02/08/2016 01:00 PM JUDICIARY
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ALASKA STATE LEGISLATURE HOUSE JUDICIARY STANDING COMMITTEE February 8, 2016 2:39 p.m. MEMBERS PRESENT Representative Gabrielle LeDoux, Chair Representative Wes Keller, Vice Chair Representative Bob Lynn Representative Charisse Millett Representative Matt Claman Representative Max Gruenberg MEMBERS ABSENT Representative Neal Foster Representative Kurt Olson (alternate) OTHER LEGISLATORS Senator Johnny Ellis Representative Lynn Gattis COMMITTEE CALENDAR CS FOR SENATE BILL NO. 23(JUD) "An Act relating to opioid overdose drugs and to immunity for prescribing, providing, or administering opioid overdose drugs." - HEARD & HELD HOUSE JOINT RESOLUTION NO. 19 Proposing an amendment to the Constitution of the State of Alaska relating to the constitutional budget reserve fund. - BILL HEARING CANCELED PREVIOUS COMMITTEE ACTION BILL: SB 23 SHORT TITLE: IMMUNITY FOR PROVIDING OPIOID OD DRUG SPONSOR(s): SENATOR(s) ELLIS 01/21/15 (S) READ THE FIRST TIME - REFERRALS
01/21/15 (S) HSS, JUD 03/18/15 (S) HSS AT 1:30 PM BUTROVICH 205 03/18/15 (S) Heard & Held 03/18/15 (S) MINUTE (HSS) 03/23/15 (S) HSS AT 1:30 PM BUTROVICH 205 03/23/15 (S) Moved SB 23 Out of Committee 03/23/15 (S) MINUTE (HSS) 03/25/15 (S) HSS RPT 3DP 2NR 03/25/15 (S) DP: STEDMAN, ELLIS, GIESSEL 03/25/15 (S) NR: KELLY, STOLTZE 04/01/15 (S) JUD AT 1:30 PM BELTZ 105 (TSBldg) 04/01/15 (S) Moved CSSB 23(JUD) Out of Committee 04/01/15 (S) MINUTE (JUD) 04/02/15 (S) JUD RPT CS 4DP NEW TITLE 04/02/15 (S) DP: MCGUIRE, COGHILL, COSTELLO, WIELECHOWSKI 04/18/15 (S) TRANSMITTED TO (H) 04/18/15 (S) VERSION: CSSB 23(JUD) 04/19/15 (H) READ THE FIRST TIME - REFERRALS 04/19/15 (H) HSS, JUD
01/26/16 (H) HSS AT 3:00 PM CAPITOL 106
01/26/16 (H) Heard & Held
01/26/16 (H) MINUTE (HSS) 02/04/16 (H) HSS AT 3:00 PM CAPITOL 106 02/04/16 (H) Moved HCS CSSB 23(HSS) Out of Committee 02/04/16 (H) MINUTE (HSS) 02/05/16 (H) HSS RPT HCS (HSS) NT 7DP 02/05/16 (H) DP: VAZQUEZ, STUTES, TARR, TALERICO, FOSTER, WOOL, SEATON 02/08/16 (H) JUD AT 1:00 PM CAPITOL 120 WITNESS REGISTER SENATOR JOHNNY ELLIS Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented SB 23 as prime sponsor. SARAH EVANS, Staff Senator Johnny Ellis Alaska State Legislature Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, offered a sectional analysis and answered questions. PAULA COLESCOTT, M.D. First Care Medical Center Anchorage, Alaska POSITION STATEMENT: During the hearing of SB 23, offered expertise regarding substance addiction and the opioid overdose drug. REPRESENTATIVE LYNN GATTIS Alaska State Legislature Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, offered testimony and support. TERRIA WALTERS Palmer, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. KARA NELSON, Director Haven House Juneau Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. MICHELE MORGAN Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. GARY MILLER Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. KATHERINE BOTZ Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. TERRA BURNS Community United for Safety and Protection (CUSP) Fairbanks, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. DONNA BALDWIN Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. ANDREA ROBINSON Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, testified in support. MEGAN WALLACE, Attorney Legislative Legal Counsel Legislative Legal and Research Services Legislative Affairs Services Juneau, Alaska POSITION STATEMENT: During the hearing of SB 23, answered questions. ACTION NARRATIVE 2:39:47 PM CHAIR GABRIELLE LEDOUX called the House Judiciary Standing Committee meeting to order at 2:39 p.m. Representatives Claman, Gruenberg, Keller, Lynn and LeDoux were present at the call to order. Representative Millett arrived as the meeting was in progress. SB 23-IMMUNITY FOR PROVIDING OPIOID OD DRUG 2:40:14 PM CHAIR LEDOUX announced that the only order of business would be (S)CS FOR SENATE BILL NO. 23(JUD), "An Act relating to opioid overdose drugs and to immunity for prescribing, providing, or administering opioid overdose drugs." CHAIR LEDOUX reminded the committee that the House of Representatives decided that committees would not take legislation unless it directly impacts the budget in the form of revenue or budget bills. She opined that SB 23 is the one exception to that decision because this bill is important and with every day of delay a life may be lost. [Audience applause] 2:42:03 PM SENATOR JOHNNY ELLIS, Alaska State Legislature, advised that Representative Lynn Gattis is a cross-sponsor on SB 23, and she would like to testify under public testimony. He offered his appreciation to those working behind the scenes, including Chair LeDoux who made certain this bill would be heard today, and he extended that her actions transcend politics as usual or any type of partisanship in this building. CHAIR LEDOUX interjected that this bill transcends politics or anything else that goes on in this building. 2:43:06 PM SENATOR ELLIS described this bill as literally involving life or death. He stated that he knew there was a breakthrough in the subject of opioid addiction and medically assisted treatment when he heard presidential candidates on both sides of the aisle discussing this issue in presidential forums and debates. As with Alaska, New Hampshire has an epidemic of opioid abuse and overdose. He acknowledged that the Anchorage Police Department advised that in Alaska, heroin use is back in force and heroin related overdoses are claiming more young lives than traffic fatalities. He noted that Dr. Jay Butler, Chief Medical Officer and Director, Division of Public Health, Alaska Department of Health and Social Services (DHSS) testified in the House Health and Social Services Standing Committee that in 2015, 54 Alaskans died of opioid pain killer overdoses, another 34 Alaskans died of heroin overdoses, and 8 of those deaths were in Juneau. He expressed that the support from Juneau of friends and family of heroin addicts, opioid addicts, and overdosed deaths has been overwhelming and much appreciated. The abuse and overdose epidemic is largely driven by addiction to prescription opioids, such as OxyContin and Vicodin, which has become more expensive and harder to come by in recent years. Therefore, he explained, leading addicts to turn to the much more wildly available and less expensive opiate of heroin. He conveyed that people tend to think that heroin abuse is a problem plaguing the poor, but this epidemic hits the affluent particularly hard all over the state. For approximately 12 years he has tried to gather support for treatment in methadone clinics in Fairbanks and Anchorage, and suboxone through private physicians in communities without methadone clinics, he remarked. He said that he read an opinion piece 25 years ago in the New York Times indicating that the future number one drug problem would be the abuse of prescription drugs. He acknowledged that doctors have since apologized and have discussed the "loose prescriptions" of opioids leading to people switching to "black tar heroin," smuggled into Alaska by the Mexican drug cartel addicting Alaskans all across the state. 2:46:30 PM SENATOR ELLIS reiterated that heroin and other opioid abuse has reached epidemic levels in Alaska, as with the rest of the nation. Everyone knows, he said, that these highly addictive drugs are extremely deadly and are killing Alaskans at alarming rates. Luckily, he noted, opioid overdose is typically reversible through the timely administration of the medication naloxone, and provision of emergency care, yet it is often not available where and when it is needed. He advised that this bill seeks to make this life-saving, safe miracle drug more widely available because overdose often occurs when the victim is with friends or family members who may be best situated to act to save his or her life by administering naloxone or Narcan. He advised that the bill came to him with the idea to join most other states due to medical professionals being wary of prescribing and lay person's worry of administering opioid overdose drugs due to potential civil liability. The bill removes civil liability from a doctor who prescribes, and a lay person who administers, naloxone in cases of opioid overdose, he explained. He pointed out that contained within the committee packets are numerous letters of support from around the state with no known opposition to the bill. 2:48:22 PM SARAH EVANS, Staff, Senator Johnny Ellis, Alaska State Legislature, explained that the bill discusses naloxone, also known as Narcan, which is a medication called an opioid antagonist and is used to counter the effect of opioid overdose from drugs such as, OxyContin, morphine or heroin. She described naloxone as extremely safe and effective at reducing opioid overdose to counteract the life threatening depression of the central nervous system by allowing the overdose victim to breathe normally. She explained that in the event a person has too many opioids in their system, the opioids cover all of the brain receptors, thereby causing a person to physically stop breathing. At that point, she further explained, their lips and nails turn blue with many signs of distress in not being able to breathe. She related that once naloxone is administered into a person, the naloxone clears off the receptors causing the person to no longer feel the effects of the drug, and they are revived. She said that naloxone is not a controlled substance, it has no abuse potential, and with zero effect if administered to someone without opiates in their system. She said naloxone is liken to an EpiPen, except it is safer because it will do nothing to the person if there are no opiates in their system. The sponsor would like naloxone in the hands of family members, friends, or addicts themselves because typically an overdose occurs within one to three hours, although earlier in some cases, leaving a brief window of opportunity for intervention. Naloxone takes effect immediately and can last between 30 and 90 minutes, she said. 2:50:50 PM MS. EVANS turned to Section 1, of the bill and said it basically allows a pharmacist to dispense naloxone to any person in front of the pharmacist requesting it because a prescription is not necessary for naloxone or Narcan. She referred to [Section 1, AS 08.80.030(b)(13), page 2, lines 24-26], which read: (13) establish standards for the independent dispensing by a pharmacist of an opioid drug under AS 17.20.085, including the completion of an opioid training program approved by the board. MS. EVANS explained that the language reads that education and training must be administered to the person being dispensed naloxone. 2:52:03 PM CHAIR LEDOUX inquired as to whether there are any other opioid overdose drugs other than naloxone. MS. EVANS replied not currently, not in the manner the bill defines an opioid overdose drug, it is strictly naloxone. She noted that naloxone can be administered in three different ways. 2:52:30 PM REPRESENTATIVE LYNN asked whether this is an expensive drug and whether it is covered by a typical insurance program. MS. EVANS answered that the sponsor left it up to pharmacists and doctors to supply naloxone in one of the three different ways. Certain insurance companies, including Medicaid, only cover a certain way to administer naloxone, and the different ways are more or less expensive. She explained the three ways as follows: a nasal injector involving two doses, and CVS recently advised it would require approximately $50; the auto- injector, similar to the EpiPen can be more expensive; and a muscle injection by using a syringe and inserting it into a meaty part of the arm or thigh. MS. EVANS, in response to Representative Lynn's comment, agreed that it is similar to insulin. MS. EVANS reiterated that the bill leaves it up to the pharmacist or doctor to dispense naloxone to a person based upon their insurance and the training necessary for that manner of administering naloxone. 2:54:12 PM REPRESENTATIVE CLAMAN surmised that the language means that if medical technology advances and produce another drug with the same benefit, the legislature would not have to come back for the pharmacist to be able to administer the new drug. MS. EVANS replied that it is the sponsor's hope, although, the sponsor does not foresee any new medications coming out because doctors have said that this is such a safe drug. Although, she noted, the sponsor is hoping for FDA approved easier ways for the public to administer naloxone. CHAIR LEDOUX offered that at some point there may be a generic form of the drug. 2:55:02 PM MS. EVANS referred to Sec. 2, [AS 08.80.168(b)(1), page 2, line 29], which read: (1) "opioid overdose drug" has the meaning given in AS 17.20.085; MS. EVANS explained that the provision defines an opioid overdose drug in the correct sections. She then referred to page 4, lines 24-25, [AS 09.65.340(d)(3)], which read: (3) "opioid overdose drug" means a drug that reverses in whole or in part the pharmacological effects of an opioid overdose; 2:55:32 PM MS. EVANS referred to Sec. 3, [AS 08.80.168(c), page 3, lines 2- 5], which read: (c) A pharmacist may independently dispense an opioid overdose drug if the pharmacist has completed an opioid overdose drug training program approved by the board and otherwise complies with the standards established by the board under AS 08.80.030(b). MS. EVANS explained that it refers to the Board of Pharmacy. 2:55:51 PM MS. EVANS referred to Sec. 4, [AS 08.80.480(27), page 3, lines 12-13], which read: (27) ... ; the independent dispensing of opioid overdose drugs; MS. EVANS said the provision was amended under the practice of pharmacy. 2:56:12 PM MS. EVANS referred to Sec. 5, [AS 09.65] and advised that the added section offers civil immunity to health care professionals to prescribe, provide, and administer opioid overdose drugs except as provided in [AS 09.65.340](c) of this section, which read: (c) This section does not preclude liability for civil damages that are the result of gross negligence or reckless or intentional misconduct. MS. EVANS described (c) as typical language with a medication wherein if a person does not believe a person is experiencing an overdose and administers the drug, they would not be covered under civil liability. 2:57:28 PM CHAIR LEDOUX pointed to Ms. Evans' previous testimony that there is zero effect if naloxone is administered to someone without opiates in their system. In that regard, Chair LeDoux understood the drug to be perfectly harmless. MS. EVANS agreed, and offered that the drafter of the bill, Megan Wallace, Legislative Legal and Research Services, previously answered the same question and advised that it is typical language to include in a bill where there is a medication given by lay persons. 2:57:54 PM5, MS. EVANS explained that the bill includes an education component within Sec. 5, [AS 09.65.340(a)(2)], page 3, lines 29- 31, and page 4, lines 1-3, which read: (2) each person to whom the opioid overdose drug is prescribed or provided has been educated and trained in the proper emergency use and administration of the opioid overdose drug by the health care provider of the opioid overdose program; education and training under this paragraph may be provided by any reasonable means, including through the use of electronic, video, or automated education or training resources. MS. EVANS explained that when a person administers, prescribes, or provides an opioid overdose drug they can only do so if they also provide training and education on how to administer the drug. The language electronic, video, or automated education or training resources was added because this has passed in 41 other states and the District of Columbia, she said, and these states have prepared "really great" educational programs. She explained that the bill allows people to use these other means showing how to safely administer the drug, and to call 911. 2:59:52 PM CHAIR LEDOUX surmised that under this bill, a doctor doesn't actually have to prescribe naloxone. MS. EVANS replied no, they do not. Under the language regarding prescribing and providing through health care professionals, a pharmacist could directly dispense the drug, she said. Many times, she offered, doctors deal directly with clients who are addicts, or family members of addicts, and they can prescribe and provide the training of any opioid overdose drug at that time. 3:00:41 PM REPRESENTATIVE GRUENBERG pointed to AS 08.80.050 relating to Board of Pharmacy, and paraphrased that, "the board shall comply with the Administrative Procedures Act (APA) in its activities." He asked whether, when setting these standards to establish the training program, it will require adoption of a regulation in accord with the APA. MS. EVANS answered "That's my understanding," and a person in the room from the Alaska Pharmacy Association could speak to the difficulty of adopting a regulation. She opined that it is very easy for the board to "make up" these regulations and rules and the training program. REPRESENTATIVE GRUENBERG said he would ask that person at the appropriate time whether they must go through a certain procedure. He asked whether there was an accompanying concurrent resolution for the title change. CHAIR LEDOUX advised that her staff has provided HCR 22, changing the title. MS. EVANS responded that the title change came into place because the sponsor asked the Board of Pharmacy to make some changes. REPRESENTATIVE GRUENBERG noted that sections 1-4 of the bill were added in the House of Representatives necessitating the title change. He asked whether other changes were made in the House of Representatives. MS. EVANS replied yes, other than allowing the pharmacist to dispense and having the training component, under the definition of health care provider the sponsor added "nurse" as someone who could provide training and dispense naloxone. 3:03:32 PM REPRESENTATIVE GRUENBERG opined that Ms. Evans was referring to the language at least on page 5, lines 14-16, and asked whether it was defined in any other section in the bill. MS. EVANS, in response to Representative Gruenberg, pointed to [AS 09.65.340(d)(1)], page 4, lines 19-21, [page 5, lines 14- 16], which read: (1) "health care provider" means a licensed physician, advanced nurse practitioner, physician assistant, nurse, village health aide, or pharmacist operating within the scope of the health care provider's authority; MS. EVANS then referred to [Sec. 5, AS 09.65. 340(a)(2)], page 4, lines 1-3, which read: (2) ... overdose program; education and training under this paragraph may be provided by any reasonable means, including through the use of electronic, video or automated education or training resources. MS. EVANS explained that the House Health and Social Services Standing Committee wanted more language as to how the training component could be performed, and those were the only new parts. 3:04:57 PM REPRESENTATIVE KELLER asked whether, in previous hearings, there had been a discussion regarding the definition of "opioid overdose drugs," because there are also "opioid addiction drugs." He offered concern that there could be confusion there, and there would be a liability release because of the fact that it takes gross negligence, or whatever. He asked that Ms. Evans be very clear during further testimonies as to the pharmacological effects of the opioid overdose, and to clarify that definition. MS. EVANS responded that Dr. Paula Colescott will speak to that issue as her Anchorage practice involves addiction medicine. She opined that Dr. Colescott will testify that the opioid overdose drug, as defined, narrows it to naloxone. REPRESENTATIVE KELLER commented that the House Judiciary Standing Committee must have the language as tight as possible, thereby not creating a problem while trying to fix a problem. 3:06:55 PM REPRESENTATIVE GRUENBERG asked Representative Keller whether he was referring to the standard of tort immunity ... the gross negligence standard. REPRESENTATIVE KELLER responded no, in that his concern has to do with how that would apply to the definitions used in this bill. He opined that the definition in this bill means a drug that reverses in whole or in part the pharmacological effect of an opioid overdose. He explained, "If I read this the first time and I thought methadone, frankly, you know, ... is there a danger of somebody else out there that is authorized to give naloxone ... if they could have that confusion." He asked that the definition be "nailed down". CHAIR LEDOUX opened invited testimony. 3:08:47 PM PAULA COLESCOTT, M.D., First Care Medical Center, said she is a practicing addiction specialist, and offered excitement regarding SB 23 as it can begin to save lives of opiate dependent people. She explained that many of her clients start with prescription opiates and when they are no longer able to secure those, transition over to heroin or another opiate off the street. Any of these opiates, the synthetics, can cause an increase in tolerance wherein a person finds themselves using more and more to get the same effect they desire. However, she noted, as the person increases doses, very often the respiratory does not keep pace with that tolerance and the person can easily overdose. She opined that she doesn't have a client who has not witnessed an overdose in front of them, which is common in the community commonly using injectables, or even oral opiates. Often, in response to witnessing an overdose, the person is put into a tub of cold water to resuscitate or they are dragged outside in the cold, and it often is not successful. She expressed that this community could benefit from [naloxone], and being taught about it. In her office, she explained, there are folks that are put on replacement opiate therapy to stabilize the brain while taking them through the recovery process of rebuilding their lives. Suboxone, Buprenorphine, or methadone are lifesaving agents if people have access through Medicaid or private insurance, she described. However, not everyone has that type of access and they will then defer to a needle exchange program where they'll inject heroin but they will not contract HIV, or Hepatitis C and, she noted, that the program has proven to be beneficial. These agents, naloxone, which is what will be in either the nasal or auto-injectable forms, act within minutes and can last up to 30-60 minutes. She described it as a very rapid acting agent, at an acceptable dose, that would hopefully restore the ability of that person to breathe until emergency help arrives. She explained that usually two doses are in the nasal or injectable kit, and the GoodRx app offers approximate over-the-counter retail prices, as follows: the nasal product is $136; and Evzio (naloxone hydrochloride injection) similar to an EpiPen is $757, which would vary with Medicaid or insurance. 3:13:57 PM DR. COLESCOTT, in response to a previous question, answered that the agents that immediately reverse opiate intoxication, failure to breathe, or an individual turning blue, not breathing not responsive, are agents that have been used over four years in the emergency room (ER) setting. Narcan is routinely injected in the ER, and this is an agent that you don't need to give IV, but "you can actually have the person ... injected into the nasal passage" and it will be absorbed and, she reiterated, it begins to have an onset within a few minutes that can be lifesaving for these people. Obviously, she said, the response could be a bit more rapid if you inject Evzio, but more pricey. She remarked that she is unaware of any other good opiate reversal agents used routinely in the ER. Again, the importance of this bill is that these are situations in which emergent ... 3:15:17 PM [Technical difficulties] 3:15:39 PM DR. COLESCOTT explained that both the nasal and injectable application would have an immediate effect that could be lifesaving. In the event a person is not breathing, the [immediate goal] is to restore respirations to prevent undesirable neurologic outcomes within 10-15 minutes. She emphasized that in order to avoid anoxic brain injury or injury to the brain due to lack of oxygen it has to be onsite, has to be immediately available to people at risk for overdosing. 3:16:43 PM CHAIR LEDOUX asked whose insurance company a family member or friend would submit the naloxone insurance claim, and noted that they would not necessarily have a prescription. Usually, without a prescription the insurance companies won't pay for it. She stressed that her question is not a reason to not pass the bill, but the discussion has been around significant amounts of money. She asked whether there is a way the insurance companies will pay for it. DR. COLESCOTT responded that within her circumstances in the methadone clinic, it would be dispensed to "probably all the people on methadone" through the medical director's standing order. The clients she sees for Buprenorphine, for instance, or anyone that failed to progress through the program and stops Buprenorphine, would be given a prescription because they put themselves at risk of resuming heroin and overdosing. In that setting, she would personally write the prescription or in the clinics, dealing with large numbers of people, it would be by standing order from the medical director, she explained. 3:18:24 PM CHAIR LEDOUX put forth Representative Keller's concern that there not be confusion between methadone and naloxone. She opined that methadone is not a narcotic reversal medication. DR. COLESCOTT agreed, and explained that methadone is an opioid, a synthetic opioid, first synthesized in Germany, and after World War II the United States received the rights to methadone. Two biochemists in New York then theorized that in giving a heroin addict the correct dose of an opiate lasting all day, it would somehow stabilize the brain, stop cravings, they wouldn't inject, and they would feel normal. She explained that from that research the federal government stepped in and began developing federally run methadone clinics for opioid dependent people. These drugs would never be given [under this bill] and are only prescribed by a physician or practitioner with the DEA schedule permit. She further explained that methadone stimulates receptors as an opiate, is very long acting, treats pain, and can be used to stabilize the brain in people that are shooting up heroin 4-6 times a day. If there is something on the receptor that has caused over stimulation, such as methadone, oxycodone, hydrocodone, or morphine, and that person is not breathing, naloxone will knock the opiate off the receptor and restore breathing immediately. 3:21:02 PM REPRESENTATIVE CLAMAN opined that before naloxone could be dispensed, the state would have a particular drug identified by the Board of Pharmacy. He said, to the extent there was another drug meeting the definition, people would still need to rely on the regulations being issued by Board of Pharmacy. He continued, "Rather than saying, 'Oh look, this is what the statute says ... the statute' ... you still are left in the regulation." DR. COLESCOTT replied "Yes, that is my understanding." She replied to Chair LeDoux that she did not have further testimony, and that [the bill] would be something that could be very helpful to people that are trapped in this process. 3:22:12 PM REPRESENTATIVE GRUENBERG pointed out that the language at the beginning of the bill deals with pharmacists and the training program for them; however, pharmacists are not the only health care professionals who can prescribe these drugs. He pointed to the health care providers listed on page 4, lines 19-21, and also page 5, lines 14-16, [text provided previously] and noted that pharmacists are only one profession and they are well covered at the beginning of the bill. He further noted that the other professions do not appear to be similarly covered and asked whether the bill should contain similar language covering the other professionals so they do not get in trouble and disciplined. REPRESENTATIVE GRUENBERG further asked whether the sponsor is careful and sure these other people will not be criminally liable, and should the bill give civil liability. 3:24:12 PM CHAIR LEDOUX pointed out that those are questions for the bill sponsor or Legislative Legal and Research Services. DR. COLESCOTT commented that Representative Gruenberg is correct and that maybe it could be broadly worded to include health providers/pharmacists. In response to the notion of civil liability, she said, she recently attended the annual conference of the American Society of Addiction Medicine (ASAM) and there was great discussion regarding this issue. The overarching opinion was that for physicians to ... or when a physician prescribes something in the ordinary practice that is a legitimate reason for dispensing a drug there is no increased civil liability at all. She stressed that for prescribing something lifesaving there would not be any increased civil liability, but there's been enough concern that in this setting people have wanted to be exempt from this. She opined that it should obviously be included in this. 3:25:57 PM REPRESENTATIVE GRUENBERG stated he would like a "real expert" to determine whether there are other types of health care providers not listed in the bill, such as a dentist, naturopath, or whoever, and further stated that he wants to be certain that anyone who legitimately does this should be covered. [CHAIR LEDOUX closed invited testimony and opened public testimony to allow Representative Lynn Gattis to testify.] 3:26:54 PM REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, paraphrased written testimony as follows: [original punctuation provided] For the record my name is Lynn Gattis, I represent district 7, the greater Wasilla area. I want to thank Senator Ellis for his tremendous work on this bill and for reaching across the aisle to work with me on it. I strongly support SB23 for the simple reason that it's literally a life-saver. - Across Alaska, and certainly the Matsu, heroin abuse is having a deadly impact on Alaskan communities. - Too many people are getting caught in a terrible addiction, and too many people are dying. - There is one last line of protection we can offer addicts, families, and friends - Narcan. - SB23 gives addicts and loved ones the opportunity to have lifesaving medication with them if the worst does occur. - We need to stop treating addiction as something we hide under the rug. Let me be clear - I don't condone any drug use or substance abuse. I also don't think we can stand by and do nothing while people are dying. - What Senate Bill 23 does is give mothers and grandparents, even addicts themselves, a chance to save their loved ones. - This bill would allow pharmacies to offer Narcan, and a mom or grandma to go and purchase it over the counter - just like you would Sudafed today. - To finish my comments Madam Chair, to me this is a life-saving bill. We have a medicine that can save lives and has no adverse impacts, no high to be obtained. - Even if we save just one life - this bill would do its job. So let's allow Alaska that opportunity. Thank you for your time Madam Chair and I'm available for any questions. 3:30:14 PM TERRIA WALTERS, offered testimony, as follows: My name is Terria Walters, and I am a person in long- term recovery from heroin and meth, and I am also a recovery advocate and started a program ... a ministry called (indisc.) Ministries where I help addicts and inmates transition back into the community after incarceration. I wanted to share a little bit about how I support this bill ... or why I support this bill. Um ... while I was in my addiction I watched many many people that I cared about ... um, overdose. And as Dr. Colescott stated that most ... the solution a lot of the time was to take that individual that was overdosing and put them in a cold bath ... um, with ice in it to ... to get them revived, lips would be turning blue. And of course all of us that was watching this happen would be freaking out because we didn't know what to do ... um, other than ... um, put down ... immerse them into ... um, a bathtub ... um, with ice and cold water. Um ... I um ... I have also OD'd, but thanks to the grace of God I ... um, did not die. Um ... and a ... eventually I came out of ... um, the overdoses. And my addiction started with pain pills. Um ... and then a ... overprescribing of methadone by my pain management doctor where I was taking ... um, a ... seven 10 milligram methadone pills a ... three times a day ... a with 210 milligrams of methadone for pain management. Eventually I ended up getting off of that that. Um ... once I got clean and sober ... um, in 2000 ... April 2, 2005 is my clean date and I will be celebrating 11 years clean and sober on April 2nd of this year. CHAIR LEDOUX congratulated Ms. Walters. 3:32:07 PM MS. WALTERS continued her testimony, as follows: Um ...thank you so much. Um ... I ... um want to share that I also ... the reason why I support this is because I have had loss of my friends and an ex- boyfriend that overdosed four years ago and died. Um ... I think that this a ... this um ... medication is essential to ... um, the ... you know ... a ... people eventually getting their ... you know ... not ODing and then ... a ... being unable to be pulled out it. Um ... I don't know ... if some of you know who I am and some of you don't. Um ... but I am also a mother of an addict that was murdered on June 22, 2015, it'll be seven months here pretty soon where I ... or eight months here pretty soon where I've had to deal with ... um, the murder of my son by somebody that was also a heroin addict that went to great lengths to ... support his drug addiction. Um ... while we have lack of a ... treatment services in this state, including medical detox ... um, a lot of individuals continue to use drugs because ... um, and some of them really don't want to because I know I've been there and I deal them ... a ... a ... daily on the ... um, through private message and phone calls. Parents of addicts trying to get their children help but unfortunately they continue to use ... they're turned away from hospitals. Ultimately, ... um, if they get a strong batch and ... do a dose that ... the same amount that they get from somebody else ... sometimes that ... that heroin would be a lot stronger than the batch that they did before. Ultimately, possibly, leading to ... um, a drug overdose. Um ... sorry, I'm trying ... this ... um, this bill ... um, is essential to ... to be passed to stop this. While we push for recovery services that include ... um, eventual abstinence from all substances ... all substances including suboxone and methadone, which are both narcotics. I'm not a fan of the maintenance program but I'll only ... tapering. I'm more of a fan of medical detox coupled with an Evzio shot. Um ... as a person of long-term recovery, I support this bill. Um ... I'm not sure if you guys are well aware of the Evzio shots, but it is also a blocker and it does not ... um, it's not a narcotic like methadone and suboxone. Um ... basically because of my own experiences and what I deal with on a daily basis, and then the loss of my own child, and friends that have lost their children to overdoses, I think that this is ... um, as a person that lives this lifestyle ... lives this lifestyle and also deals with it in the community. This medication would save lives and ... um, not hurt their family members where they are having to bury their children, or their husbands, or their wives. CHAIR LEDOUX thanked Ms. Walters and related that her testimony is quite compelling. 3:35:33 PM CHAIR LEDOUX closed public testimony and opened invited testimony. 3:35:44 PM KARA NELSON, Director, Haven House Juneau, offered testimony, as the follows: My name is Kara Nelson and I am the director of Haven House Juneau. Well, thank you very much. This ... it's an honor to be here. I've followed SB 23 for quite some time, and have come a long ways since our early testimonies, I think. Um ... and as you can see, thank you for allowing Terria to go ... she had to go to work, but she is such a powerful voice in this ... um, cause of recovery and long-term recovery as well as every life matters. So, I've testified prior about my own story ... um, overdosing three times myself. Today I am a person of long-term recovery and what that means for me is that I have not taken a drink or a drug since June 1, 2011. Ironically, that's also the day I was released from Lemon Creek Correctional Center. And so it's my ... by the grace of God, after 20 plus years of active addiction, and several overdoses, I am here today serving my community. Um ... you know, this has been a long process of watching our legislative ... kind of this new era that is coming towards us with criminal justice and the recovery movement coming together. And that's how I see it because most of the people I work with, as well as myself ... you know we were incarcerated for our substance abuse and mental health disorders without the proper supports around that. Every life does matter. 3:37:17 PM MS. NELSON continued her testimony, as follows: On 12/10/15, we had our very first relapse in our home as well as overdose. When I got the call about 2:00 a.m., I was in Anchorage with several women who were striving to be the best that they could ever be in their life. They were very confident, who were moving forward and this is a disease. And without having those supports there, this woman overdosed, was gone literally about one-half hour, overdosed, her friend had the sense to call the police. They came, they revived her by Narcan, and then of course had to do that several times afterwards. What we know about (indisc.) on Narcan is ... I wish I would have brought with me, but Evzio ... um, shot. I actually have one at my house -it's a very simple ... I've seen several people utilize the nasal spray as well as the EpiPen. It's just a little box, stick it on your thigh, five seconds, administer the drug. Um ... I've been to several different ... I mean, since then I've been to several different ... um, national ... you know, rallies and different things, really highlighting that right now we're still treating it, because we're having these different conversations about ... and I know this isn't necessary on this bill. But, in the different conversations surrounding this bill, what I've seen is ... you know, kind of like people are still treating it as a moral issue and not a medical issue. And so, to come in here and hear the different dialogue from last year is very rewarding, it's very hopeful, and very ... um, I just want to say thank you to every person that has been involved. Obviously Johnny Ellis is one of our personal heroes in the recovery community because we know that this works and our lives do matter. If I hadn't come back out of those overdoses, if this woman hadn't been revived by Narcan, she wouldn't have been with her daughter yesterday, as she was still striving for long-term recovery. You know, this is not a choice that we're making. We want to continue ... people want to have help and sometimes those helps are not available. So, I am in support of SB 23, I'm in support of naloxone and Narcan. I also know, and my colleague said this last time, I'm going to say it again, the only side effects of Narcan is life. And it's that simple. CHAIR LEDOUX related that Ms. Nelson's testimony was compelling. 3:39:57 PM REPRESENTATIVE GRUENBERG asked Ms. Nelson to explain how the medication is simple to administer. MS. NELSON explained that one way to administer Narcan is with an EpiPen, which is in a little box, the bottom is pulled off, place it on the thigh, click it, count 5-4-3-2-1, administered. At that point, she said, some of the education would be that people will then go back into an overdose after a period of time, again 5-4-3-2-1, although by then the hope is that they would be at a medical facility. REPRESENTATIVE CLAMAN noted he had to leave for another appointment and expressed that he strongly supports this bill and would sign "do pass." 3:41:27 PM MICHELE MORGAN, said she is representing herself and said she runs the Juneau Sports Association where people out of high school and play softball with "us older people," and families. She expressed that last year four of their softball players died and no one talked about why they died. Their parents would have loved to testify but they are too broken and cannot speak. Ms. Morgan offered testimony, as follows: When our first softball player died, his name is Ryan. He was 24 years old, he was with a party of about seven people, they'd just played in the championship game of softball and they were partying afterwards. A friend that was there called Ryan's dad and said "Ryan's not doing well," and the dad asked, "Well, what are you guys doing?" He said, "Oh, we're just drinking a few beers, you know we played in the championship game. The dad assumed ... he said, "Just watch him if he's drank too much call me, I'm in Sitka, if he gets worse we'll have someone come over." So they called again, and Ryan's dad sent his sister over, and Ryan had overdosed, he was dead. 3:43:02 PM MS. MORGAN emphasized that there were seven people in the room and they reached out to get help but they were using so they were high, and they were afraid and didn't know what to do. She stressed that if naloxone had been in the hands of our community last year, Ryan would be here, and his mom and sisters wouldn't be broken. She said her main purpose in starting Juneau's Stop Heroin Start Talking purpose was to get people talking about this and to save our children. She said she appreciates the support the program has received, and she thanked Senator Ellis and the bill's co-sponsors for putting this out there. She referred to the question of pricing, and said that the Washington Health and Social Services purchases Narcan nasal spray in bulk and the cost is $14 for two doses, which it hands out. She said the Juneau Police Department (JPD) advised that 200-400 people in Juneau are using heroin every day, a town of 36,000 people runs out to be 1 in 80 people doing heroin every day. 3:44:15 PM MS. MORGAN stated that it is about $9 a hit of heroin in Seattle, and $100 in Juneau. She remarked that a person doing four hits of heroin a day in Juneau will burn through their family, friends, everyone, and could become a criminal to support their habit. People from all over the state are reaching out to just talk about this issue, and she stressed that if "we can get this out there for one kid, I think Ryan would have been alive right now." 3:45:29 PM CHAIR LEDOUX closed invited testimony and opened public testimony. 3:46:07 PM GARY MILLER, offered testimony, as follows: My name is Gary Miller, I live here in Juneau, I'm here representing myself. On May 17th last year my daughter died of a drug overdose with heroin. We have her ashes interred out at the Shrine of St. Therese. I visit her at night so I can cry in private. I bring her a red rose that was her favorite flower. And I tell her how much I love her and how much I miss her. This bill will save other parents from going through the grief that my wife and I live with. It'll also give other addicts another opportunity to live, so please pass this bill. Thanks. CHAIR LEDOUX thanked Mr. Miller and offered him her condolences. 3:47:15 PM KATHERINE BOTZ, said that she is representing herself, that she is 28-years old, and that she sees her generation suffering from heroin overdoses and dying from it. She said she lost a friend last September due to a heroin overdose, and that he was not only a friend, he was a co-worker, and almost like another brother of hers. His family knew me, my family knew him, and they would hang out quite a bit. She then paraphrased a letter his mother wanted to share, as follows: After Verner's (indisc.) death, one of his friends told me he broke a rule - do not do alone, always have others with you. We think that he may have abused with another person and the reaction was to put him in his truck and drive him to Fred Meyers and leave him there. We will never know. I think that my comment would be, to give these users a fighting chance. Please. MS. BOTZ said that as a 28-year old person, she is seeing friends die, her classmates die, co-workers die, and of this generation, she does not want to be the last one standing. MS. BOTZ then said that JPD has confiscated almost $4 million of drug money, and Kodiak confiscated approximately $3 million of drug money. She said that families and friends are wondering where that money is going, and how to help people who are using, help drug addicts, and facilities and health clinics as well. 3:51:15 PM TERRA BURNS, Community United for Safety and Protection (CUSP), said she represents the Community United for Safety and Protection (CUSP). She stated she is a lifelong Alaskan and has always had people in her community that she cared about and have been narcotics users. Ms. Burns advised that she has received harm reduction training and is trained to administer Narcan in Canada, Oregon, California, and New York. Within many of those states Narcan is freely given out by people involved in harm reduction education and, she said, that commonly it is included in shooting kits if needed. She stressed that Alaska should have Narcan available as it saves lives as she used it once to reverse an overdose. She noted she has also been in the position of attempting to resuscitate when Narcan was not available. Public comments have been to not allow Narcan due to how hard it is on the person administering the drug but, she emphasized, it is much harder not to have it. As an individual and representative of CUSP, she strongly supports this bill and having this lifesaving measure available to Alaskans would be a new public treasure, she said. 3:53:07 PM MS. BURNS, in response to Representative Gruenberg, advised she had read the bill. REPRESENTATIVE GRUENBERG referred to [Sec. 09.65.340(a)(2), [text provided previously], and restated that each person to whom the drug is prescribed or provided must have been educated and trained in the proper emergency use and administration of the drug in order to receive the tort immunity. He then referred to a previous witness's statement in that its application is easy and similar to a diabetic. In reference to other states, he asked whether the person administering the drug must receive special training. MS. BURNS opined no, and advised that she is most familiar with the State of New York's policy in that people can be trained to become peer educators, carry Narcan across state lines, and can also hand Narcan out to people "so, you know, there's always somebody, you know, telling you how to do it when they give it to you." Also, she advised that the instructions with Narcan are quite clear and that she is most familiar with the nasal administration. She noted that even though she had not received training in five-seven years, a couple of years ago she read the instructions and successfully administered Narcan. 3:55:52 PM REPRESENTATIVE GRUENBERG referred to [Sec. 5, AS 09.65.340(a)] page 3, lines 18-23, which read: (a) Except as provided in (c) of this section, a person is not liable for civil damages resulting from an act or omission in prescribing or providing an opioid overdose drug to a person at risk of experiencing an opioid overdose or to a family member, friend, caregiver, or other person in a position to administer an opioid overdose drug to a person at risk of experiencing an opioid overdose if REPRESENTATIVE GRUENBERG offered concern that if the above-list of people must have "a bunch of training," the people available to administer the drug may be dissuaded from administering it. He surmised that the people in New York are not required to obtain training, rather they just administer the [Narcan]. MS. BURNS opined that the nasal administration is more commonly used, the least expensive option, and is covered by more health insurance companies. She reiterated that Narcan is not difficult to use, and she used the example of a doctor providing an EpiPen and providing an explanation [of administration], or reading the instructions. 3:57:16 PM DONNA BALDWIN, advised that she is one of four long-term recovery coaches in Juneau, and in response to Chair LeDoux stated she is testifying on her own behalf. She stressed that watching the process of SB 23 in action, because it didn't happen for so many years, is a miracle and that the committee is "awesome to do this work because it is so needed." She opined that if a person is "not living in that, you don't know that it exists," she said, and is thankful her children are still with her, and that she does not want to see any more parents tell their story about their lost children. She pointed out that the Juneau Police Department (JPD) wants to help these people and believes it really is a disease, and that our mistakes don't define who individuals are but what is done to make a difference does. She stressed that while this is a good beginning, it is by no means the end of the problem. She emphasized that more support and recovery facilities are needed because every single day treatment is unavailable for people asking for help. She added that "we've even brought addicts into our own homes to detox because there was nowhere to bring them." She asked that the legislature not stop here. 4:01:30 PM ANDREA ROBINSON, offered testimony, as follows: Hi, I'm Andrea Robinson from the Haven House in Juneau, I'm also in recovery. Um ... I have overdosed three times myself and I'm very grateful to be here. Um ... but in November of 2014, on my three-year olds birthday, my brother overdosed. They found him underneath the parking garage, right down there. His girlfriend found him. Um ... thankfully she called the ambulance, he got the Narcan shot, ah ... they brought him back. They had to do it several more times. And then they did it at the ER, and thankfully he got that or else he wouldn't be here today. Um ... I'm grateful for it, I definitely think that it could save a lot of lives. Everybody in our house, I know ... I mean just living in a sober house, I think that we should have that available just because for all recovery addicts there is no telling if ... I mean, I could relapse tomorrow and if we didn't have that in our house ... you know, one of us could just ... I mean we wouldn't really know what to do except call 911, and who's to say they would be there right away. Um ... I think it should be available in all places, halfway houses, everywhere. Um ... so yeah, I just want to thank you guys for this and ... yeah, thank you. 4:03:19 PM REPRESENTATIVE MILLETT thanked Ms. Robinson for being brave and sharing because the legislature needs to hear from people going through this and have experience with it. She emphasized the importance of this issue and that the legislature is not going to give up on anyone going through any type of addiction. She reiterated that the legislature is here, with Senator Johnny Ellis's help, to support her and she again thanked Ms. Robinson for testifying as it is an emotional issue. 4:04:17 PM CHAIR LEDOUX closed public testimony after ascertaining no one further wished to testify. CHAIR LEDOUX emphasized that this is an important bill and asked whether there were comments from the committee. REPRESENTATIVE GRUENBERG noted he had offered several questions that had not yet been answered by the lawyers. 4:04:57 PM MEGAN WALLACE, Attorney, Legislative Legal Counsel, Legislative Legal and Research Services, Legislative Affairs Services, asked Representative Gruenberg to please repeat the specific questions. 4:05:48 PM REPRESENTATIVE GRUENBERG referred to page 3, lines 29-31, and page 4, lines 1-3, [text provided previously] and asked for clarification that under the bill in order to receive immunization from tort liability, the person administering the drug must have been educated and trained in the proper emergency use and administration of the opioid overdose drug. [CHAIR LEDOUX passed the gavel to Representative Millett.] MS. WALLACE answered that is correct. She said the prescribing or providing health care provider would have to prescribe it or provide it to a person who has had that education and training. REPRESENTATIVE GRUENBERG referred to the definition of health care provider, and noted that the chair of the House State Affairs Standing Committee said it does not include, for example, a paramedic or ambulance driver. He said he has been given several definitions of health care providers from other parts of the code, for example, AS 09.55.560 lists approximately 20 different professions under health care provider. He pointed out that some of whom are probably not appropriate, but some probably are. Also, AS 21.07.250 goes to the opposite extreme and paraphrased, "Health care provider means a person licensed in this state or another state of the United States to provide medical care services, whatever that is defined in here." He asked whether Ms. Wallace had a comment. MS. WALLACE explained that the bill would only apply to health care providers as defined in the bill. She further explained that defining a health care provider is a policy choice and the sponsor or committee can make that decision. 4:08:43 PM REPRESENTATIVE MILLETT announced, for the record, that she is sitting as chair of the House Judiciary Standing Committee while Representative LeDoux stepped out. 4:08:52 PM REPRESENTATIVE GRUENBERG questioned whether the bill only applies to immunity from civil damages, and not to immunity from criminal damages or damages or actions that may be taken by a licensing board. MS. WALLCE responded that is correct. The bill only applies to civil immunity and does not affect any criminal law and does not affect any licensing or regulatory action that a board or other committee could take, she said. [REPRESENTATIVE MILLETT passed the gavel back to Chair LeDoux.] 4:09:35 PM CHAIR LEDOUX announced she had returned to the committee and was in possession of the gavel. REPRESENTATIVE GRUENBERG offered that he does not know the interplay between this law and federal law, and asked whether someone immunized under state law could still face some sort of action under federal law since the federal law is so involved in this area. MS. WALLACE commented that she has not looked deeply into that issue and does not want to misstate the law, but did note that in order for a federal civil action to impose damages on a health care provider there would have to be some sort of federal jurisdiction and normally these kinds of civil damages claims are governed by state jurisdiction. She advised she could not think of anything that would allow a federal court original jurisdiction over a civil damages case relating to Alaska law. REPRESENTATIVE GRUENBERG commented that he was not trying to be difficult but rather to be certain "we do what we need to." 4:10:54 PM REPRESENTATIVE LYNN offered a scenario of several people in a home where someone experiences an overdose, and asked whether anyone in that room could give the medication while not having had any type of training. He stressed that he would give the medication even if he didn't have the training. MS. EVANS responded that the House Health, Education and Social Services Standing Committee tried to expand how the training could be implemented, and referred to page 4, lines 1-3 [text previously provided]. She explained that the availability of Narcan over the counter is a law in 41 other states, plus the District of Columbia. "There's so much out there about how to educate and train the public on how to administer naloxone that that's why we put that information in there and ... so it would be a quick easy way to get the training out there and available for all persons," she stated. 4:12:54 PM REPRESENTATIVE LYNN restated his question and asked the consequences of him never having had any of this training whatsoever, happens to be at a party, sees a person overdosing, and administers the medication. MS. EVANS stated that "The correct answer would be that you would not be provided civil immunity the way this bill is written." She offered that she didn't think anyone would go after him. REPRESENTATIVE LYNN agreed that probably no one would go after him because a life had been saved. Nonetheless, why require all of the training when it really isn't needed if he gives the medication without training which, he reiterated, he would do. 4:13:54 PM MS. WALLACE answered that there are some civil immunities for rendering emergency aid in AS 09.65.090. She explained that a person rendering emergency aid without training may have immunity under that section. MS. WALLACE, in response to Representative Lynn, advised that he was correct that it is the Good Samaritan law. MS. EVANS offered that last session the Good Samaritan House Bill 369 passed, allowing a good samaritan to summon emergency responders or act on something such as SB 23, without any negative legal consequences. 4:14:52 PM CHAIR LEDOUX asked why the bill is written so that the person administering [Narcan] has to have the education. CHAIR LEDOUX then announced that, although she had originally intended to pass the bill out of committee today, the bill would be held over. She thanked everyone for their testimony, and particularly thanked Senator Ellis and Ms. Evans for their work on the bill. 4:16:28 PM ADJOURNMENT There being no further business before the committee, the House Judiciary Standing Committee meeting was adjourned at 4:16 p.m.