alcohol spectrum
disorders (FASD),
(3) Facilitate a network for sharing of best
practices,
(4) Identify women and children to participate in the
study on a voluntary basis,
(5) Provide LARC to participants who are at a high
risk for unintended pregnancies that may result in
prenatal drug or alcohol exposure,
(6) Evaluate the cost and effectiveness of providing
LARC to reduce the occurrence of NAS and FASD,
(7) Develop a cohort of women and children who can be
evaluated in later studies regarding NAS and FASD,
(8) Provide a data driven framework to establish a
comprehensive strategy for using LARC to reduce NAS
and FASD in Alaska.
(B) Directs the University to complete two interim
reports by June 30 of 2019 and 2020 and a final report
by June 30, 2021.
(C) Provides definitions for "fetal alcohol spectrum
disorder," "long-acting reversible contraception," and
"neonatal abstinence syndrome."
Section 2:
Repeals Section 1 on June 30, 2021, which coincides
with the date of the final report on the project
3:17:06 PM
SENATOR KELLY, in response to Representative Zulkosky, explained
that the NEST program was the Neonatal Abstinence Evaluation
Support & Treatment program to treat women with substance abuse
problems at Alaska Regional Hospital. He said that this was an
example of the kind of program that would be partnered with in
the proposed research program under SB 198.
REPRESENTATIVE ZULKOSKY reflected on the research regarding the
efficacy of long-acting reversible contraception and asked what
medical question remained that was necessary to cover in the
proposed bill.
SENATOR KELLY offered his belief that the depth of information
derived from the pregnancy test dispensers revealed a question
as to what was effective and for what populations.
3:19:39 PM
MS. CARPENTER explained that this was applied health research,
that the long-acting reversible contraception (LARC) would be
provided and data would be gathered. She stated that it was
important to have a smaller test group. She explained that the
NEST program was doing a good job providing intense services,
pointing out that it cost $88,869 for treatment of an infant
with NAS (Neonatal Abstinence Syndrome). She noted that the
fiscal note would help fund provision of the LARC.
REPRESENTATIVE ZULKOSKY stated that the Department of Health and
Social Services had reported more than 3400 Medicaid claims for
coverage of LARCs and asked what were the barriers that Ms.
Carpenter referred.
3:23:08 PM
MS. CARPENTER offered her belief that, although 80 percent of
women stopped drinking when they found out they were pregnant,
the LARC study would impact "this very vulnerable population who
have alcohol and addiction." She shared that there were about
120 new cases of FASD (fetal alcohol spectrum disorder)
diagnosed and that the NEST program was serving a lot of this
high-risk population. She reported that, for women with an FASD
or NAS baby, there was a high likelihood for having another baby
with FASD or NAS. This would offer a woman an option right
after birth to have LARC or some other contraception.
SENATOR KELLY offered that this population may never attempt to
get those contraceptive services, which may separate them from
the general Medicaid population.
3:24:01 PM
REPRESENTATIVE KITO noted that he did not see a request from the
University research department for this study.
SENATOR KELLY replied, "yes." In response to Representative
Kito, he said that it may not be in the material, his office had
been asked to move forward with this.
3:24:22 PM
REPRESENTATIVE KITO asked where that was stated in the material,
as there did not appear to be a formal request.
SENATOR KELLY said that he would obtain a request.
3:24:28 PM
REPRESENTATIVE KITO shared that none of the members of the
legislature were research scientists and that, as this proposed
study appeared to be a political policy direction not based on
any scientific knowledge, this caused him "grave concern." He
declared that when the legislature requested money to generate a
data set, that data set was not objective. He referenced an
earlier statement that 20 percent of women did not quit drinking
[when pregnant] and that this study would target those women.
He asked whether this 20 percent of women were all in the NEST
program.
3:25:53 PM
SENATOR KELLY expressed his agreement that, as the members of
the legislature were not scientists, the UAA Center for Alcohol
and Addiction Studies had requested to conduct the program. He
added that the idea for the study was to get to a more
representative smaller population. He stated that this was just
a research program, not a program for statewide distribution of
contraceptives.
3:26:21 PM
REPRESENTATIVE KITO offered his belief that the original
statement had been for this data to be used to inform future
policy. He expressed his concern that, as this question was not
scientifically posed, the information would not be universally
useful.
SENATOR KELLY reiterated that this was the reason to have the
Center for Alcohol and Addiction Studies run the program.
3:27:01 PM
REPRESENTATIVE JOHNSTON suggested that this study was for how we
can best provide a birth control service that would be helpful
to the community and how to eradicate FAS. She mused that it
was more of a pilot process for how to create an effective
program for the State of Alaska.
SENATOR KELLY added that it was also for "studying this
particular population."
3:28:04 PM
REPRESENTATIVE TARR expressed her concern that this set up a
situation that separated a woman from her addiction by focusing
on control of her ability to reproduce. She offered her belief
that, although this may be a temporary way to relieve a
situation for as long as she has the LARC and would not become
pregnant, the underlying problem was the addiction. She
declared that it was necessary to "view the woman as a whole
person, pregnant or not pregnant, with addiction or not having
addiction." She asked how the other needs would be met "through
participation in this potential research program." She declared
that it was necessary for a woman to get comprehensive
information to choose the method that was right for her. It
should not be an assumption entering this study that the LARC
was the best method. She pointed out that there were adverse
health and cultural issues to be addressed, and she suggested
that, if a woman did choose to participate and had some adverse
effects, there should be the ability for follow up health care
and counseling.
SENATOR KELLY expressed his agreement that the addiction and the
reproduction should not be separated.
3:31:30 PM
MS. CARPENTER directed attention to the fiscal note, which
included payment for a case manager position to ensure that all
the women would receive assistance and critical services such as
addiction treatment and access to housing. She offered her
belief that it was a benefit to do the research this way, as
there was a high bar to work through the university.
3:32:44 PM
REPRESENTATIVE ZULKOSKY asked about the fiscal note, which
indicated that, although the funding would cover the personnel
costs for the investigators and the case management, and the
associated medical costs for providing the contraceptive, there
was no indication for the cost of removal if there were an
adverse reaction to the LARC.
MS. CARPENTER explained that this was one of the pieces that
would be addressed by the University while setting up the
program.
3:34:05 PM
CHAIR SPOHNHOLZ opened invited testimony on SB 198.
3:34:17 PM
AMANDA SLAUNWHITE, Associate Professor, Center for Alcohol and
Addiction Studies, College of Health, University of Alaska
Anchorage, stated her support for the proposed bill. She
declared that "this critical project will partner the university
with a network of hospitals and health care providers lead by
the NEST program at Alaska Regional to evaluate increased access
to substance abuse treatment and effective contraception to
women in need, including mothers with opioid use disorder." She
said that women with substance abuse disorders reported an
unintended pregnancy rate of nearly 90 percent, and that
significant barriers existed for access to substance abuse
treatment and effective long lasting reversible contraceptives.
She added that most mothers addicted to opioids when leaving
hospitals would not have access to substance abuse treatment
services or effective family planning services. She reported
that, as almost 70 percent of mothers with one child exposed to
drugs or alcohol in utero will have another, it was very
important to figure out a way to solve these challenges for
unintended pregnancies and access to substance abuse treatment.
She stated that the ethical oversight offered by the
institutional review board would protect all the human subject
research at UAA to ensure that the research fulfilled the
federal regulations and requirements and operated in an ethical
and non-coercive manner. She added that the staff were highly
experienced in conducting applied health research projects with
vulnerable populations. She offered an example of the Vivitrol
evaluation project being completed in conjunction with the
Department of Corrections. She noted that UAA offered assurance
to the Department of Health and Social Services that they would
meet all the requirements outlined in federal regulations, which
ensured that projects conducted by researchers met the highest
ethical standards, including that risk was minimized, the
protocols were not coercive, and informed consent was obtained.
She declared that participation was always voluntary and that
participants could withdraw at anytime for any reason. She
declared that the program fully anticipated that the proposed
bill would result in improved health outcomes to mothers and
infants, and significantly reduce the cost and social impact
associated with unintended pregnancy and prenatal drug and
alcohol exposure.
3:38:41 PM
REPRESENTATIVE KITO asked about her doctorate.
DR. SLAUNWHITE said that her PhD was in Health Geography, with
background as a research scientist.
3:39:10 PM
REPRESENTATIVE KITO asked who would provide the medical
oversight for the participants.
DR. SLAUNWHITE said that an advisory board would be guiding the
development of the protocols for the research.
3:39:32 PM
REPRESENTATIVE KITO pointed out that these were invasive medical
procedures on people and reiterated his question for the medical
responsibility to the patients.
DR. SLAUNWHITE explained that they would work in partnership
with the NEST program at Alaska Regional Hospital.
3:40:10 PM
REPRESENTATIVE KITO asked for verification that the medical
director and the doctors would be providing medical oversight
for these participants.
DR. SLAUNWHITE expressed her agreement, noting that the
participants would be patients of Alaska Regional Hospital.
3:40:27 PM
REPRESENTATIVE KITO asked about any relationships with other
hospitals for this study.
DR. SLAUNWHITE opined that the advisory group would approach
interested hospitals about participation. She shared that she
had on-going relationships with numerous other hospitals.
3:41:11 PM
REPRESENTATIVE KITO asked for a request to this study since he
did not see it in members' packets.
DR. SLAUNWHITE explained that they had been working to get
funding in place to conduct the work. She listed some of the
applications submitted but pointed to the urgency for getting
the work underway due to the opioid epidemic. She stated that a
large portion of the study would focus on women currently
struggling with opioid use disorder and would collect data on
the mothers and children to track them through adolescence and
adulthood.
3:42:34 PM
REPRESENTATIVE KITO offered his agreement that prevention of an
unwanted pregnancy during alcohol or drug use would result in
better outcomes for the child and asked what was the question
seeking a resolution. He mused that the only need was to
provide for the appropriate contraception to individuals with
alcohol or drug problems and that it was not necessary to study
whether a contraceptive would decrease incidences of FAS or NAS.
DR. SLAUNWHITE replied that it was necessary to find the way to
do that. She shared that, as many women were detached from
health care providers and would not seek pre-natal care, the
question was how to reach these women to offer addiction
treatment and family planning resources.
3:44:44 PM
REPRESENTATIVE KITO suggested that, as family planning,
counseling, and contraceptive use would be beneficial, why was
there a focus on the LARCs.
DR. SLAUNWHITE explained that past research had indicated that
women with substance abuse issues did not have a high adherence
to traditional forms of birth control. She added that LARCs
were often chosen because of the ease.
3:45:50 PM
REPRESENTATIVE KITO offered his belief that this should be a
decision between the patient and a medical professional, and not
directed by a study.
DR. SLAUNWHITE pointed out that the women had full choice for
birth control including LARC.
3:46:10 PM
REPRESENTATIVE KITO asked if the proposed bill included more
than a LARC, as that was not stated in the bill, and if so, then
the proposed bill needed to be corrected.
CHAIR SPOHNHOLZ suggested that there were more questions about
the protocol and the entry point for women participating in the
study.
3:46:37 PM
REPRESENTATIVE JOHNSTON asked if the advisory council would be
part of the initial development of the study, how it would
interact with the academic committee, and what would be its
makeup.
DR. SLAUNWHITE replied that the advisory council would be fully
integrated into the academic research component of the project.
She said that she would fully expect that the advisory council
would provide input and guidance on all aspects of the research
project. She opined that the council would be made up of
stakeholders from throughout the state including family
planning, women's health services, pediatricians, and the Office
of Children's Services.
3:48:04 PM
REPRESENTATIVE TARR posed that Dr. Slaunwhite had offered a much
broader description of the project than what was included in the
proposed bill. She questioned whether the National Institute of
Health would support the proposed bill. She opined that the
research question should be for the most effective intervention
for women at high risk for substance use disorders that could
result in pregnancies with the offspring having FAS. She
declared that the research project should not be entered with
any kind of inherent bias as it would negate the value of the
study. She offered her belief that this also made the choices a
bit coercive as the study was geared toward the use of LARCs.
She reiterated that the proposed bill and the study as described
by Dr. Slaunwhite were different.
DR. SLAUNWHITE said that the bill did describe the development
of a cohort related to the broadening that had been referenced.
REPRESENTATIVE TARR said that research from Alaska Regional
Hospital, the largest urban center in the state, should not be
applied statewide as it was not relevant, especially to
questions for access. She noted that there was not any
indication where the other collaborations would be. She
declared that $500,000 was not enough money to do this study
properly because one adverse reaction with one woman which
required hospitalization could "eat up thousands and thousands
of dollars in short order." She added that there was not any
follow up care addressed in the proposed bill.
DR. SLAUNWHITE said that Alaska Regional Hospital was the only
unit in Alaska that was specifically designed to treat neo-natal
abstinence syndrome. She said that data had shown that 82
percent of infants born with in-utero opioid exposure were from
the Anchorage area. She declared that it was desired to have
collaborators from throughout the state to have the rural-urban
diversity.
3:52:34 PM
REPRESENTATIVE ZULKOSKY asked for elaboration about the research
question, offering her belief that it "treads really closely to
some historic issues around forced sterilization for certain
subsets of the population."
DR. SLAUNWHITE reported that women would have the choice for the
type of birth control, if any, that they would prefer to
receive. She explained that the focus was on LARC because of
the scientific foundation that LARC were very effective for
women with substance abuse disorders in reducing rates of
unintended pregnancy. She added that women who receive the LARC
would be the intervention group, and women who decide to either
not receive any birth control or receive a different form of
birth control would be the comparison group.
3:55:20 PM
REPRESENTATIVE ZULKOSKY asked if the research dollars would
cover women using a type of birth control other than LARC. She
asked how the research would address access to contraceptive
counseling training for health care providers, and whether there
were experts in family planning and contraceptive counseling
included in the design and implementation plans for the proposed
study.
DR. SLAUNWHITE replied that they would like to have family
planning experts "heavily involved in this project" and engaged
in the conversations for the research protocol. She suggested
that coverage for the removal and medical care could be covered
by Medicaid. She offered an example for a similar situation to
the aforementioned vivitrol program. She added that the
substance abuse treatment services and case management would be
provided to women in the NEST program at Alaska Regional
Hospital, as the health insurance status of the participants
could be determined. She stated that a broader discussion for
the options to women without health insurance would be a
conversation with the advisory group in order to determine
participation in the study.
3:57:58 PM
REPRESENTATIVE ZULKOSKY questioned the necessity of the expense
for a $0.5 million study when it was already known that Alaska
women eligible for Medicaid had access to LARCs if they so
desired. She suggested that the money be used to provide a
process or comprehensive care, instead of "looking at the need
for efficacy in a particular group of women."
DR. SLAUNWHITE said that it was known that this group of women
was not accessing these services and that it was necessary to
learn more for how to reach these women and how to provide care,
treatment, and services after delivery of a drug or alcohol
exposed infant.
3:59:41 PM
CHAIR SPOHNHOLZ reflected on the question of contraception to
address Fetal Alcohol Syndrome (FAS) and neo-natal abstinence
syndrome (NAS) and asked if the study was about the care
coordination as much as about delivery of contraception.
DR. SLAUNWHITE acknowledged that, although it was known that
contraception, especially LARCs, was successful, it was the
coordination for delivery and the services that was the core of
the intervention. She said that these were not currently being
provided in maternity services.
4:00:40 PM
CHAIR SPOHNHOLZ asked if this was "a care delivery model that is
being framed as a study."
DR. SLAUNWHITE expressed her agreement and said that the Alaska
Regional Hospital NEST program was selected as the first pilot
site because it was a unique program using an evidence based,
anti-stigma, family-oriented approach toward the birth of an
infant exposed to opiates and other drugs. She declared the
desire to build on this existing model as it was known to be
effective for reducing the need for medication during withdrawal
and for increasing mother-baby bonding. She said that these
services would get the mother into addiction treatment and
provide family planning resources.
4:02:07 PM
CHAIR SPOHNHOLZ asked if there were partnerships with any other
hospitals.
DR. SLAUNWHITE replied that there were partnerships and
collaborations with researchers and medical staff at many other
institutions throughout Alaska. She noted that conversations
with facilities in Fairbanks for their program changes had
indicated this as "a really great second site, if they're
interested because they are starting to use some of the
approaches used by the NEST unit."
4:03:01 PM
CHAIR SPOHNHOLZ asked how the program would specifically
identify the patients and the type of care available as part of
this process.
DR. SLAUNWHITE explained that the protocols would be developed
with the advisory council, as this discussion was just
beginning. She said that a woman who had disclosed a substance
exposed pregnancy could potentially be approached by medical or
research staff for participation in the study and she would be
briefed on her rights as a participant. She would be given a
lengthy consent form and then a care coordinator and social
worker would be provided to collect information.
4:05:03 PM
CHAIR SPOHNHOLZ asked if contraceptive care was paid for by the
study from the point of consent to participate.
DR. SLAUNWHITE replied that there would be an evaluation to
determine whether the participant had health insurance coverage.
If not, there was an amount in the budget to cover the cost of
birth control.
4:06:00 PM
CHAIR SPOHNHOLZ asked if contraception would be provided,
regardless of the type or her ability to pay.
DR. SLAUNWHITE replied that was her understanding.
4:06:20 PM
CHAIR SPOHNHOLZ asked whether, if a woman opted for a type of
contraception other than LARC, that care would be paid by the
study.
DR. SLAUNWHITE offered her belief that this would be a small
number of participants as her research indicated that many women
had health insurance coverage.
4:07:10 PM
CHAIR SPOHNHOLZ expressed her concern that there was not a
coercive motivation to use one form of contraception over
another form, especially for a woman who did not have health
insurance.
DR. SLAUNWHITE said that a woman would be free to choose and
that any form of birth control included in the study would be
offered, as determined by the advisory group. She expressed her
understanding for the ethical concerns for "even an appearance
of coercion."
4:08:43 PM
CHAIR SPOHNHOLZ reflected on the Institutional Review Board
(IRB) process and asked for more detail about the review of a
human subject research project.
DR. SLAUNWHITE explained that it would include a full
application to the board for the way participants would be
recruited, who was eligible to participate in the study, all
sites where the research would be conducted, all instruments
used to gather data, any medical records, and any other data or
processes used to gather the data. She said that the University
of Alaska Anchorage (UAA) IRB would review the packet. After
the review, there would be a meeting with faculty, community
members, and the chair of the IRB with an opportunity for
questions about the protocol. She shared her experience that
this was a very rigorous process that could last for several
months, with revisions of protocol and surveys after advice from
the group.
4:11:20 PM
CHAIR SPOHNHOLZ asked who served on the IRB.
DR. SLAUNWHITE replied that there were two community members,
often representative from specific groups, as well as research
professors for feedback on protocols and instruments.
4:11:53 PM
CHAIR SPOHNHOLZ asked if any necessary follow up care for women
without health insurance would be covered by the study.
DR. SLAUNWHITE offered her belief that there would be follow up
care while at Alaska Regional Hospital, and that part of the
service "would be to obtain some form of health insurance
especially because as part of this project we want to provide
case management and a direct pathway into substance abuse
treatment for these women." She noted that, as these women
would be going into treatment, there would be an associated
cost, payment of which would be determined through the advisory
board and the protocol development. She reported that, with a
link to addiction treatment, there would be a requirement to
have health insurance, most likely to be Medicaid.
4:13:40 PM
CHAIR SPOHNHOLZ asked who the principal investigator was for
this research project.
DR. SLAUNWHITE said that she was the principal investigator.
4:13:50 PM
REPRESENTATIVE KITO asked if there were any medical doctors on
the IRB.
DR. SLAUNWHITE replied that the chair of the IRB was a clinical
psychologist, and although there were not any medical doctors on
the IRB, there were temporary IRB members added, as needed. She
expressed her hope that, through the advisory council, there
would be a group of experts including pediatricians, OB GYNs,
and representatives from family planning and women's health
sectors.
4:15:21 PM
REPRESENTATIVE TARR expressed her concern for coercion, opining
that the process "sounds horrible." She shared that, as a woman
with a substance disorder, most likely with a difficult
pregnancy, and having health impacts after delivery unrelated to
substance use disorder, she would not be fully "of my right
mind" because of the throes of addiction. She would need a
significant period of time for detoxification to have full
capacity for decision making. If she was a vulnerable women,
she had probably not had positive experiences with government or
police and now, post-delivery, there would be someone with
lengthy paperwork telling her to read and to sign something she
may not comprehend. She declared that in this scenario, a woman
would not have real choice, and that this was a problematic
process. She directed attention to page 2, lines 14 - 19, of
the proposed bill, and pointed out that there was no mention of
care coordination or the correct interventions for the woman to
access health care, addiction treatment, and birth control. She
declared that what Dr. Slaunwhite had described and what the
proposed bill said were not the same. She reiterated that this
was not a situation whereby a woman had full choice over these
decisions.
4:18:39 PM
DR. SLAUNWHITE replied that if a woman was incapacitated or
going through significant detoxification and unable to
comprehend or fully understand the project, they would not be
accepted for participation. She declared that people with
addiction issues consented to be involved in research projects
all the time. She said that they could fully understand what
was being asked and what were the risks and benefits associated
with the project. She pointed out that they did not have any
interest in participation by someone who did not want to be
involved. She reiterated that it was fully voluntary, and the
person was free to withdraw from the study at any time. She
relayed that they would do everything to ensure that the
information and the consent forms were communicated at a low
reading level, to ensure understanding and that there would not
be any coercion for anything. She acknowledged that she may
have communicated the research somewhat differently that the
proposed bill, although the proposed bill did articulate the
research questions that she had described for evaluating the
costs for providing LARC and its effectiveness for reducing the
occurrence of FAS and NAS, as well as the cohort development to
facilitate the long-term study of the development of infants
born with substance exposure.
4:22:05 PM
REPRESENTATIVE TARR declared that the idea of choice was
impacted by physical condition. She suggested that the
individual have an advocate whose purpose was to monitor the
needs of a vulnerable individual with no motivation for
participation in the program. She offered her belief that this
should be more accurately described in the language of the bill.
She opined that there was a difference between the Vivitrol
intervention and the control of a woman's right to make
reproductive choices. She reminded that there was a terrible
history for segmenting different women and trying to control the
ability to reproduce. She reiterated that she had strong
concerns as this was a significant medical intervention.
4:24:16 PM
REPRESENTATIVE ZULKOSKY, pointing to an earlier statement that
participation in the study would be fully voluntary and that
participants could withdraw at any time for any reason, asked
whether it was a penalty to not have removal or follow up costs
for care be covered by the study. She noted that, as the study
in its current form did not cover these costs, this could be a
coercive way for participation. She declared a need for
"greater wrap around services for care coordination or greater
resources for substance abuse treatment, not necessarily access
to birth control." She suggested that there was a segment of
women, and possibly children, viewed as a cost risk to the
state, and instead, the state should be dealing with the
holistic needs of an individual.
DR. SLAUNWHITE expressed her understanding and offered her
belief that approval for the project would necessitate a
protocol to ensure that women would be able to have the LARC
device removed, should they wish, with no penalty. She added
that there should also be a protocol to give women a clear
choice for the type of birth control available, and that there
would not be any penalty for discontinued use.
4:27:37 PM
JEFFREY JESSEE, Dean, College of Health, University of Alaska
Anchorage, shared that he had previously been CEO of the Alaska
Mental Health Trust Authority for 22 years. He noted that, as a
lot of the material had already been covered, it was important
to keep a few points in mind. He said that all hospitals were
required by law to report to the Office of Children's Services
(OCS) any positive drug screen on any mother or child. He
pointed out how traumatic it was to both the mother and the
child, as often the child was removed from the mother. He
stated that much of this applied research was for how to take
the next step and do better than this process. He said that, as
currently there was not comprehensive counseling and referral
services, many of these mothers ended up back in the community,
still addicted, with data indicating a high probability for
having another affected child. He reiterated that this was not
a study of the effectiveness of birth control, if it was used
reliably, and he stated that the LARC was one form of birth
control which was easiest for women who wanted to remain on
birth control with no interference from an addiction or chaotic
personal life. He acknowledged that, although the best solution
would be for the women to become sober and have housing and a
better life experience, there was not the technology to help
everyone who was addicted to get sober. He said that some
addictions were so pervasive and ingrained in an individual's
life that it was not known how to get them sober. He pointed
out that one reason for the Housing First concept for people
with chronic alcoholism was to provide effective treatment and
support, instead of being prisoners of their addiction, waiting
for the next terrible thing to happen. He declared that this
proposal was the next step for these women who had been
repeatedly traumatized and would be referred to the Office of
Children's Services at the end of their pregnancy. He declared
that the points by the committee were excellent, that there
should not be a coercive element to the program and that the IRB
would work with researchers to ensure this was considered. He
added that, for full data of the research, not everyone should
choose LARC, which would allow for a control group to test for
the most effective strategy to help these women gain control
over at least part of their future. He declared that it was
absolutely essential to have "the highest quality medical care
that we can possibly give them." He noted, however, that
hospitals were limited in the ability to follow through with
effective case management to access critical services such as
treatment and safe housing. He added that many women were
concerned with accepting services from a hospital which had just
referred them to the OCS. He opined that this applied research
project would offer more objective assistance to these mothers
than total reliance on the hospitals for these services. He
reiterated that the purpose of the University [of Alaska] was to
assist legislators in "getting the best bang for your dollars
and the best outcome for the public policy outcomes that you
want to see." He declared that it was necessary to "look at how
to best approach these women; how to best present an option; how
to best help them follow through with at least housing, if not
treatment; and help them to move forward in their lives in a
more positive way... " He declared that there was a commitment
to respect the rights of the women, and, as the women were
offered a full range of options, this would provide answers to
the many questions asked by the legislature for how to move
forward and reduce the incidences for these affected children.
He added that healthy living would lead toward a more fulfilling
life for these women.
4:38:04 PM
REPRESENTATIVE ZULKOSKY lauded the great mental health work and
advocacy performed by Mr. Jessee. She acknowledged that they
had shared goals for the reduction of pre-natal exposure to
drugs and alcohol for Alaska children, as well as resolution to
the conundrum around the provision of care and services to a
population of women that may not otherwise seek this care. She
directed attention to the proposed bill which explicitly stated
that the intention of the study was to provide long acting
reversible contraception to participants who were at risk for
unintended pregnancies that may result in pre-natal drug or
alcohol exposure. She added that another intent of the proposed
bill was to provide a data driven framework to establish a
comprehensive strategy for using long active reversible
contraception to reduce fetal alcohol spectrum disorders (FASD)
and neo-natal abstinence syndrome (NAS) in Alaska. She
expressed her concern for social justice and racial equity as
there had not been any discussion for the issues of demographics
for women in Alaska who may fall into this population. She
declared that she did not see any difference from forced
sterilization on women who could not advocate for themselves.
MR. JESSEE reported that forced sterilization was "a very dark
part of our past in this country" which had been conducted as
the perceived solution for many reasons, including developmental
disabilities and mental illness. He added that this was not a
system of support but a means of control, specifically of the
reproductive rights. He reported that there were even court
orders supporting these practices. He stated that this proposed
bill was not about these practices but was about working with
women who were currently not able to get sober and were at a
much higher risk for unintended pregnancy. He shared his
surprise that 50 percent of all pregnancies were unintended and
noted that the percentage of unintended pregnancies was much
higher, over 80 percent, for this group of addicted women. He
declared that it was not helping these women to bring them to a
hospital, deliver the babies, refer them to OCS, provide minimal
support, and then send them back into the community. He
acknowledged that these women could not be forced to use any
birth control, to seek treatment, or to stay in safe housing.
He referenced the Housing First model and reported that this was
a valuable service which gave addicted people a belief that
something positive was happening and they had some control over
their life. He reported that many people at Housing First
reduced their drinking, while "some even get sober," and that
most all have improvements to their health condition. He stated
that the opportunity to control reproductive health with the
choice of birth control was the exact opposite of forced
sterilization. He declared that the proposed bill would be a
benefit to the individuals and the community and would offer a
better understanding for how to work with these women to achieve
the desired outcomes.
4:45:41 PM
REPRESENTATIVE ZULKOSKY opined that it was important to
acknowledge the history for full choice of reproductive rights,
regardless of an individual's station in life. She shared her
struggle of coming from a rural area as an Alaska Native woman
with the background for challenges to the Alaska Native
community. She stated that there were many similarities for
ostracizing a subsect of the community for the advancement of an
institution and declared that it was "deeply disturbing."
DEAN JESSEE expressed his agreement for the trauma experienced
by the women and their children and declared that not enough was
being done to avoid further trauma. He said there was not "a
magic wand" to help these women become sober, pointing out that
they did not have control over their addiction or the trauma it
included. He emphasized that it was necessary to take the next
step in order "to value these women and believe that there's a
better future for them."
4:50:18 PM
ART DELAUNE, Legislative Chair, Governor's Council on
Disabilities and Special Education, stated that the Council
supported the proposed bill and agreed with the concept for the
option to LARC for women who are known to have substance abuse
disorders. He shared a personal anecdote for his two sons with
FASD and with his background as a parent navigator for the
Fairbanks FASD diagnostic team. He stated that FASD was 100
percent preventable and that women needed access to resources,
information, support, and care or treatment. He said that the
research from the proposed bill had the potential to identify
barriers and examine the long-term cost and savings to Alaska.
4:54:09 PM
REPRESENTATIVE TARR added that it was necessary for a holistic
approach.
MR. DELAUNE expressed his agreement.
CHAIR SPOHNHOLZ shared the difficulties for understanding FASD
and its effects.
4:56:38 PM
TREVOR STORRS, Executive Director, Alaska Children's Trust,
shared that ongoing research had shown that social determinants
could be a predictor to the level of risk for a child
experiencing child abuse and neglect. By identifying these
social determinants that influence this level of risk, it was
possible to move further "upstream" to prevent this child abuse
and neglect. He stated that the proposed bill was an example
for achievement of this goal. He pointed out that Alaska had
been able to identify key social determinants which included
unplanned and unwanted pregnancies. He shared that 49 percent
of pregnancies were unintended, and that, for women age 19 and
younger, more than 4 out of 5 pregnancies were unintended, while
under the age of 15, 98 percent of the pregnancies were not
planned. He reported that unplanned or closely spaced births
were associated with adverse maternal and child health outcomes,
which included depression, smoking, alcohol consumption, poor
mental health, increased risk of physical violence during
pregnancy, reduction of the likelihood for breast feeding, and
lower mother-child relationship quality. For the children, the
result included greater infant mortality, likelihood to be less
physically and mentally healthy, less likely for success in
school, and more likely to live in poverty, need public
assistance, and have delinquent and criminal behavior. He
reported that 90 percent of women stopped drinking once aware of
their pregnancy, which meant that the highest risk for exposure
of the fetus to alcohol was between conception and realization
of pregnancy. He pointed out that all of these adversities
resulted in greater economic and social impacts on the state,
and to reduce unplanned and unwanted pregnancies, it was
necessary to ensure better access to the most effective
contraceptive methods. He referenced an article which stated
that experts suggested that programs which improved family
planning would be the best strategy for prevention of child
maltreatment and would reduce FAS and pre-natal drug exposure.
5:00:34 PM
CHAIR SPOHNHOLZ announced that SB 198 would be held over.
SB 208-MARCH: SOBRIETY AWARENESS MONTH
5:00:56 PM
CHAIR SPOHNHOLZ announced that the final order of business would
be SENATE BILL NO. 208, "An Act establishing the month of March
as Sobriety Awareness Month."
5:01:28 PM
JACOB TATUM, Staff, Senator Berta Gardner, Alaska State
Legislature, presented the proposed bill and read from a
prepared statement [original punctuation provided]:
For the record my name is Jacob Tatum, staff to
Senator Berta Gardner.
Madame Chair, members of the committee, good evening
and thank you for giving me the opportunity to testify
before you on the importance of permanently
recognizing March as Sobriety Awareness Month.
Unfortunately, Senator Gardner could not be here
today, but the sponsor wanted to be sure to thank
Chair Spohnholz for truly paving the way for this
legislation; for sharing her personal story and all
the work that she has done and continues to do in the
area of substance abuse treatment and recovery. So, on
behalf of Senator Gardner, Chair Spohnholz, THANK YOU.
On a similar note, there have been many other
individuals and organizations that have contributed
greatly to the cause of sobriety in Alaska, whom,
without their efforts, this legislation might not be
possible. Specifically, the sponsor would like to
recognize the Alaska Federation of Natives, who
originally passed a resolution in 1989 to start the
AFN Sobriety Movement and for, in 1996, encouraging
Alaska lawmakers to add statutory language in the form
of AS 47.37.010, which reads, "It is the policy of the
state to recognize, appreciate, and reinforce the
example set by its citizens who lead, believe in, and
support a life of sobriety".
Another individual is musher and sobriety activist
Mike Williams, who ran the 1992 Iditarod carrying
10,000 signatures pledging sobriety, in what became
known as the "Idita-pledge for Sobriety" and is a key
reason for the selection of the month of March.
Another person is former Representative Irene Nicholia
of Tanana who first passed a resolution to recognize
Sobriety Awareness Month in 1995, making Alaska the
first state in the Union to recognize sobriety as a
lifestyle. To all of these folks, THANK YOU. So,
without further ado?
SB 208 celebrates and calls attention to the efforts
of the many Alaskans who live healthy lives free of
mind and mood-altering substances by establishing
March as Sobriety Awareness Month.
As you all know, Alaska experiences some of the
highest rates of substance abuse in the nation, at a
total economic cost to the state of nearly $3 billion,
not to mention the immeasurable cost to Alaskan
communities and families that cannot be captured by a
simple dollar amount.
5:04:00 PM
With this legislation, it is the intention of the
sponsor and cosponsors, to promote and celebrate the
tens of thousands of Alaskans who live their lives
free of mind and mood-altering substances, in order to
not only mitigate the costs associated with substance
abuse, but perhaps even more importantly, to help
foster a culture that is conscious of this State's
multi-faceted substance abuse challenges and how they
can ultimately be overcome.
Furthermore, sobriety has also been recognized as a
youth protective factor that is strongly correlated
with lower rates of future substance abuse and overall
positive life outcomes; so, by recognizing a month for
the sobriety movement, it is the hope that the state
of Alaska will help establish positive social norms
and send a message to young people that, "contrary
what they might think, the majority of their peers in
fact do not use alcohol and drugs."
So, in summary:
By passing SB 208, permanently recognizing March as
Sobriety Awareness Month, the state of Alaska will
accomplish 4 key goals.
1. Meeting Alaska policy under Alaska Statue
47.37.010, which I referred to earlier.
2. Mitigate the costs, both economic and otherwise,
associated with substance abuse.
3. Set an example for the younger generation, and
perhaps adults too, with positive social norms, that
communicate that alcohol and drugs are in no way
essential or necessary for enjoying life.
4. To celebrate people living sober lifestyles and
break down the stigma around sobriety, both for those
who freely choose to abstain and those who are in
long-term recovery, for these people truly are an
asset to the State of Alaska, its communities and
families.
5:06:39 PM
CHAIR SPOHNHOLZ opened invited testimony on SB 208.
5:06:50 PM
TIFFANY HALL, Executive Director, Recover Alaska, reported that
Recover Alaska worked to reduce excessive alcohol use and harms
across the state, as alcohol was recognized as the number one
health issue in Alaska. She reported that, as alcohol cost the
state $1.84 billion every year, the goals of Recover Alaska was
for prevention, treatment and recovery, and a change for social
norms around alcohol. She noted that funding for these recovery
programs was often tied to metrics, and that it was very hard to
capture metrics about recovery. She declared that community was
a big part of recovery, and although there were not quantitative
numbers, there was a lot of qualitative feedback. She shared a
personal anecdote about recovery and the shame of addiction.
She reported that 78 percent of high schoolers did not drink
alcohol. She pointed out that, as it was necessary for role
models, Recover Alaska highlighted Alaskans in sobriety and
honored and celebrated this choice.
5:11:09 PM
CHAIR SPOHNHOLZ opened public testimony and after ascertaining
no one wished to testify, closed public testimony on SB 208.
5:11:21 PM
CHAIR SPOHNHOLZ shared that she was a strong personal advocate
for sobriety and that Sobriety Awareness Month was an
opportunity for celebration of the choice for a sober life. She
pointed to the importance of shining light on "what recovery
looks like and what sobriety looks like for people." She shared
that she was in long term recovery, had not had a drink in more
than 16 years, and that sobriety had made her life "more joyful
and meaningful and satisfying in a lot of ways." She expressed
her hope that more people would recognize the empowerment that
could come from sobriety and the role models in sobriety that
could allow celebration for the choice not to drink.
5:13:17 PM
REPRESENTATIVE ZULKOSKY moved to report SB 208, Version 30-
LS1470\A, out of committee with individual recommendations and
the accompanying fiscal notes. There being no objection, SB 208
was moved from the House Health and Social Services Standing
Committee.
5:13:49 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:13 p.m.