SENATE BILL NO. 79 "An Act relating to the prescription of opioids; establishing the Voluntary Nonopioid Directive Act; relating to the controlled substance prescription database; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; relating to the practice of optometry; relating to the practice of veterinary medicine; related to the duties of the Board of Pharmacy; and providing for an effective date." 1:34:46 PM JENNIFER STUKEY, REPRESENTATIVE, BOARD OF NURSING (via teleconference), stated that she had worked with opioid abuse and addressed the issue of possible overprescribing of opioids. She believed that the bill would be helpful to combat the opioid addiction epidemic. Senator Micciche wondered if there was an "opioid awareness class." Ms. Stukey replied that she would like to have an opioid awareness class. She stressed that Alaska was different than the lower 48, so there should be a continuing education course. Senator Micciche assumed that creation of the class would not be easy, but noted that there did not seem to be that shared concern. Ms. Stukey replied that the creation of the course would not be a difficult process. Co-Chair MacKinnon wondered where the education should come from at the state level. She noted that there would be a variety of professions that would be affected by the legislation. Ms. Stukey replied that the state should provide that education to ensure that all professions were in line. She stated that there was an opioid summit that may be a good place to start the education. Co-Chair MacKinnon wondered who should influence the state. Ms. Stukey responded that the Board of Medicine could influence the state. 1:40:14 PM Co-Chair Hoffman queried the seven-day limit for prescription opioid. Ms. Stukey replied that it was a very good idea. She felt that there were exceptions for chronic pain and end of life services. Co-Chair MacKinnon wondered who would be the appropriate party to set the standard for maximum doses. Ms. Stukey replied that medical doctors had guidelines for prescribing, so that decision should be left to the physician. Senator Micciche remarked that there were some physicians who may be too focused on the comfort of the client, that they may be ignoring the adverse effects of the overuse of opioids. He noted that the Board of Medicine had expressed concern over what the seven-day supply would provide. Ms. Stukey replied that the education was important, and stressed that the addition of addiction understanding would help physicians to prescribe opioids in a better manner. Co-Chair MacKinnon wondered whether Ms. Stukey had worked in a hospital environment. Ms. Stukey replied in the negative. Co-Chair MacKinnon recalled that there was an assessment in the hospital for a level of pain. She wondered who would provide information about that assessment. Ms. Stukey replied that the Board of Medicine would be the best contact. 1:45:22 PM DOCTOR THOMAS WELLS, PRESIDENT, BOARD OF DENTAL EXAMINERS (via teleconference), stated that the bill was a good start. He shared that the board had no comment on the bill. He stated that he looked forward to regulations that would enforce the issue. Co-Chair MacKinnon noted the ambiguity in the bill about education and a seven-day supply limit. She remarked that only a doctor would have influence on a seven-day supply. Dr. Wells replied that there were guidelines for dosages. Co-Chair MacKinnon queried the guidelines to limit the opioid prescriptions. Dr. Wells replied that the drug companies provided dosage guidelines. Co-Chair MacKinnon wondered whether the pharma // Dr. Wells replied in the negative. Senator Olson queried the frequency of prescribing the amount that would cause addiction. Dr. Wells replied that it depended on the practitioner. He asserted that there was a population who may receive dental work in order to receive narcotics. 1:50:28 PM Senator Olson wondered whether there was ever a complaint of an overprescribing licensee. Dr. Wells replied in the negative. Senator Olson queried the lack of requirement in the law for the dental community. Dr. Wells replied that it was not a burden. He stressed that many addicts used dentists to get drugs. Senator Olson surmised that Dr. Wells agreed with the course. Dr. Wells agreed. Senator Hughes wondered whether there were some dentists who would see a benefit to the education, and curb overprescribing. Dr. Wells replied that many dentists were overprescribing. Senator Hughes surmised that a dentist would typically prescribe more than seven days' worth of opioids. Dr. Wells replied that the issue was more about repeated prescriptions. Senator Micciche felt that the value of the class was whether or not there needed to be an opioid prescription. Co-Chair Hoffman stressed that there were some people that have chronic pain, so they need the opioids to treat that pain. He wondered whether a person in a rural village would be required to travel to receive a prescription. 1:56:52 PM DOCTOR PAUL BARNEY, CHAIR, BOARD OF OPTOMETRY (via teleconference), stated that optometrists already had a four-day limitation on prescription opioids. He also supported the education element. He was in support of the legislation. Co-Chair MacKinnon wondered how the board established the four-day limitation. Dr. Barney replied that the legislative process resulted in the decision to limit to four days. Senator Micciche wondered whether the recent bill removed the four-day limit. Dr. Barney replied that the bill did remove the four-day limit. He stated that the board would put a four-day limit in regulation. Senator Olson remarked that bill referenced the seven-day supply. 2:01:13 PM DOCTOR JAMES HAGEE, CHAIRMAN, BOARD OF VETERINARY (via teleconference), stated that the veterinary profession was trained to deal with animals. He stated that the issue in the veterinary profession was that drugs were prescribed for the pets could get diverted for human use. He stressed that most opioid use in veterinary medicine was dispensed in house as injectables. He understood that the people could consume the drugs that were prescribed to the animals. He felt that the education would be very important for veterinarians. Senator Olson wondered queried the number of veterinarians who had a Drug Enforcement Agency (DEA) number, and how many prescriptions they could write. Dr. Hagee replied that the person who held the license was responsible for the prescription. Senator Olson wondered whether veterinarians could prescribe Schedule 1 or 2 drugs. Dr. Hagee replied that veterinarians could not prescribe Schedule 1 drugs. He stated that they could prescribe Schedule 2, 3, 4 and 5 could be prescribed. He stated that most Schedule 2 drugs were injectables. The Schedule 3 and 4 could be dispensed. He hoped that the veterinary community would stop prescribing opioids. 2:07:49 PM LEIF HOLM, CHAIRMAN, BOARD OF PHARMACY (via teleconference), replied that the pharmacy had been involved of the prescription drug management program (PDMP) and its use in curbing abuse in the state. He stated that he agreed with most of the changes in PDMP. Vice-Chair Bishop queried the difference between a generic and brand name drug. Mr. Holm replied that there was no clinical difference between the drugs. Vice-Chair Bishop queried the amount of continuing opioid education was required by pharmacists. Mr. Holm replied that there was no requirement. Co-Chair MacKinnon queried the challenges that pharmacists face moving from a monthly to daily reporting. Mr. Holm replied that there would not be a heavy burden, except that one must remember to do it every day. 2:14:40 PM Senator Hughes surmised that changing from monthly to daily reporting would not address the state opioid problem. Mr. Holm replied that he wanted to see the effect before he could respond to that question. Senator Hughes wondered whether an addiction could occur in less than seven days. Mr. Holm replied that addiction could occur with the first dose. Co-Chair MacKinnon remarked that there was an issue of "doctor shopping" to receive the drug. She remarked that a daily report would prove that an individual who was "doctor shopping." Mr. Holm felt that the daily reporting would only report those who were newly addicted. He felt that month long or week-long patterns would show a seasoned addict. Co-Chair MacKinnon queried the practice as a business owner for pharmacists who might identify an addict. Mr. Holm replied that the pharmacy would contact the physician. Co-Chair MacKinnon wondered whether the PDMP could be accessed in the pharmacy. Mr. Holm replied in the affirmative. 2:20:21 PM Senator Hughes wondered whether a patient must return to a physician for a physical prescription. She stated that there may be an electronic prescription required. Mr. Holm replied that all prescriptions could be electronic, but must be approved through the DEA. He guessed that a village may not have the electronic prescriptions, so there may be need to provide more than the limit. Senator Hughes wondered how many pharmacies would require the patient to return to the physician. Mr. Holm did not know. Senator Hughes remarked that there may be some with chronic pain that required opioids. She remarked that there was a concern about those people being under scrutiny. Mr. Holm replied that there may be a concern. He stated that he witnessed patients with high quantities of opioid use, so there could be a stigma with the seven-day mandate. He remarked that there would be no use for the seven-day mandate, if a physician was allowed to go beyond that limit based on their professional judgment. He stressed that the reporting in the PDMP would be more beneficial, and make major headway in reducing the opioid epidemic. 2:27:37 PM Senator Hughes remarked that there was a letter from the Medical Board about whether the Pharmacy Board could limit the prescribing of opioids. Mr. Holm replied that he was not aware of that guideline. Senator Hughes replied that it would be helpful to have the State Medical Board clarify their position on the bill. 2:31:07 PM DOCTOR JAY BUTLER, CHIEF MEDICAL OFFICER, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, introduced himself. Vice-Chair Bishop remarked that wondered whether there was curriculum already available, or would the education requirements be "site specific to Alaska." Dr. Butler replied that there were many materials that were available for education. Senator Hughes wondered whether Dr. Butler could speak to the letter from the State Medical Board. Dr. Butler replied in the affirmative. The question of the role of the Pharmacy and Medical Boards should be deferred to the chairs of those two boards. Senator Hughes felt that the boards should work together. Co-Chair MacKinnon replied that the State Medical Board chose not to participate in the day's meeting, and submitted a letter instead. Dr. Butler felt that interdepartmental collaboration would improve government efficiency. 2:35:31 PM Senator Micciche wondered whether the state was in "extraordinary times" as it related to drug and opioid use. Dr. Butler replied in the affirmative. Senator Micciche surmised that most street users began with prescription drugs. Dr. Butler agreed. Senator Micciche wondered whether prescription opioids killed twice as many Alaskans as street opioids. Dr. Butler replied that it was often use of more than one drug. Senator Micciche stressed that there were several people who felt the bill was inconvenient. Dr. Butler replied that the day's meeting reflected the conversations he had with multiple colleagues. Senator Micciche felt that there might be a generational difference in prescribing for pain management. The requirements of the bill were a reminder that the prescription could encourage addiction. 2:42:48 PM SARA CHAMBERS, DEPUTY DIRECTOR, DIVISION OF BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, reinforced the importance of interdepartmental collaboration in solving the problem. Co-Chair MacKinnon wondered whether there was merit in state standardized curriculum and whether there was a fiscal note that would reflect that development. Ms. Chambers replied that she did not anticipate developing a curriculum, but understood the benefit of an Alaska-focused education. Co-Chair MacKinnon wanted to know the recommendation about how the curriculum would be delivered. 2:47:46 PM Senator Hughes remarked that she knew of people who had problems with opioids. She also noted that physicians were concerns about whether the legislature would "hit the target." She remarked that there was not current data about overprescribing problems. She felt that the problem should be targeting the over prescribers. She wondered whether there was a way to stop the addicts who were "shopping." She wondered whether the boards currently could regulate on their own, or were in need of the statutory language. Dr. Butler agreed that there needed to be guidelines for opioid use. 2:53:49 PM Ms. Chambers continued that the boards worked together to come together on common guidelines. Senator Hughes wondered whether the boards were already working towards regulation, before the bill's introduction. Ms. Chambers replied that the Medical and Nursing Boards had overarching regulations. Senator Hughes queried the expectation of reduction in opioid related deaths and the opioid problem. Dr. Butler replied that there was a hope that the bill would be a major step in the right direction to address some of the roots of the problem, including the volume of opioids in the community and pain management. 3:00:12 PM Senator Hughes stressed that she was concerned with the issue. Co-Chair Hoffman wondered whether the language related to allowing a patient in a rural area to receive more than a seven-day dose. He would consult the tribal entities to be sure that the language was adequate. Senator Micciche remarked that the boards would determine a seven-day dose. He stressed the necessity of the bill. Co-Chair MacKinnon wondered whether America had the highest opioid usage in the world. Dr. Butler replied in the affirmative. 3:05:30 PM Co-Chair MacKinnon surmised that health care costs were driven by four factors: providers, hospitals, prescription drugs, and insurance providers. Dr. Butler felt that it was a broad, reasonable assessment. Co-Chair MacKinnon remarked that the state provided 60 percent of the overall health care in Alaska. Senator Micciche wanted to compare what was passed out of the house. Co-Chair MacKinnon replied that the work could be done later in the day. Ms. Chambers stated that she had a comparison available to the committee. Co-Chair MacKinnon wondered whether the comparison included the amendments. Ms. Chambers replied in the affirmative. SB 79 was HEARD and HELD in committee for further consideration.