HB 268-OPIOID PRESCRIPTION WARNINGS  3:47:40 PM CHAIR SPOHNHOLZ announced that the final order of business would be SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 268, "An Act relating to the prescription of opioids; relating to the Department of Health and Social Services; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; and relating to the practice of optometry." 3:48:32 PM REPRESENTATIVE LES GARA, Alaska State Legislature, paraphrased from the Sponsor Statement [Include in members' packets], which read: House Bill 268 seeks to help address the opioid addiction crisis in Alaska, by making sure patients are advised of the potential addictive dangers of these prescription drugs. Opioid drugs include oxycodone, hydrocodone, and other pain reducing drugs. In many cases these drugs are needed to address acute physical pain, but the facts show that these drugs can also have powerful addictive effects. Furthermore, studies show many heroin users started as opioid drug users. The relatively low cost of heroin as a substitute drug can lead to the transition by many Americans and Alaskans to heroin. Obviously, this can occur when a medical provider will no longer provide additional prescription medication. A small but troubling percentage of people who become addicted to opioid drugs later become heroin addicts. These addictions can destroy families, destroy a person's ability to hold employment, and destroy lives. Addiction treatment is costly for consumers, who pay indirect insurance costs, as well as for the state, which often covers and pays for addiction treatment. In the worst case, overdose deaths also result from opioid use. According to the Department of Health and Social Services, 14,000 Americans died from opioid use in 2014 and 91 Americans die every day. Alaska's per capita death rate is twice the national average. According to the Department, between 2009- 2015, 774 Alaskans died from opioid overdose. This bill recognizes a reality. Since 1999, the number of opioid prescriptions has tripled. More Americans and Alaskans have been prescribed these often useful, but potentially dangerous drugs. House Bill 268 is a patient information bill. It requires prescribers to let patients know about the potentially addictive qualities of these drugs when they are prescribed, and that they can potentially lead to opioid abuse and addiction. Providers must also offer information about opioid use being a potential risk factor for future heroin addiction. Patients can then use this knowledge to help themselves and their family members guard against overuse and abuse when prescribed these medications. To keep the requirements flexible, and as non- burdensome as feasible, while still protecting patients, medical providers who prescribe these drugs will be required to provide this information to their patients in their "own words". The bill also requires the Department of Health and Social Services to prepare a very short handout with some facts on the dangers of opioid addiction, and the potential association between opioid addiction and heroin use. To increase the chances that this information will be presented in a form that is useful, it is required to be concise, and may include graphics. The handout is Important because it recognizes that the patient-provider discussion may not be long and detailed, and a patient may not remember what is told to them by a medical provider in this regard. It also serves to reinforce the information. This bill does not create opportunities for new civil lawsuits against providers, thus protecting the patient-provider relationship. Instead of imposing civil liability, and raising the specter of lawsuits, the enforcement mechanism in the bill allows the providers' Board to consider sanctions for "habitual" violations of this statute that occur without "good cause". Exceptions to the legislation's requirements, borrowed from a similar statute passed in New Jersey, include medical services where opioids may be necessary such as for opioid addiction treatment and hospice care. REPRESENTATIVE GARA declared that this was a world-wide problem, and opined that, as heroin was cheap, it could be substituted if the prescription opiates were no longer available from a doctor. He relayed his request that the Department of Health and Social Services put a link on its website for physicians to use to download a concise handout. He offered his own experience with opioid prescriptions, that he had never been told that they were potentially addictive or any link between opioid use and eventual heroin use. 3:54:34 PM REPRESENTATIVE SULLIVAN-LEONARD asked about offering the choice of another pain relieving, non-narcotic based product. She shared that pharmaceutical representatives had tried to offer this to doctors, but the response had been that the patients wanted quick relief. REPRESENTATIVE GARA expressed his agreement, and he pointed out that the proposed bill required that a reasonable alternative to the opioid must be mentioned to the patient. 3:55:49 PM REPRESENTATIVE JOHNSTON asked if the proposed bill was just for written prescriptions as a patient may not be able to read. REPRESENTATIVE GARA explained that the bill was intended for written prescriptions. He reported that there was some opioid use that was not prescription use, and he cited examples of a hospice care center or a heroin addiction treatment center. He stated that the proposed bill did not affect these centers. He explained that the proposed bill was a requirement for any prescription from an authorized provider. 3:57:36 PM REPRESENTATIVE JOHNSTON said that she was thinking of trauma cases in emergency rooms. REPRESENTATIVE GARA expressed his agreement that it should not affect emergency rooms and immediate care facilities. CHAIR SPOHNHOLZ pointed out that there were times when you could and could not give consent. 3:58:12 PM REPRESENTATIVE TARR directed attention to page 11, line 6, and suggested that the mechanism of action with opioid use needed to be described to a patient to better understand the health effects, even after the end of the prescription use. She asked if the Department of Health and Social Services would consider this, absent legislation, as there would be immediate positive effect. REPRESENTATIVE GARA offered his belief that the Department of Health and Social Services would not require medical practitioners to read a statement or provide a handout, hence the need for legislation to make this a mandatory requirement. He pointed out that should a warning become too long, there would be resistance from physicians. He acknowledged that any appropriate additional information could be included in the written handout. 4:01:18 PM REPRESENTATIVE TARR asked if the department would put something on its website more immediately. REPRESENTATIVE GARA replied that it was already on the DHSS website. 4:01:53 PM CHAIR SPOHNHOLZ added that the Office of Substance Misuse and Addiction Prevention had a lot of information and resources available to the public and health care practitioners. 4:02:09 PM REPRESENTATIVE SADDLER (alternate) asked about the extent of impingement on a professional's judgement and who made the determination for "without good cause" for failing to provide information. REPRESENTATIVE GARA replied that the goal of the proposed bill was to be non-burdensome on medical practitioners and not to create a hostile litigation relationship between patient and provider. He pointed out that the discipline for providers was very relaxed, noting that there was no lawsuit liability created by the bill. He explained that the enforcement mechanism was for habitual violators of the provisions of the bill who did not have good cause. REPRESENTATIVE SADDLER asked who defined good cause and what constituted habitual. 4:03:56 PM REPRESENTATIVE GARA replied that it was only habitual if the person was not following the law on a consistent basis. REPRESENTATIVE KITO asked how a violation was determined and who would determine these violations. REPRESENTATIVE GARA explained that the regulatory board for each profession would determine the violations and the need for punishment. He stated that the legal standard for habitual was determined by the dictionary definition. 4:04:54 PM REPRESENTATIVE KITO asked how the board members were made aware of the violation. REPRESENTATIVE GARA replied that "somebody would have to complain to them" and he opined that it would be rare as medical practitioners would not want to violate the law. 4:05:37 PM CHAIR SPOHNHOLZ said the bill would be held over.