04/04/2019 03:00 PM House HEALTH & SOCIAL SERVICES

             HB 89-OPIOID PRESCRIPTION INFORMATION                                                                          
                                                                                                                                
3:31:03 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY  announced that  the  next  order of  business                                                               
would be HOUSE BILL NO. 89,  "An Act relating to the prescription                                                               
of opioids;  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; and relating                                                               
to the practice of pharmacy."                                                                                                   
                                                                                                                                
3:31:35 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
3:32:09 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR  moved  to   adopt  the  proposed  committee                                                               
substitute (CS)  for HB  89, labeled  31-LS0421\U, Fisher,4/3/19,                                                               
as the working draft.                                                                                                           
                                                                                                                                
CO-CHAIR ZULKOSKY objected for discussion.                                                                                      
                                                                                                                                
3:32:25 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ introduced  HB 89,  explaining that  this was                                                               
re-visiting  a  bill  that  had  previously  been  introduced  by                                                               
Representation Gara in 2018.  She  stated that the purpose of the                                                               
proposed bill was  to ensure that Alaska  did everything possible                                                               
to  reduce  access  to opioids  and  the  associated  unnecessary                                                               
risks.    She introduced  a  PowerPoint  titled "House  Bill  89:                                                               
Opioid Addiction Risk  Disclosure."  She reported  that there had                                                               
been 100 overdoses  from opioids in 2017, and  although there had                                                               
been  progress through  a prescription  drug monitoring  program,                                                               
easier disposal of opioids, and a  reduction of use, it was still                                                               
a  problem as  80 percent  of  addiction to  street level  heroin                                                               
began  with legally  prescribed opioids,  whether or  not it  was                                                               
their  legal prescription.   She  suggested that  it was  best to                                                               
flip  the conversation  and  begin with  an  introduction to  the                                                               
risks  associated  with opioids  before  they  were taken.    She                                                               
stated that the proposed bill  offered "a couple of opportunities                                                               
for a  patient to be  educated about  the risks of  addiction and                                                               
dependence on opioids  before they can consume it."   She allowed                                                               
that there  would be exclusions  for emergencies and  other times                                                               
when it  was not possible for  an informed consent.   She offered                                                               
her belief  that education should  take place at  multiple points                                                               
as research  had indicated  that it takes  multiple times  for an                                                               
individual  to   hear  a  message   before  the   information  is                                                               
internalized.     She   paraphrased   slide   3,  "Research   and                                                               
Statistics," which read:                                                                                                        
                                                                                                                                
     A recent  meta-analysis of research (Schmidt  & Eisend,                                                                    
     2015)  published in  the Journal  of Advertising  found                                                                    
     that  it  takes an  average  of  8-10 exposures  for  a                                                                    
     person to remember a concept.                                                                                              
          The  more often  a patient  hears a  message about                                                                    
     the  inherent risks  of opioids,  the more  likely they                                                                    
     are  to have  an increased  awareness of  the potential                                                                    
     dangers of physical dependence and addiction.                                                                              
                                                                                                                                
     Statistics on Opioid Misuse and Opioid Related Deaths:                                                                     
          Drug  overdose  was   Alaska's  leading  cause  of                                                                    
     accidental death  in 2016 (Alaska Department  of Health                                                                    
     and Social Services).                                                                                                      
          More than  3 out  of 5  drug overdoses  involve an                                                                    
     opioid (Centers for Disease  Control and Prevention, AK                                                                    
     DHSS).                                                                                                                     
          4  out  of 5  heroin  users  started out  misusing                                                                    
     prescription  opioids  (American Society  of  Addiction                                                                    
     Medicine).                                                                                                                 
                                                                                                                                
     New research  (Weinheimer, Michelotti,  Silver, Taylor,                                                                    
     & Payatakes, 2018) on effective pain management:                                                                           
          A   combination   of    Ibuprofen   200   mg   and                                                                    
     Acetaminophen  500 mg  is  approximately  3 times  more                                                                    
     effective  than 15  mg of  Oxycodone. (Dr.  Don Teater,                                                                    
     Teater Health Solutions).                                                                                                  
                                                                                                                                
CO-CHAIR SPOHNHOLZ moved on and paraphrased slide 4, "Goals of                                                                  
House Bill 89, which read:                                                                                                      
                                                                                                                                
     Reduce  the  use of  opioids  for  pain management  and                                                                    
     increase use  of non-opiate  pain management  tools and                                                                    
     medications.                                                                                                               
     Increase communication  about the dangers and  risks of                                                                    
     opioids.                                                                                                                   
     Decrease  opioid misuse  and  opioid-related deaths  in                                                                    
     Alaska.                                                                                                                    
     Mitigate  the  opioid   related  public  health  crisis                                                                    
     Alaska is currently facing.                                                                                                
     Provide a  positive example to  other states in  the US                                                                    
     that are facing similar public health crises.                                                                              
                                                                                                                                
3:36:45 PM                                                                                                                    
                                                                                                                                
MIRANDA DORDAN, Intern, Representative Ivy Spohnholz, Alaska                                                                    
State Legislature, paraphrased slide 5, "Section 1: Legislative                                                                 
Findings" which read:                                                                                                           
                                                                                                                                
     Legislative findings  hold that the state  has a moral,                                                                    
     financial,  and  public  health  interest  in  reducing                                                                    
     opioid and heroin addiction in Alaska.                                                                                     
                                                                                                                                
     Medically   documented  evidence   finds  that   opioid                                                                    
     prescription drugs can lead  to physical dependence and                                                                    
     potential addiction.                                                                                                       
                                                                                                                                
     Studies have shown that a  significant amount of heroin                                                                    
     users started as opioid drug users.                                                                                        
                                                                                                                                
     The Opioid  Epidemic increases crime in  the state, and                                                                    
     the presence  of heroin  dealers in  the state  poses a                                                                    
     public safety threat.                                                                                                      
                                                                                                                                
     Opioid  addictions  tear   families  apart,  destroy  a                                                                    
     person's ability to hold a job, and decimate lives.                                                                        
                                                                                                                                
     Addiction  treatment is  costly and  hard on  families,                                                                    
     affecting quality of life.                                                                                                 
                                                                                                                                
     Addiction treatment and  additional public safety costs                                                                    
     are also expensive for consumers and the state.                                                                            
                                                                                                                                
3:38:08 PM                                                                                                                    
                                                                                                                                
MS.  DORDAN paraphrased  slide 6,  "Section  2: Dentists,"  which                                                               
read:                                                                                                                           
                                                                                                                                
     Requires dentists  to inform patients of  the potential                                                                    
     addictive  dangers   of  opioids  and   any  reasonable                                                                    
     treatment   alternatives   using   oral   and   written                                                                    
     information before prescribing an opioid.                                                                                  
                                                                                                                                
     The  State Board  of Dental  Examiners  will craft  and                                                                    
     enforce  regulations that  satisfy  requirements of  HB
.                                                                                                                        
                                                                                                                                
MS. DORDAN directed  attention to a handout on  the Department of                                                               
Health and  Social Services website  as a visual aide  with great                                                               
information for opioid statistics specific to Alaska.                                                                           
                                                                                                                                
3:40:02 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  pointed out  that the  bill sponsors  did not                                                               
want to over prescribe the way  this should be implemented at the                                                               
Board  level,  but  to  instead,  allow each  of  the  Boards  to                                                               
identify for themselves  the best way to regulate  and manage the                                                               
information.   She emphasized  that the  sponsors only  wanted to                                                               
ensure  that  providers  in  Alaska   offered  oral  and  written                                                               
communication about the risks and alternatives.                                                                                 
                                                                                                                                
3:40:40 PM                                                                                                                    
                                                                                                                                
MS. DORDAN moved  on to paraphrase slide 7,  "Section 3: Medical,                                                               
Osteopathy, and Podiatry Providers," which read:                                                                                
                                                                                                                                
     Requires  Medical, Osteopathy,  and Podiatry  Providers                                                                    
     to inform  patients of the potential  addictive dangers                                                                    
     of  opioids and  any reasonable  treatment alternatives                                                                    
     using oral  and written information  before prescribing                                                                    
     an opioid.                                                                                                                 
                                                                                                                                
     The  State   Medical  Board  will  craft   and  enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:41:51 PM                                                                                                                    
                                                                                                                                
MS. DORDAN directed attention to  slide 8, "Section 4: Registered                                                               
Nurses," which read:                                                                                                            
                                                                                                                                
     Requires registered  nurses to  inform patients  of the                                                                    
     potential   addictive  dangers   of  opioids   and  any                                                                    
     reasonable  treatment   alternatives  using   oral  and                                                                    
     written information before prescribing an opioid.                                                                          
                                                                                                                                
     The  Alaska Board  of Nursing  will  craft and  enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:42:24 PM                                                                                                                    
                                                                                                                                
MS. DORDAN shared slide 9 "Section 5: Optometrists," which read:                                                                
                                                                                                                                
     Requires  optometrists   to  inform  patients   of  the                                                                    
     potential   addictive  dangers   of  opioids   and  any                                                                    
     reasonable  treatment   alternatives  using   oral  and                                                                    
     written information before prescribing an opioid.                                                                          
                                                                                                                                
     The State  Board of Examiners  in Optometry  will craft                                                                    
     and  enforce regulations  that satisfy  requirements of                                                                    
     HB 89.                                                                                                                     
                                                                                                                                
3:42:56 PM                                                                                                                    
                                                                                                                                
MS. DORDAN indicated slide 10 "Section 6: Pharmacists," which                                                                   
included the changes in the proposed committee substitute,                                                                      
Version U, which read:                                                                                                          
                                                                                                                                
     Requires   pharmacists  to   inform  patients   of  the                                                                    
     potential addictive  dangers of opioids using  oral and                                                                    
     written information before dispensing an opioid.                                                                           
                                                                                                                                
     The  Alaska Board  of Pharmacy  will craft  and enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:44:57 PM                                                                                                                    
                                                                                                                                
MS. DORDAN directed attention to slide 11 "Section: Visual Aid,"                                                                
which read in part:                                                                                                             
                                                                                                                                
     DHSS must create  a visual aid that  providers can hand                                                                    
     out  to   patients  when  they  are   being  prescribed                                                                    
     opioids.                                                                                                                   
                                                                                                                                
MS. DORDAN reiterated that the handout had already been created                                                                 
and was on the Department of Health and Social Services website.                                                                
                                                                                                                                
3:46:16 PM                                                                                                                    
                                                                                                                                
MS. DORDAN shared the references  and letters of support on slide                                                               
12,  "Letters  of  Support:" which  included  the  Alaska  Dental                                                               
Society and Fallen Up Ministries.                                                                                               
                                                                                                                                
3:46:37 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON offered her  belief that doctors had taken                                                               
an  oath  to do  everything  within  their  power to  keep  their                                                               
patients healthy  and that  there was  a federal  requirement for                                                               
doctors to explain each drug and  its side effects.  She asked if                                                               
the proposed bill  was requiring the state to  manage doctors for                                                               
how they inform and educate their patients.                                                                                     
                                                                                                                                
3:47:37 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ explained that  the proposed bill was designed                                                               
to add  another layer of  education for  patients.  She  shared a                                                               
personal  experience  with  opioids   and  noted  that  the  bill                                                               
proposed to begin the conversation  in the health care provider's                                                               
office.   She  offered her  belief that  more conversation  would                                                               
reduce   the  number   of  opioids   prescribed,  consumed,   and                                                               
distributed into our communities.                                                                                               
                                                                                                                                
3:49:34 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JACKSON  acknowledged  awareness for  the  opioid                                                               
crisis, with  a variety of  organizations enforcing  education on                                                               
opioids.   She  asked for  clarification that  Co-Chair Spohnholz                                                               
had been offered medications without any education.                                                                             
                                                                                                                                
CO-CHAIR SPOHNHOLZ replied  that she had been  offered opioids by                                                               
a full range of medical professionals.                                                                                          
                                                                                                                                
REPRESENTATIVE JACKSON  asked if  the proposed bill  would ensure                                                               
monitoring through the various Boards  that doctors were offering                                                               
this education.                                                                                                                 
                                                                                                                                
CO-CHAIR SPOHNHOLZ replied  that the intent of  the proposed bill                                                               
was to  require medical personnel  to educate patients  about the                                                               
risks associated  and give them  printed materials to  take home.                                                               
The  proposed  bill  would  give  the power  to  the  Boards  for                                                               
enforcement.  She  emphasized that it was not  intended to define                                                               
in law  specific steps  that should  be taken.   She  offered her                                                               
belief  that  a   way  to  build  consensus  was   to  allow  the                                                               
professionals to determine the best way to regulate and enforce.                                                                
                                                                                                                                
3:51:51 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JACKSON  acknowledged  that  "the  idea  and  the                                                               
intention is  fabulous" but asked  if there had  been discussions                                                               
with  the various  boards for  a timeframe.   She  suggested that                                                               
enforcement legislation  may be necessary  if the boards  did not                                                               
comply.                                                                                                                         
                                                                                                                                
CO-CHAIR SPOHNHOLZ  shared the history  of a prior  compromise to                                                               
allow  Department of  Health and  Social Services  to create  and                                                               
distribute information.   However,  it had  been decided  that it                                                               
was time  to introduce legislation,  as the boards had  a limited                                                               
scope of responsibility and needed a  law in order to take on new                                                               
regulations.    She  stated  that   she  had  been  talking  with                                                               
providers to craft a bill  that was practical while achieving the                                                               
public health goal for reduction of opioid dependence.                                                                          
                                                                                                                                
3:53:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  directed  attention   to  slide  2  and                                                               
expressed  her surprise  regarding the  combination of  ibuprofen                                                               
and acetaminophen  as three  times more effective  than 15  mg of                                                               
oxycodone.  She  asked if this was a  prescription combination or                                                               
was it available over the counter.                                                                                              
                                                                                                                                
CO-CHAIR  SPOHNHOLZ explained  that the  combination was  a legal                                                               
over  the counter  level  for  each of  those  medications.   She                                                               
acknowledged  that this  combination was  so much  more effective                                                               
than opioids.                                                                                                                   
                                                                                                                                
3:55:44 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  directed  attention   to  slide  3  and                                                               
expressed that she was impressed  with the 36 percent decrease in                                                               
opioid  overdoses   and  a  67   percent  decrease   in  fentanyl                                                               
overdoses.  She asked if each overdose resulted in death.                                                                       
                                                                                                                                
CO-CHAIR  SPOHNHOLZ clarified  that these  were overdose  related                                                               
deaths and not just overdoses.   She reported that overdose death                                                               
had  decreased with  the  broad distribution  of  naloxone as  it                                                               
allowed emergency responders to reverse an overdose.                                                                            
                                                                                                                                
3:57:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  referred to  slide  7  and asked  about                                                               
exemptions for palliative and hospice care.                                                                                     
                                                                                                                                
MS.  DORDAN  explained that  these  exemptions  could be  offered                                                               
although ultimately the Board would decide who was exempt.                                                                      
                                                                                                                                
CO-CHAIR SPOHNHOLZ  added that,  as the  delivery of  health care                                                               
was  very complex,  it was  the intention  not to  define in  law                                                               
exactly where the education should  take place and that, instead,                                                               
the medical  professionals make  that decision.   She  noted that                                                               
the  implementation  could  be  addressed  later  if  there  were                                                               
concerns.                                                                                                                       
                                                                                                                                
3:59:12 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  pointed  to  slide 9  and  asked  about                                                               
treatments performed by optometrists which required an opioid.                                                                  
                                                                                                                                
CO-CHAIR SPOHNHOLZ  explained that,  although it was  not routine                                                               
care,  optometrists could  perform  some  minor procedures  which                                                               
could create some  pain and necessitate the  prescription of pain                                                               
medication.                                                                                                                     
                                                                                                                                
4:00:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY removed her objection.   There being no further                                                               
objection,  the proposed  committee  substitute (CS)  for HB  89,                                                               
labeled 31-LS0421\U,  Fisher,4/3/19, was  adopted as  the working                                                               
draft.                                                                                                                          
                                                                                                                                
4:01:05 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
4:01:22 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY said she would keep public testimony open.                                                                    
                                                                                                                                
[HB 89 was held over.]