ALASKA STATE LEGISLATURE  SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  May 9, 2017 3:31 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator Natasha von Imhof, Vice Chair Senator Cathy Giessel Senator Peter Micciche Senator Tom Begich MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 186 "An Act relating to the donation of food; and relating to foodbanks." - MOVED HB 186 OUT OF COMMITTEE SENATE BILL NO. 79 "An Act relating to the prescription of opioids; establishing the Voluntary Non-opioid 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." - MOVED CSSB 79(HSS) OUT OF COMMITTEE PREVIOUS COMMITTEE ACTION  BILL: HB 186 SHORT TITLE: FOOD DONATIONS SPONSOR(s): REPRESENTATIVE(s) TALERICO 03/17/17 (H) READ THE FIRST TIME - REFERRALS 03/17/17 (H) HSS 03/30/17 (H) HSS AT 3:00 PM CAPITOL 106 03/30/17 (H) Heard & Held 03/30/17 (H) MINUTE(HSS) 04/04/17 (H) HSS AT 3:00 PM CAPITOL 106 04/04/17 (H) Moved HB 186 Out of Committee 04/04/17 (H) MINUTE(HSS) 04/05/17 (H) HSS RPT 7DP 04/05/17 (H) DP: JOHNSTON, TARR, EDGMON, SULLIVAN- LEONARD, KITO, EASTMAN, SPOHNHOLZ 04/12/17 (S) HSS AT 1:30 PM BUTROVICH 205 04/12/17 (S) 04/14/17 (H) TRANSMITTED TO (S) 04/14/17 (H) VERSION: HB 186 04/14/17 (S) HSS AT 5:15 PM BELTZ 105 (TSBldg) 04/14/17 (S) 04/15/17 (S) READ THE FIRST TIME - REFERRALS 04/15/17 (S) HSS 05/09/17 (S) HSS AT 3:30 PM BUTROVICH 205 BILL: SB 79 SHORT TITLE: OPIOIDS; PRESCRIPTIONS; DATABASE; LICENSES SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 03/06/17 (S) READ THE FIRST TIME - REFERRALS 03/06/17 (S) L&C, HSS, FIN 03/14/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/14/17 (S) Heard & Held 03/14/17 (S) MINUTE(L&C) 03/16/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/16/17 (S) Scheduled but Not Heard 03/21/17 (S) L&C AT 9:30 AM BELTZ 105 (TSBldg) 03/21/17 (S) Bill Postponed to 1:30 p.m. 3/21/17 Meeting 03/21/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/21/17 (S) Heard & Held 03/21/17 (S) MINUTE(L&C) 03/23/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/23/17 (S) -- MEETING CANCELED -- 04/04/17 (S) L&C AT 9:00 AM BELTZ 105 (TSBldg) 04/04/17 (S) 04/14/17 (S) L&C AT 9:00 AM BELTZ 105 (TSBldg) 04/14/17 (S) Moved CSSB 79(L&C) Out of Committee 04/14/17 (S) MINUTE(L&C) 04/15/17 (S) L&C RPT CS 4DP NEW TITLE 04/15/17 (S) DP: COSTELLO, MEYER, STEVENS, GARDNER 04/16/17 (S) FIN AT 9:00 AM SENATE FINANCE 532 04/16/17 (S) -- MEETING CANCELED 05/09/17 (S) HSS AT 3:30 PM BUTROVICH 205 WITNESS REGISTER REPRESENTATIVE DAVID TALERICO Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Sponsor of HB 186. JULIE MORRIS, Staff Representative David Talerico Juneau, Alaska POSITION STATEMENT: Provided a sectional analysis for HB 186. SAMANTHA KIRSTEIN, representing self Fairbanks Foodbank Fairbanks, Alaska POSITION STATEMENT: Testified in support of HB 186. DR. JAY BUTLER, Chief Medical Officer Alaska Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Provided an overview of SB 79. SARAH CHAMBERS, Deputy Director Division of Corporations, Business and Professional Licensing Alaska Department of Commerce, Community and Economic Development Juneau, Alaska POSITION STATEMENT: Provided a sectional analysis on SB 79. STACY KRALY, Chief Assistant Attorney General Civil Division Human Services Section Alaska Department of Law Juneau, Alaska POSITION STATEMENT: Addressed prescription limits regarding SB 79. JONATHAN LARSON, representing self Dillingham, Alaska POSITION STATEMENT: Testified in support of SB 79. DAN NELSON, Director of Pharmacy Tanana Chiefs Conference Fairbanks, Alaska POSITION STATEMENT: Testified in support of SB 79. MICHAEL CARSON, Chair Mat-Su Opioid Task Force Mat-Su Valley, Alaska POSITION STATEMENT: Testified in support of SB 79. ROBIN MINARD, Director of Public Affairs Mat-Su Health Foundation Wasilla, Alaska POSITION STATEMENT: Testified in support of SB 79. DAVID REES, representing self Eagle River, Alaska POSITION STATEMENT: Testified in support of SB 79. TRACEY WIESE, Co-Chair Alaska Advanced Practice Registered Nurse Alliance, Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 79. TOM CHARD, Executive Director Alaska Behavioral Health Association Juneau, Alaska POSITION STATEMENT: Testified in support of SB 79. ACTION NARRATIVE 3:31:09 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 3:31 p.m. Present at the call to order were Senators Micciche, Giessel, von Imhof, and Chair Wilson. HB 186-FOOD DONATIONS  3:31:57 PM CHAIR WILSON announced the consideration of HB 186. 3:32:09 PM REPRESENTATIVE DAVID TALERICO, Alaska State Legislature, Juneau, Alaska, sponsor of HB 186, explained that HB 186 seeks to reduce the amount of wasted food in the state by increasing the amount of food donated to foodbanks and other charitable organizations. He detailed that nearly 15 percent of Alaskans fall into the category of food-insecure individuals. He said many businesses are currently donating excess food; however, many desire to do so but are not because of liability or perceived liability. He disclosed that many charitable organization do not receive sufficient food donations to feed the homeless and hungry. 3:32:41 PM SENATOR BEGICH joined the committee meeting. REPRESENTATIVE TALERICO specified that HB 186 allows hotels, restaurants, stores, and other food donors to donate all their excess food, unsold food, or outdated food; they can donate to foodbanks or charitable organizations. He noted that HB 186 would clarify "charitable organizations" in Alaska's statutes. He disclosed that he was once responsible for a solid-waste facility and detailed the challenges in dealing with excess food that led to inefficient use of space, animal attraction, and creating a bacteria issue. 3:36:39 PM JULIE MORRIS, Staff, Representative David Talerico, Juneau, Alaska, provided a sectional analysis for HB 186 as follows: Sec. 1 - AS 17.20.345  Amends AS 17.20.345 (a) by adding charitable organizations in statute next to foodbanks to be able to receive donated food from donors who may donate their food free from liability. Amends AS 17.20.345 (b)(l) by adding a sentence clarifying that the labels referenced in this statute do not include the new label referenced in section two of this bill; which requires heated-donated food to be labeled. Amends AS 17.20.345 (b) by adding a third bullet point allowing donors of food to donate food with an expired date on it. Amends AS .17.20.345 (c) by adding charitable organizations in statute along with foodbanks to be able to receive donated salmon from hatcheries. Sec. 2 - AS 17.20.345  Amends AS 17.20.345 is amended by adding a new section which allows donors of food to donate excess hot food to foodbanks and charities as long as they label it as previously heated food. Sec. 3 - AS 17.20.346  Amends AS 17.20.346 (a) by adding charitable organizations in statute next to foodbanks to be free from liability to donate received food to hungry individuals as long as they first inspect it and deem it fit for human consumption. Amends AS 17.20.346(b) by adding charitable organizations in statute next to foodbanks to be free to receive donated food with an expired date on it. Sec. 4 - AS 17.20.347  Amends AS? 17.20.347 (1) by adding delicatessen, restaurant, hotel and store under the definition of donor. Amends AS 17.20.347 (2) by deleting part of the definition of a foodbank so as to separately define a nonprofit organization in a new section. Sec. 5 - AS 17 .20.347  Amends AS 17.20.347 by adding three new definitions: 1. "Charitable Organization" means a nonprofit organization that provides food without charge to individuals who do not have money to pay for the food or who do not have homes; 2. "Food" includes unsold hot food; 3. "Nonprofit Organization" means an organization recognized by the state or federal government as a nonprofit organization. 3:40:14 PM SENATOR MICCICHE asked if there has been any opposition to HB 186 from the foodbanks or nonprofits. REPRESENTATIVE TALERICO replied that he is not aware of any opposition. He noted that only one negative comment has been received and it was not connected with any foodbank or nonprofit. SENATOR MICCICHE asked what the negative comment related to. REPRESENTATIVE TALERICO said the individual claimed that the intent was to make this incredibly dangerous for people to consume bad food. He explained that the bill makes no changes to the proper handling of food in Title 18 of the Alaska Administrative Code, which is known as the "Alaska Food Code." The bill does not change any of the monitoring currently done by the Department of Environmental Conservation. SENATOR VON IMHOF read the following verbiage from the bill: HB 186 will allow hotels, restaurants, stores, and other food donors. SENATOR VON IMHOF surmised that "other food donors" could potentially include private individuals. She asked if private individuals are currently donating food specifically related to events with significant excess food. She asked if private individuals are currently donating food. REPRESENTATIVE TALERICO replied that private donation does occur. He related a story about a food retailer that throws out hot food due to a liability concern and noted the application of the Good Samaritan Act. He said his hope is that HB 186 will ultimately remove the liability thought for not donating. 3:44:19 PM SENATOR VON IMHOF replied that she appreciated Representative Talerico's comments that proper food handling is observed for food donations. She noted that foodbanks will have to consider adding additional personnel due to added donations in addition to expanded storage and refuse capacity. She opined that a foodbank having to hire additional personnel is a good problem to handle the added food donations. 3:45:07 PM SENATOR WILSON opened public testimony on HB 186. 3:45:39 PM SAMANTHA KIRSTEIN, representing self, Fairbanks Foodbank, Fairbanks, Alaska, testified in support of HB 186. She concurred with Representative Talerico that the legislation will provide a little more comfort for the people who donate food such as the commercial grocers. She asserted that donations are important to foodbanks. 3:46:35 PM CHAIR WILSON closed public testimony on HB 186. 3:46:54 PM SENATOR VON IMHOF moved to report HB 186, [version 30-LS0654\J], from committee with individual recommendations and attached fiscal note(s). 3:47:04 PM CHAIR WILSON found no objection, and HB 186 moved from the Senate Health and Social Services Standing Committee. 3:47:10 PM At ease. SB 79-OPIOIDS; PRESCRIPTIONS; DATABASE; LICENSES  3:48:42 PM CHAIR WILSON announced the consideration of SB 79. 3:49:18 PM DR. JAY BUTLER, Chief Medical Officer, Alaska Department of Health and Social Services, Juneau, Alaska, stated that Alaska's opioid epidemic continues and reported the following statistics: • More than 90 Alaskans died of an opioid overdose in 2016. • The 90-overdose deaths are twice the number of Alaskans who died of acquired immune deficiency syndrome (AIDS) at the peak of the human immunodeficiency virus (HIV) epidemic. • Often the overdose deaths occurred among young people. • Two-thirds of opioid overdoses involved a prescription. • The majority of people who use heroine and other illicit opioids report becoming hooked when using prescription opioid painkillers, often on the advice of a trusted and generally well-meaning provider. DR. BUTLER explained that Alaska is responding to the opioid epidemic as follows: • Citizens have actioned community collations. • State government passed SB 91 to increase access Naloxone opioid-overdose kits. He conceded that overdose kits do not solve the opioid epidemic and detailed what SB 79 proposes to do: • SB 79 adds to the state's multi-faceted approach to addressing the opioid epidemic and aligns with the current science on pain management as well as addiction medicine based on recommendations from: square4 Centers for Disease Control and Prevention (CDC); square4 U.S. Surgeon General, U.S. Department of Health & Social Services; square4 Professional groups including the American College of Physicians; square4 Best practices and learned experiences from the Opioid Safety Initiative, U.S. Department of Veterans Affairs. DR. BUTLER stated that SB 79 addresses three opioid areas: • Patience, • Providers, • Prescription Drug Monitoring Program (PDMP). He specified that SB 79 provides the following for patients and health-care providers when an opioid prescription is voluntarily limited or eliminated: • Provides for an opioid advance directive for patients that do not wish to receive opioid medications. The directive is voluntary and revocable. • Protects health-care providers with civil liability if an opioid is withheld by the directive as well as the inadvertent administering of an opioid in an emergency situation. • Provides in state statute the authority of patients to request a partial-opioid prescription: square4 Reinforces the authority of the pharmacists to honor a partial-fill request without the need to immediately void the remaining portion of the prescription as provided under the federal Comprehensive Addiction and Recovery Act of 2016. He said SB 79 addresses the amount of opioids that providers dispense as follows: • Data analysis has shown that persons who receive larger first-time opioid prescriptions are more likely to become chronic-opioid users. • Increased-usage risk particularly occurs for first-time prescription for more than a five to seven-day supply. • Alaska Medicaid claims from last year indicate that at least half of all first-time opioid prescriptions had claims for more than a 15-day supply. • Dartmouth study indicates that opioid-prescribing practices vary from no drugs to 120 pills. 75 percent of all prescribed pills were never taken and remained in the patients' homes. DR. BUTLER related recent situations in Alaska where a student after surgery returned 120-Vicodin pills and another person requested drug-disposal bags after accumulating over 250-opioid pills after hip replacement where the pain was managed within the first 48 hours. He explained that SB 79 proposes that first-time opioid prescriptions observe the following: • Limited to no more than a 7-day supply. • Allows a waiver based on the provider's professional judgement for severe-acute pain, chronic pain, cancer pain, and palliative care. • Allows a waiver due to Alaska's travel logistics. • Seven-day-dispensing limit requires medical record documentation on why additional opioids are needed. He disclosed that the concept of accountable justification has been shown to improve the quality of drug usage. He added that the bill authorizes professional boards to require that continuing education be designated for pain management or the basics of addiction. He addressed opioid substance-use disorder as follows: • Nearly 10 percent of adults have some type of substance-use disorder. • Addiction is also a chronic-health condition that requires awareness throughout the medical profession. • The science of substance dependency and addiction is evolving fast and has been ignored by too many providers. • Concerns may be raised by providers regarding continual medical education (CME) credit: square4 Free online CME courses are available, square4 CDC has put out CME programs that focus on how to manage chronic pain, square4 Search for additional options for endorsements in meeting needs. He addressed the PDMP proposed in SB 79 as follows: • Emerging data shows reductions in overdose-death rates and Medicaid expenditures in states that require providers to use the PDMP database. • SB 79 authorizes the Department of Commerce to issue regular-unsolicited reports to prescribers. • SB 79 provides peer self-comparison reports as non-punitive feedback for providers' prescribing habits in comparison to peers. Ten states have peer self-comparison-report programs. • PDMP depends on timely data and the bill proposes to increase reporting intervals from weekly to daily. Twenty- five states require daily reporting intervals. • Daily reporting by smaller pharmacies in rural communities has been addressed and an implementation date in mid-2018 is proposed to provide more time to comply. • Requires veterinarians to register for the PDMP. Cases where people have intentionally injured animals in the Lower 48 to receive opioids have occurred. DR. BUTLER summarized that addressing Alaska's opioid epidemic is going take everyone. He quoted U.S. Congressman Hal Rogers as follows: There's no silver bullet to stem the tide of prescription drug abuse in America. The lack of an easy solution requires all of us to treat the opioid crisis as a non-partisan issue and adopt an all-hands- on-deck approach. He set forth that SB 79 is part of Alaska's call for all-hands- on-deck to support Alaskans living in recovery and reduce the number of persons who become newly dependent on opioids while supporting the care of those that truly need opioids. 4:06:54 PM SARAH CHAMBERS, Deputy Director of the Division of Corporations, Business and Professional Licensing (CBPL), Alaska Department of Commerce, Community and Economic Development, Juneau, Alaska, provided a sectional analysis on SB 79 as follows: Sec. 1:  Amends the Board of Dental Examiners statutes by requiring the board to adopt regulations for renewal of licensure to include a minimum of two hours of continuing education in pain management and opioid misuse and addiction in the previous two years preceding renewal, unless the licensee has demonstrated to the satisfaction of the board that the licensee does not currently hold a valid federal Drug Enforcement Agency (DEA) registration number.   Sec. 2:  Amends the Board of Dental Examiners statutes by requiring the board to adopt regulations for licensure qualifications to include a minimum of two hours of education in pain management and opioid misuse and addiction in the two years preceding the application for a license, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number Sec. 3:  Amends the Board of Dental Examiners statutes for disciplinary authority; it allows the board to discipline, revoke, suspend, reprimand or censure a license of a dentist, if the board finds a licensee has prescribed or dispensed an opioid in excess of the maximum dosage authorized under AS 08.36.355, or procured, sold, prescribed, or dispensed drugs in violation of a law, regardless of whether there has been a criminal action or patient harm.   Sec. 4:  Adds a new section to the Board of Dental Examiners statutes limiting the dosage for an opioid prescription to a seven-day supply for an adult or minor. The dentist must discuss with the parent or guardian of a minor why the prescription is necessary, and the risks associated with the opioid use. A dentist may issue a prescription for greater than a seven-day supply to an adult or minor patient if, in the professional judgement of the dentist, more than a seven-day supply is necessary for chronic-pain management or a patient who is unable to access a practitioner within the time necessary for a refill because of a logistical or travel barrier. The dentist must document in the patient's medical record the condition requiring the excess of a seven-day supply and indicate a non-opioid alternative was not appropriate to treat the condition. The section defines "adult" and "minor." Sec. 5:  Amends the Board of Dental Examiner statutes by adding a definition of an "opioid." Sec. 6:  Amends the Medical Board statutes for qualifications for physician assistants. The board shall adopt regulations for physician assistant to include education on pain management and opioid use and addiction. Sec. 7:  Amends the Medical Board statutes for qualifications for physicians. The additional language requires physician applicants to receive education in pain management and opioid use and addiction prior to licensure, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number.   Sec. 8:  Amends the Medical Board statutes for qualifications for osteopaths. The additional language requires osteopath applicants to receive education in pain management and opioid use and addiction prior to licensure, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number. The language in this section refers to the physician applicant qualifications in section 8, and duplication in (4) of the same statute. Sec. 9:  Amends the Medical Board statutes for qualifications for podiatrists. The additional language requires podiatry applicants to receive education in pain management and opioid use and addiction prior to licensure, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number. The language in this section refers to the physician-applicant qualifications in section 8, and duplication in (3) of the same statute. Sec. 10:  Amends the Medical Board statutes for qualifications for foreign graduates. The additional language requires foreign-graduate applicants to receive education in pain management and opioid use and addiction prior to licensure, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number. The language in this section refers to the physician applicant qualifications in section 8, and duplication in (a)(2)(B) of the same statute. Sec. 11: Amends the Medical Board statutes for License by credentials. The amendment includes the addition of qualifications for licensure of osteopath applicants. Sec. 12:  Amends the Medical Board statutes by adding a new subsection for qualifications for licensure by credentials for physicians, osteopaths and podiatrists by requiring the board to adopt regulations for applicants to include requiring the applicant to demonstrate professional competence in pain management and addiction disorders. The professional competence may include professional experience or professional instruction as proof of professional competence. Sec. 13:  Amends the Medical Board statutes for continuing education requirements for renewal of a license. A licensee of medicine, osteopathy, and podiatry must receive no less than two hours of education in pain management and opioid misuse and addiction for every 40 hours of instruction received, unless the licensee demonstrates to the satisfaction of the board that the licensee's practice does not include pain management and opioid treatment or prescribing. An applicant for renewal may not be exempted from the requirement to receive at least two hours of instruction on pain management and opioid misuse and addiction, unless the person has demonstrated to the satisfaction of the board that the person does not currently hold a valid federal DEA registration number. Sec. 14:  Amends Medical Board disciplinary authority. The board may impose a disciplinary sanction if the board finds that a licensee has prescribed or dispensed an opioid in excess of the maximum dosage. Sec. 15:  Adds a new section to the Medical Board statutes limiting the dosage for an opioid prescription to a seven-day supply for an adult or minor. The licensee must discuss with the parent or guardian of a minor why the prescription is necessary, and the risks associated with the opioid use. A licensee may issue a prescription for greater than a seven-day supply to an adult or minor patient if, in the professional judgement of the licensee, more than a seven-day supply is necessary for; an acute medical condition, chronic-pain management, pain associated with cancer, pain experienced while the patient is in palliative care, a patient who is unable to access a practitioner within the time necessary for a refill of the seven- day supply because of a logistical or travel barrier, or treatment of a patient's substance abuse or opioid dependence. The licensee must document in the patient's medical record the medical condition requiring the excess of a seven-day supply, and indicate a non-opioid alternative was not appropriate to treat the medical condition, or the substance abuse or opioid dependence. The section defines "adult," "emancipated minor," and "minor." Sec. 16:  Amends Medical Board statute for prescription of drugs without a physical examination. It adds the board may not impose disciplinary sanctions on a physician for prescribing, dispensing, or administering a controlled substance if the requirements in the new section AS 08.64.363, under Sec. 12 of this document, are met. 4:10:29 PM Sec. 17:  Amends Medical Board statute by adding and defining "opioid" to include the opium and opiate substances and opium and opiate derivatives listed in AS 11.71.140. Sec. 18:  Amends the Board of Nursing to provide authority to adopt regulation to comply with new continuing education requirements. Sec. 19:  Amends the Board of Nursing statute by giving the board the authority to deny, suspend, or revoke the license of a person who: prescribed or dispensed an opioid in excess of the maximum dosage authorized under AS 08.68.705; or has procured, sold, prescribed, or dispensed drugs in violation of a law, regardless of whether there has been a criminal action or patient harm. Sec. 20:  Amends the Board of Nursing statute to include enforcement authority for failure to meet regarding enforcement actions for continuing competency requirements. A license may not be renewed unless the advanced-practice-registered nurse has completed a minimum of two hours of education in pain management and opioid misuse and addiction within the two years preceding renewal of the license, unless the licensee has demonstrated to the satisfaction of the board that the licensee does not currently hold a valid federal DEA registration number. Sec. 21:  Adds a new section to article 6 of the Nursing Board statutes limiting the dosage for an opioid prescription to a seven-day supply for an adult or minor. The advance-practice-registered nurse must discuss with the parent or guardian of a minor why the prescription is necessary, and the risks associated with the opioid use. An advanced-practice-registered nurse may issue a prescription for greater than a seven-day supply to an adult or minor patient if, in the professional judgement of the advanced-practice- registered nurse, more than a seven-day supply is necessary for: an acute-medical condition, chronic- pain management, pain associated with cancer, pain experienced while the patient is in palliative care, or a patient who is unable to access a practitioner within the time necessary for a refill of the seven- day supply because of a logistical or travel barrier. The advanced-practice-registered nurse must document in the patient's medical record the condition requiring the excess of a seven-day supply, and indicate a non-opioid alternative was not appropriate to treat the condition. The section defines "adult," "emancipated minor," and "minor." Sec. 22:  Amends Nursing Board statute by adding and defining "opioid" to include opium and opiate substances and opium and opiate derivatives listed in AS 11.71.140. Sec. 23:  Amends the Board of Optometry to require the board to adopt regulations for advanced-practice-registered nurses to include education on pain management and opioid use and addiction. Sec. 24:  Amends the Board of Optometry statute for qualifications for licensure by credentials. The applicant must have received education in pain management and opioid misuse and addiction adequate for the practice of optometry and may include professional experience or professional education, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number. Sec. 25:  Amends the Board of Optometry statute for continuing education requirements for renewal of a license. The optometrist must complete a minimum of two hours of education in pain management and opioid misuse and addiction in the four years preceding renewal, unless the applicant has demonstrated to the satisfaction of the board that the applicant does not currently hold a valid federal DEA registration number. Sec. 26:  Amends the Board of Optometry disciplinary authority. The board may impose disciplinary sanctions on an optometrist who has procured, sold, prescribed, or dispensed drugs in violation of a law, regardless of whether there has been a criminal action or patient harm. Sec. 27: Amends powers and duties of the Board of Pharmacy, 08.80.030(b)(13). The current law that takes effect July 17, 2017, will require pharmacists with a DEA registration number, to register with the controlled- substance-prescription database (PDMP). Pharmacists do not obtain DEA registration numbers, only pharmacies; therefore, this section removes the DEA registration number requirement. Sec. 28: Amends the Board of Pharmacy statutes to add a new section to allow the pharmacist filling a prescription for a schedule II or III controlled substances, to dispense a lesser quantity than prescribed at the request of the individual for whom the prescription is written. Sec. 29: Amends the Board of Veterinary Examiners statute under powers and duties of the board. The board shall require a licensee who has a federal DEA registration number to register with the controlled substance prescription database under AS 17.30.200(o). The section requires the board to identify resources and develop educational materials to assist licensees in identifying an animal owner who may be at risk for abusing or misusing an opioid. Sec 30:  The board may deny, suspend, or revoke the license of a person who: prescribed or dispensed an opioid in excess of the maximum dosage authorized under AS 08.68.705; or has procured, sold, prescribed, or dispensed drugs in violation of a law, regardless of whether there has been a criminal action. Sec. 31:  The section allows an individual to execute a voluntary non-opioid directive in a format prescribed by the Department of Health and Social Services. The section further provides that a licensed-health-care providers, hospitals, and employees, and pharmacists are exempt from licensing board discipline, civil and criminal liability for failure to administer, prescribe, or dispense an opioid to an individual who has executed a voluntary non-opioid directive. The non-opioid directive does not limit a health-care provider or pharmacist from prescribing, dispensing, or administering an opioid overdose drug or an opioid for the treatment of substance abuse or opioid dependence. 4:13:59 PM Sec. 32: Amends AS 17.300.200(a) to exclude certain facilities from the requirements of the PDMP. This section references a section "u" of the PDMP (see section 41) where by correctional facilities are exempt from the PDMP except when prescribing opioids to an inmate at the time of the inmate's release as in-patient pharmacies and emergency rooms are exempt if they are only prescribing less than a 24-hour supply of opioids. (See also section 41). Sec. 33:  Amends AS 17.300.200(a) to exclude correctional facilities from the requirements of the controlled substance prescription database except when prescribing opioids to an inmate at the time of the inmate's release. Sec. 34: Amends AS 17.30.200(b) as amended by sec. 23, chapter 25, SLA 2016 by substituting "weekly" with "daily." The change will require the pharmacist-in-charge of a pharmacy, and each practitioner who dispenses a schedule II, III, or IV controlled substance, to submit the information to the controlled substance prescription database daily instead of weekly. Sec. 35:  Amends AS 17.30.200(d) as amended chapter 25, SLA 2016 to clarify that to clarify that information contained in the PDMP can be shared with federal, state, and local law enforcement that have a valid search warrant or court order. Sec. 36:  Amends AS 17.30.200(e) as amended by chapter 25, SLA 2016 to clarify that a pharmacist, the individual filling a prescription, is required to submit information into the database; it is the responsibility of the practitioner, the individual writing the prescription, to review the database. Sec. 37: Amends AS 17.30.200(p) as amended by chapter 25, SLA 2016 to require the Board of Pharmacy shall promptly notify the Board of Veterinary Examiners when a practitioner registers with the database under (o) of the section. Sec. 38: Amends AS 17.30.200(q) as amended by, chapter 25, SLA 2016 is amended by allowing the Board of Pharmacy to provide unsolicited notification to the practitioner's licensing board if a patient has received one or more prescriptions for controlled substances in quantities or with a frequency inconsistent with generally recognized standards of safe practice. The unsolicited notification to a practitioner's licensing board under the section must also be provided to the practitioner, is considered confidential, may not disclose confidential information under the section, and may be in a summary form sufficient to provide notice of the basis for the unsolicited notification. 4:17:04 PM Sec. 39:  Amends AS 17.30.200(r) as amended by chapter 25, SLA 2016 to provide guidance so to when the board must update the requirement that pharmacists and prescribers must comply with the database on a daily basis rather than a weekly basis. Sec. 40:  Amends AS 17.30.200(n) as amended by chapter 25, SLA 2016 to update the definition of opioid to include the opium and opiate substances and opium and opiate derivatives listed in AS 11.71.140. Sec. 41:  Adds a new section (t) to AS 17.30.200, giving the Board of Pharmacy the authority to issue periodic unsolicited "report cards" with non-identifiable information comparing the practitioner's opioid- prescribing practices with others in the same occupation. [Information is confidential]. Also adds a new section (u) to AS 47.17.200, giving the Board of Pharmacy the ability to exempt in-patient pharmacies and emergency rooms from the review and submission requirement of the PDMP when they are dispensing no more than a 24-hour supply of opioids upon discharge. Sec. 42:  Amends AS 18.05.040 to give authority for the Commissioner of Health & Social Services shall adopt regulations consistent with existing law for implementation of AS 13.55, Voluntary Non-opioid Directive Act. Sec. 43: Repeals various sections from chapter 25, SLA 2016 related to the July 2018 effective dates for the PDMP in SB 74. Sec. 44:  Provides transitional authority for the Department of Commerce and Economic Development to draft regulations to implement changes to the PDMP prior to the effective date of certain sections. This is a technical fix. Sections 45, 46, 47, 48, 49, 50:  Relate to the various changes to the PDMP related to the effective dates under SB 74. This is necessary because the changes to the PDMP under SB 74 are not in effect until July 18, 2017. Sec. 51:  New effective dates from the PDMP (July 1, 2018). Sec. 52:  The advanced directive sections of the bill (sections 1 and 4) take effect on July 1, 2019. Sec. 53:  All other provisions of the bill take effect immediately. 4:19:34 PM SENATOR MICCICHE noted that the seven-day supply applied to most of the providers, but asked if veterinarians were also limited to a seven-day supply. MS. CHAMBERS noted that optometrists have a four-day limit in statute and asked Ms. Kraly to address the supply limit for veterinarians. 4:20:17 PM STACY KRALY, Chief Assistant Attorney General, Alaska Department of Law, Juneau, Alaska, addressed opioid supply limits for veterinarians as follows: There is a similar provision within the bill as to a seven-day limit for veterinarians currently that is not included in the bill. SENATOR MICCICHE asked if veterinarians are currently statutorily limited to seven days for opioids. MR. KRALY replied no and specified as follows: No, the seven-day limit is being adopted in this legislation. Other boards, as Ms. Chambers mentioned, may have other limits and there's other guidelines that boards may follow, but this specific seven-day limit is as to boards that we have identified as having the ability to prescribe opioids, the seven-day limit is contained in this legislation. SENATOR MICCICHE noted that he will keep looking because he had not seen the seven-day limit for veterinarians in the bill. MS. KRALY answered that she thought the seven-day limit for veterinarians is an omission in SB 79. SENATOR GIESSEL confirmed that Senator Micciche did identify an omission. CHAIR WILSON asked how many pills are in a seven-day supply. He noted that the term seven-day supply is identified in the bill, but the specific number of pills is not addressed. 4:22:19 PM DR. BUTLER replied that the number of pills is dependent on the medication. CHAIR WILSON asked that when a patient is red-flagged by the database if the patient is notified in addition to the prescriber and pharmacist. MS. CHAMBERS answered that patients may request their history and information at any time. She specified that the idea behind the practitioner receiving notification is to have the option of notifying the patient. SENATOR BEGICH disclosed that opposition to the bill is related to the shortened time period for prescriptions and its impact on lifetime suffers of chronic pain. He asked if additions have recently been made to the bill that addressed patients with chronic pain. 4:24:22 PM DR. BUTLER replied that the provision that Senator Begich referenced is part of the original bill and the topic is frequently misunderstood. He specified that the bill does provide for the opportunity for waivers. He pointed out that the added step is a stop-check procedure for accountable justification. SENATOR BEGICH asked if a provider who has a number of chronic- pain clients could potentially have a bad report card. DR. BUTLER replied that the report card is not punitive. SENATOR BEGICH stated that he wanted to be sure that the report card does not have a dampening effect on providing relief and not creating any more obstacles for those with chronic pain. He noted that Senator Micciche brought up a good point regarding the veterinarian-limit omission and asked if the veterinarian omission needs to be corrected. DR. BUTLER answered that he would have to think about Senator Begich's question prior to answering. He explained that medication prescriptions for animals varies from humans. 4:27:18 PM SENATOR MICCICHE noted that Senate Finance is the next committee of assignment and asked Dr. Butler to address his question at that time. He pointed out that some Alaskans have chosen to obtain their opioids through veterinarians and the issue is something that the Legislature should deal with. MS. CHAMBERS added that since CBPL regulates the Board of Veterinary Examiners that she will pose the opioid prescription limitations to the board. CHAIR WILSON asked that Ms. Chambers provide the committee with the information she receives from the Board of Veterinary Examiners. MS. CHAMBERS replied that she will provide the committee with the information that Chair Wilson requested. CHAIR WILSON addressed the documentation required to prescribe additional opioids and asked why documentation for all opioid prescriptions is not required. 4:29:00 PM DR. BUTLER replied that in general the spirit of the bill is trying to do what Chair Wilson is suggesting in addition to keeping the administrative burden as small as possible. He asserted that the bill's focus is to really try and limit the prescriptions that are most dangerous which is dispensing the larger number of pills. CHAIR WILSON asked if the bill will add to the administrative costs for the prescribing practitioners. DR. BUTLER conceded that added documentation will occur. He specified that new requirements are not being imposed; however, current requirements are being earmarked to focus on. MS. CHAMBERS disclosed that the chair for the Board of Pharmacy members indicated that software makes the reporting change from weekly to daily minimal for his mom-and-pop pharmacy. 4:32:17 PM SENATOR GIESSEL said one of the things she thought about for the PDMP is perhaps having a small registration fee to help offset some of the cost. She asked if a fee has been considered. MS. CHAMBERS replied that a fee-proposal notification is about to be sent to the Legislature for consideration. She revealed that the fee being considered is very minimal compared to all of the other fees that are charged. She detailed that the proposed fee will take the onus off the pharmacists who have been bearing the weight of the PDMP because they were the ones required to use it. She noted that two grants have been obtained with a third application just completed to obtain federal funding for program expansion like the report-card feature. DR. BUTLER added that the customer service that providers who use PDMP are receiving is good. CHAIR WILSON said his hope is that the added cost from the bill is not a burden that is ultimately passed on to the end users, the customers. 4:35:09 PM CHAIR WILSON opened public testimony. 4:35:23 PM JONATHAN LARSON, representing self, Dillingham, Alaska, testified in support of SB 79. He shared his firsthand experience with the opioid epidemic in Dillingham. 4:37:46 PM DAN NELSON, Director of Pharmacy, Tanana Chiefs Conference, Fairbanks, Alaska, testified in support of SB 79. He pointed out that there is some question as to the definition of a "practitioner," particularly in section 36. He suggested that some intent language be put into the bill regarding the responsibilities of a practitioner versus a pharmacist. 4:39:27 PM MICHAEL CARSON, Chair, Mat-Su Opioid Task Force, Mat-Su Valley, Alaska, testified in support of SB 79. He pointed out that 80 percent of heroin users start with pain-opioid pills; 75 percent of those individuals get the pills from family members or friends. He said there has been a spike in heroin use over the past 5 years and disclosed that in 2016 there were 128-drug overdoses in the state with 40 percent attributed to heroin. He noted that fentanyl is a new drug in the mix that is 25 to 50 times more powerful than heroine. He said the Mat-Su Opioid Task Force is very much in favor of the seven-day supply based on the newest research that recently came out. 4:41:48 PM ROBIN MINARD, Director or Public Affairs, Mat-Su Health Foundation, Wasilla, Alaska, testified in support of SB 79. She said the Mat-Su Health Foundation believes SB 79 will save lives. She disclosed that 26 people died from heroin in Alaska in 2016 and 83 from prescription opioids. She set forth that the provisions from SB 79 can help ensure that the state's statistics are better in the future. She said limiting the quantity of opioid drugs that can initially be prescribed, requiring training for prescribers, and fully utilizing the PDMP will help ensure that all Alaskans have the opportunity for a healthy life. 4:43:55 PM DAVID REES, representing self, Eagle River, Alaska, testified in support of SB 79. He disclosed that he has submitted testimony that addresses personal issues regarding prescription opioids, specifically regarding chronic-pain management. He noted his family's concern regarding the bill's impact on access for individuals that use opioids for chronic pain as well as potentially higher costs. 4:46:19 PM TRACEY WIESE, Co-Chair, Alaska Advanced Practice Registered Nurse Alliance (APRN), Anchorage, Alaska, testified in support of SB 79. She said APRN supports most of the bill, but noted concerns about some of the language in the bill. She stated that APRN supports Senator Giessel's suggested amendments to ensure that nurse practitioners are listed specifically as licensed- individual practitioners. She said APRN's concern revolves around the educational requirement and specified that the language as currently written describes education for opioids, addictions, and recovery. She set forth that the concern pertains to the education language that could be interpreted as the provider needing education in opioids, addictions, and recovery rather than one or the other. She added that another concern relates to undue burden of sole proprietors, providers who have small businesses. She said APRN suggests that language be introduced that states "opiates" or a specific scheduled drug that was specifically for opiates. She added that APRN suggests that a sunset clause be included for the educational requirement so that the issue can be revisited in the upcoming years to see if the legislatively-mandated-educational requirement is necessary for providers. 4:49:38 PM TOM CHARD, Executive Director, Alaska Behavioral Health Association, Juneau, Alaska, testified in support of SB 79. He specified that the association represents all of the state's mental health and drug-and-alcohol providers, both tribal and non-tribal. He set forth that the association appreciates the Legislature's efforts paid to the opioid epidemic. He said the association sees the epidemic's effect on individuals, families, and communities. He emphasized that the association appreciates the prevention and early intervention approach that the SB 79 is taking. He called attention to the continued education requirements in the bill and opined that prescribers will benefit from the provision. 4:52:14 PM CHAIR WILSON closed public testimony on SB 79, and asked if there were amendments. 4:52:27 PM SENATOR GIESSEL moved Amendment 1: 30-GS1021\O.1 Bruce 5/5/17 AMENDMENT 1  OFFERED IN THE SENATE BY SENATOR GIESSEL TO: CSSB 79(L&C) Page 6, line 26: Delete "AS 11.71.140" Insert "AS 11.71.140 - 11.71.170" Page 15, line 6: Delete "AS 11.71.140" Insert "AS 11.71.140 - 11.71.170" Page 19, line 14: Delete "AS 11.71.140" Insert "AS 11.71.140 - 11.71.170" Page 27, line 28: Delete "AS 11.71.140" Insert "AS 11.71.140 - 11.71.170" Page 32, line 20: Delete "AS 11.71.140" Insert "AS 11.71.140 - 11.71.170" SENATOR VON IMHOF objected for the purposes of discussion. SENATOR GIESSEL explained Amendment 1 as follows: Looking at the bill I noted that if you turn to page 6, line 26, though this is repeated in multiple places in the bill, it calls out AS 11.71.140; this identifies schedule IA controlled substances which contain opioids in that list, but also in AS 11.71.160, that's schedule IIIA, there are also opioids identified. Simply for completeness I offer the amendment which adds AS 11.71.160 to the line that identifies the schedules that contain opioids. I have consulted with Dr. Butler on this and he acknowledges that this additional section does contain opioids as well. SENATOR BEGICH noted a procedural question and asked if the committee ever moved the legislation itself prior to moving an amendment. He inquired if the legislation has to be before the committee. SENATOR GIESSEL replied that not if the bill is in its first hearing. SENATOR BEGICH asked to confirm Senator Giessel's statement. SENATOR VON IMHOF removed her objection. 4:53:52 PM At ease 4:55:31 PM CHAIR WILSON called the committee back to order. He asked if there was any other discussion on Amendment 1, and if the objection was maintained. SENATOR VON IMHOF said she removed her objection. CHAIR WILSON announced that hearing no further objection, Amendment 1 passes. He asked if there were any further amendments. 4:55:54 PM SENATOR GIESSEL moved Amendment 2: 30-GS1021\O.2 Bruce 5/5/17 AMENDMENT 2  OFFERED IN THE SENATE BY SENATOR GIESSEL TO: CSSB 79(L&C) Page 21, line 18: Delete "four" Insert "two [FOUR]" SENATOR VON IMHOF objected for purposes of discussion. SENATOR GIESSEL explained Amendment 2 as follows: Page 21, line 18, this section refers to optometry, it refers to their continuing education requirements which are identical to the other clinicians in this bill; however, on line 18 it says that, "In the four years preceding the application for renewal, all of the professional licensees renew every two years." So this very old piece of statute needs to be updated to reflect every two-year license renewal; it does in effect double the amount of continuing education that is identified in this bill but that's not a problem either. SENATOR VON IMHOF announced that she removed her objection. CHAIR WILSON announced that hearing no further objection, Amendment 2 passes. He asked if there were any further amendments. 4:56:54 PM SENATOR GIESSEL moved Amendment 3: 30-GS1021\O.4 Bruce 5/5/17 AMENDMENT 3  OFFERED IN THE SENATE BY SENATOR GIESSEL TO: CSSB 79(L&C) Page 1, line 7, following "pharmacists;": Insert "relating to the definition of 'practitioner';" Page 26, following line 6: Insert a new bill section to read: "* Sec. 31. AS 11.71.900(19) is amended to read: (19)"practitioner" means (A) a physician, dentist, advanced practice registered nurse, veterinarian, scientific investigator, or other person licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to, or to administer or use in teaching or chemical analysis a controlled substance in the course of professional practice or research in the state; (B) a pharmacy, hospital, or other institution licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to, or to administer a controlled substance in the course of professional practice or research in the state;" Renumber the following bill sections accordingly. Page 29, line 2: Delete "sec. 33" Insert "sec. 34" Page 34, line 10: Delete "secs. 31 and 42" Insert "secs. 32 and 43" Page 34, line 16: Delete "sec. 34" Insert "sec. 35" Page 34, line 17: Delete "sec. 39" Insert "sec. 40" Page 34, line 19: Delete "secs. 34 and 39" Insert "secs. 35 and 40" Page 35, line 10: Delete "Section 32" Insert "Section 33" Page 35, line 12: Delete "Section 33" Insert "Section 34" Page 35, line 14: Delete "Section 35" Insert "Section 36" Page 35, line 16: Delete "Section 36" Insert "Section 37" Page 35, line 18: Delete "Sections 37 and 38" Insert "Sections 38 and 39" Page 35, line 20: Delete "Section 41" Insert "Section 42" Page 35, line 22: Delete "Section 1, 2, 6 - 13, 18, 20, 23 - 25, 34, and 39" Insert "Sections 1, 2, 6 - 13, 18, 20, 23 - 25, 35, and 40" Page 35, line 24: Delete "Sections 31 and 42" Insert "Sections 32 and 43" Page 35, line 25: Delete "secs. 45 - 53" Insert "secs. 46 - 54" SENATOR VON IMHOF objected for the purposes of discussion. SENATOR GIESSEL noted that the amendment has an error, but that it would be corrected. She explained Amendment 3 as follows: Page 6, line 15, a statute is identified, AS 11.71.900; this statute again is in the controlled substances section of criminal law just as the identification of those two schedules for drugs were. This is the definition section and it calls out the definition of the word "practitioner." In the definition which you see identified here in the amendment being inserted into section 31, "advanced practice registered nurse" is left out of the definition of "practitioner." As you can see on the printed amendment, a "practitioner" means, "A physician, dentist, advanced practice registered nurse (is added), veterinarian, scientific investigator, or other person;" essentially this is updating the definition of "practitioner" in criminal law under controlled substances. 4:58:48 PM SENATOR MICCICHE asked if Amendment 3 essentially becomes a conceptual amendment. SENATOR GIESSEL answered no and explained as follows: No, actually what I was calling out, and erroneously so, the first place that this appears in the bill is on page 6, line 15. You see on line 15 it says, "There has the meaning given in AS 11.71.900." So, I said what does the definition say? So, I looked it up and the drafter chose to insert this amendment, which is amending the definition of practitioner, into section 31, then renumber the rest of the bill sections accordingly. So, my mistake for saying the amendment was drafted incorrectly. SENATOR MICCICHE asked if the amendment replaces the old section 31 with section 32. SENATOR GIESSEL answered yes. SENATOR BEGICH asked if the title change is in the very first piece and is part of the title change. SENATOR GIESSEL answered yes. SENATOR VON IMHOF removed her objection. CHAIR WILSON announced that hearing no further objection, Amendment 3 passes. He asked if there were any further amendments. 5:00:20 PM SENATOR VON IMHOF moved to report the CS for SB 79, version O as amended, from committee with individual recommendations and attached fiscal note(s). SENATOR GIESSEL commented that she appreciated Senator Micciche identifying the apparent deficiency related to veterinarians. She said she looked forward to Senator Micciche addressing the veterinarian issue appropriately in the Senate Finance Committee. SENATOR MICCICHE stated appreciation for the legislation and shared the following: I was home for a day and I went to the Freedom House grand opening which is a project by a young woman who has a severe addiction for many years. All I can say is it is an amazing facility, she's an amazing young woman, but what I want to highlight is it's so easy to become addicted to opioids, but so impossibly difficult to turn your life around. So if this gets in the way of a single Alaskan, which I hope it has a much more substantial effect, even though there's an inconvenience to providers, I strongly support this legislation. SENATOR BEGICH clarified that he supports the legislation, but will be signing "amend" based on the comments from Senator Micciche. 5:02:00 PM At ease. 5:03:14 PM CHAIR WILSON called the committee back to order. He announced that without objection CSSB 79(HSS) moved from the Senate Health and Social Services Standing Committee. SENATOR BEGICH commented on the cycle of addiction as follows: I wanted to also echo my support of the legislation, but also in particular because in my family, two of my nephews are opiate addicts and the inability of them to break that cycle is shocking to me. One of them has been in the correctional system, has taken advantage of the drugs that are provided, I'm trying to remember the name of it, Vivitrol, which has been successful and for a year after he's out, he will be able to get his Vivitrol prescription and then it will run out, it will be $1200 a month and he will not be able to pay it, so he will become an addict again; I have actually spoken to him recently, he's going to do everything he can to keep that from happening, but that is an inevitable problem with addiction if you can't stop the process. So if this does what I hope Senator Micciche and I both believe that if it stops anybody from ever entering the system, it saves not just lives, but it saves our culture, it saves everything about what we value and for me this is very deeply personal. I want to just encourage us to get this thing through as fast as we can and stop the cycle of addiction. SENATOR GIESSEL commented on the encouraging evidence related to Vivitrol as follows: I would just add an encouraging note, the research evidence does tend to favor that after a year to 16 or 18 months on Vivitrol, actually the cycle can be broken and certainly with strong family support such as your relatives have, there is a high likelihood that they will emerge successful. CHAIR WILSON stated that he appreciated the administration's support in trying to curb in any possible way the opioid epidemic throughout Alaska's communities. He said he did not think that there is one Alaskan that the opioid epidemic has not touched in some way, shape or form of whether increased cost of someone's taxes to pay for law enforcement or knowing someone personally, or dealing with some type of issue related to the opioid epidemic. He thanked testifiers as well as members in the other body that are also working on the opioid issues to help stem the epidemic. [CSSB 79(HSS) was reported from the Senate Health and Social Services Standing Committee.] 5:06:10 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Committee at 5:06 p.m.