02/27/2020 03:00 PM House HEALTH & SOCIAL SERVICES

        HB 184-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN                                                                    
                                                                                                                                
4:27:34 PM                                                                                                                    
                                                                                                                                
CHAIR ZULKOSKY announced  that the final order  of business would                                                               
be HOUSE BILL  NO. 184, "An Act exempting  veterinarians from the                                                               
requirements of the controlled substance prescription database."                                                                
                                                                                                                                
4:27:59 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE   DAVE   TALERICO,   Alaska   State   Legislature,                                                               
introduced  HB 184  and paraphrased  from  the Sponsor  Statement                                                               
[Included in members' packets], which read:                                                                                     
                                                                                                                                
     HB  184  is  proposed   to  exempt  Veterinarians  from                                                                    
     Prescription Drug Monitoring Programs (PDMPs).                                                                             
                                                                                                                                
     Prescription  Drug  Monitoring  Programs  (PDMPs)  were                                                                    
     designed for  use in human medicine  to identify doctor                                                                    
     shopping  by  human  patients  and  monitor  trends  in                                                                    
     prescribing   practices  by   health  care   providers.                                                                    
     Veterinarians want  to be part  of the solution  of the                                                                    
     opioid  crisis, but  PDMPs have  not been  an effective                                                                    
     mechanism to do this.                                                                                                      
                                                                                                                                
     By mandating  that veterinarians  query and  report the                                                                    
     owner's name  and date of birth,  there are significant                                                                    
     concerns  about  potential  violations  of  privacy  of                                                                    
     human  medical   information.  Veterinarians   are  not                                                                    
     trained   in  privacy   regulations  concerning   human                                                                    
     medical  data,  nor  are they  trained  in  appropriate                                                                    
     medications, doses, or  prescribing practices for human                                                                    
     medicine. As we have  talked informally with pet owners                                                                    
     and others  in the general  public, they are  not aware                                                                    
     that their  veterinarian would have access  to any part                                                                    
     of their medical information and  are dismayed to learn                                                                    
     this.                                                                                                                      
                                                                                                                                
     Animal  patients   themselves  cannot   be  effectively                                                                    
     tracked  through PDMPs.  Animals do  not have  a unique                                                                    
     identifier  such as  a social  security number  or even                                                                    
     date of  birth. The animal's  name may be  changed over                                                                    
     time, the  date of  birth is often  not known,  and the                                                                    
     owner may change over time.                                                                                                
                                                                                                                                
     One national survey  found that fewer than  10 cases of                                                                    
     veterinary  shopping  occur   annually  in  the  United                                                                    
     States  and  concluded  that "veterinarians  are  a  de                                                                    
     minimus  source of  controlled substances."  Even those                                                                    
     few   cases  of   veterinary  shopping   are  typically                                                                    
     identified   by  the   veterinarians  themselves,   not                                                                    
     through PDMPs.  In 2017 veterinarians  prescribed 0.34%                                                                    
     of all  the opioids  dispensed by retail  pharmacies in                                                                    
     the   country  (source   IQVIA  National   Prescription                                                                    
     Audit).                                                                                                                    
                                                                                                                                
     Exempting   veterinarians  from   the  PDMP   will  not                                                                    
     diminish  the judicious  use  of controlled  substances                                                                    
     that   is  already   practiced  by   veterinarians  and                                                                    
     regulated by the Drug Enforcement  Agency and the state                                                                    
     licensing board. Exempting  veterinarians from the PDMP                                                                    
     will   allow  veterinarians   to  provide   timely  and                                                                    
     appropriate  medical  management  for  each  individual                                                                    
     patient.  It  may save  state  funds  and increase  the                                                                    
     efficiency  of the  PDMP for  its  intended purpose  by                                                                    
     allowing   for   more    accurate   interpretation   of                                                                    
     prescription  data  and  prescribing  trends  in  human                                                                    
     medicine.                                                                                                                  
                                                                                                                                
     Over  30  states  currently exempt  veterinarians  from                                                                    
     PDMP requirements.  Several of those  states originally                                                                    
     required veterinarians to report to the PDMP but have                                                                      
       since exempted veterinarians for many of the same                                                                        
     reasons described above.                                                                                                   
                                                                                                                                
4:31:04 PM                                                                                                                    
                                                                                                                                
CHAIR  ZULKOSKY asked  about the  percentage  rate in  commercial                                                               
pharmacies.                                                                                                                     
                                                                                                                                
REPRESENTATIVE  TALERICO  stated  that,  in  2017,  veterinarians                                                               
prescribed 0.34  percent of all  the opioids dispensed  by retail                                                               
pharmacies in  the country.   In response  to Chair  Zulkosky, he                                                               
said that he did not have the hard number for this percentage.                                                                  
                                                                                                                                
4:32:00 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ  asked  what  percentage  veterinarians                                                               
were of the total prescribers in the country.                                                                                   
                                                                                                                                
REPRESENTATIVE TALERICO deferred to later testifiers.                                                                           
                                                                                                                                
REPRESENTATIVE CLAMAN asked about  the percentage of prescription                                                               
dispensing veterinarians  in Alaska relative  to the rest  of the                                                               
country.                                                                                                                        
                                                                                                                                
REPRESENTATIVE TALERICO replied that he did not know.                                                                           
                                                                                                                                
REPRESENTATIVE CLAMAN  asked whether the veterinarians  were also                                                               
the dispensers.                                                                                                                 
                                                                                                                                
REPRESENTATIVE TALERICO offered his  belief that it was necessary                                                               
to be a licensed pharmacy to dispense an opioid.                                                                                
                                                                                                                                
4:34:52 PM                                                                                                                    
                                                                                                                                
DR.  SARAH COBURN,  President,  Alaska  State Veterinary  Medical                                                               
Association  (AKVMA),  stated  the   AKVMA  was  "a  professional                                                               
association   dedicated   to   promoting   the   excellence   and                                                               
professionalism of  Alaska veterinarians in advancing  the health                                                               
and well being  of animals in the public."   She declared support                                                               
of  the proposed  bill,  as it  would  exempt veterinarians  from                                                               
participating in  the state Prescription Drug  Monitoring Program                                                               
(PDMP).   She  stated  that the  veterinary  community wanted  to                                                               
contribute to  solutions to the opioid  crisis, but participation                                                               
in  a program  designed for  use by  humans was  not appropriate.                                                               
She  reported that  more than  30  states exempted  veterinarians                                                               
from  the PDMP  requirements, and  some states  have now  enacted                                                               
legislation  which   removed  veterinarians   from  participation                                                               
because  their  inclusion  has  not   proven  to  be  helpful  in                                                               
addressing the human opioid epidemic.                                                                                           
                                                                                                                                
DR.   COBURN   listed   numerous  reasons   for   not   requiring                                                               
veterinarians  to search  or report  information  into the  PDMP,                                                               
including  that animal  patients cannot  be effectively  tracked,                                                               
and veterinarians are not trained  to evaluate human prescription                                                               
information or  in privacy  regulations concerning  human medical                                                               
data.   She added that  most pet owners  were not aware  that the                                                               
licensed  veterinary  technician  was  the  delegated  person  to                                                               
access the  personal medical prescription history,  considered an                                                               
invasion of privacy  by many people.  She  expressed concern that                                                               
information entered the  PDMP for animal patients  would skew the                                                               
data and place  a disproportionate cost and  burden on veterinary                                                               
clinics  as small  business owners.    She pointed  out that  the                                                               
information  had  to  be submitted  manually  as  the  veterinary                                                               
software did not  interface with the PDMP.  She  pointed out that                                                               
exempting veterinarians  would not diminish the  effectiveness of                                                               
the PDMP  program.  She  acknowledged that although  opioids were                                                               
used by  veterinarians, these were  used for  surgical procedures                                                               
and anesthesia.  She pointed  out that veterinarians still had to                                                               
meet strict  security, record  keeping, and  storage requirements                                                               
of controlled substances.   She added that the  DEA monitored the                                                               
flow  of  controlled substances.    She  concluded, offering  her                                                               
belief the exemption  of veterinarians from using  the PDMP would                                                               
not weaken  the success  of the program  or affect  the judicious                                                               
and   highly   regulated   use  of   controlled   substances   by                                                               
veterinarians.  She reiterated that the AKVMA supported HB 184.                                                                 
                                                                                                                                
REPRESENTATIVE  CLAMAN asked  if  the  statistics she  referenced                                                               
were for Alaska.                                                                                                                
                                                                                                                                
DR. COBURN said  that these were recent statistics  from the PDMP                                                               
annual report for each profession in Alaska.                                                                                    
                                                                                                                                
REPRESENTATIVE   CLAMAN   asked   if  veterinary   clinics   were                                                               
considered retail pharmacies.                                                                                                   
                                                                                                                                
DR. COBURN said, "they are not."                                                                                                
                                                                                                                                
4:42:53 PM                                                                                                                    
                                                                                                                                
DR. JIM  DELKER, Alaska State Veterinary  Medical Association, in                                                               
response to  Representative Claman,  he said that  a prescription                                                               
for  a pet  could  be  filled either  by  the  veterinarian or  a                                                               
pharmacist.    He  declared  that   most  veterinarians  had  the                                                               
pharmacy  fill  the  prescription  for  opiates  to  relieve  the                                                               
veterinarian  of  the  pressures  to  report.    In  response  to                                                               
Representative Claman,  he said  that who dispensed  a medication                                                               
would  depend  on the  drug.    He  pointed  out that  the  drugs                                                               
indicated  in more  drug overdoses  such as  oxycontin, Percocet,                                                               
and Vicodin were not commonly dispensed by veterinarians.                                                                       
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  for  clarity  for  the  difference                                                               
between prescribing and dispensing.                                                                                             
                                                                                                                                
DR.  DELKER  said that  he  would  write  a prescription  to  the                                                               
pharmacy  for a  medication they  did  not carry,  noting that  a                                                               
controlled substance had to have  a written prescription, whereas                                                               
an antibiotic did not.                                                                                                          
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  if veterinarians  dispensed  small                                                               
quantities of opioid medication from their clinic.                                                                              
                                                                                                                                
DR. DELKER  replied that  the majority  of those  were sent  to a                                                               
retail pharmacy.                                                                                                                
                                                                                                                                
CHAIR  ZULKOSKY  asked  if Alaska  veterinarians  could  dispense                                                               
opioids within the clinic.                                                                                                      
                                                                                                                                
DR. COBURN said, "yes."                                                                                                         
                                                                                                                                
CHAIR ZULKOSKY  asked about the  percentage of  opioids dispensed                                                               
from a clinic before using a commercial pharmacy.                                                                               
                                                                                                                                
DR. COBURN  said that she  would follow up  for the number.   She                                                               
stated   that  opioids   were  in   limited   use  as   take-home                                                               
medications, that most opioids were  used in the hospital related                                                               
to surgical procedures and were not to be dispensed.                                                                            
                                                                                                                                
CHAIR ZULKOSKY  pointed out  that the  PDMP illuminated  the data                                                               
for opioid  prescriptions.  She expressed  her understanding that                                                               
there were  conditions for  opioids dispensed in  a clinic.   She                                                               
asked how  often Alaska veterinarians used  commercial pharmacies                                                               
versus directly dispensing controlled substances.                                                                               
                                                                                                                                
DR. COBURN said that she would research that.                                                                                   
                                                                                                                                
CHAIR  ZULKOSKY  shared  an  anecdote   that  animal  owners  had                                                               
intentionally  harmed  an  animal  in  order  to  drug  shop  for                                                               
controlled  substances,  and she  asked  if  there was  mandatory                                                               
reporting in Alaska for suspicion of animal abuse.                                                                              
                                                                                                                                
DR.  COBURN stated  that there  was not  mandatory reporting  but                                                               
that it was authorized to report without any privacy concerns.                                                                  
She declared  that animal abuse  was illegal in Alaska,  and that                                                               
ethical  conduct  would  lead  a veterinarian  to  report  to  an                                                               
appropriate  authority  if  there  was  concern  for  intentional                                                               
injury.    She  stated  that,  as it  was  necessary  to  have  a                                                               
veterinarian-client/patient  relationship, the  standard of  care                                                               
in veterinary medicine was for  an in-person physical examination                                                               
of the  animal to establish  that relationship.  She  shared that                                                               
the PDMP was not designed for animal data.                                                                                      
                                                                                                                                
CHAIR ZULKOSKY asked  about the training or  guidance provided to                                                               
veterinarians to utilize the PDMP.                                                                                              
                                                                                                                                
4:52:23 PM                                                                                                                    
                                                                                                                                
MS. CHAMBERS  explained that when  the PDMP became  mandatory for                                                               
all  prescribing  professions  and  pharmacists,  which  included                                                               
veterinarians,  the   Board  of  Veterinary  Examiners   had  the                                                               
authority  and ability  to work  with  the Board  of Pharmacy  to                                                               
write the regulations to figure these  out.  She declared that it                                                               
had  been a  struggle for  the Board  of Veterinary  Examiners to                                                               
wrestle with these issues for how  to make it work.  She reported                                                               
that these efforts  to make it work did not  progress, and, since                                                               
2018, there had  not been an attempt at a  regulations project or                                                               
a move to adapt the technology.                                                                                                 
                                                                                                                                
CHAIR  ZULKOSKY  reiterated  that  there was  not  broad  support                                                               
provided to  users of the PDMP  by the Department to  ensure they                                                               
had what was necessary to access or provide information.                                                                        
                                                                                                                                
MS. CHAMBERS  pointed out  that the  PDMP was  primarily designed                                                               
for human use.   When the Board of  Veterinary Examiners reviewed                                                               
the  statutes, they  realized  that,  with the  way  the law  was                                                               
written and the  way the technology was set up,  it was necessary                                                               
for more work  to understand how to advise their  licensees.  She                                                               
stated  that it  was not  possible  for her  department to  train                                                               
licensees until the Board of  Veterinary Examiners worked through                                                               
these problems with regulation and technology changes.                                                                          
                                                                                                                                
4:55:49 PM                                                                                                                    
                                                                                                                                
DR. SCOTT  FLAMME, Board of  Veterinary Examiners,  reported that                                                               
he had  been practicing in Fairbanks  for the past 17  years.  He                                                               
declared that 38  states had now exempted  veterinarians from the                                                               
PDMP.  He  acknowledged the difficulty for using a  data base for                                                               
animal data that  was designed for humans, and  shared that other                                                               
states had this same struggle.   He emphasized that it "just does                                                               
not  work."   He  declared  that  veterinarians cared  about  the                                                               
opioid  epidemic and  wanted to  do  their part  to help  prevent                                                               
addiction and  to prevent any harm  to Alaskans.  He  pointed out                                                               
that veterinarians in Alaska only  prescribed 0.34 percent of the                                                               
controlled  substances.    He  offered an  analogy  of  buying  a                                                               
$60,000 pickup  truck to plow  a driveway  that was 12  feet long                                                               
and 5 feet  wide., adding that it  did not make any  sense as the                                                               
data was not helpful.                                                                                                           
                                                                                                                                
DR. FLAMME  stated that the  PDMP was  costly to the  public, and                                                               
that the  public was shocked  when it learned  that veterinarians                                                               
who  had no  training  in  human medicine  or  privacy laws  were                                                               
mandated to access the private  health data before prescribing to                                                               
an  animal  patient.    He  added that  the  public  was  equally                                                               
dismayed when their  PDMP risk scores were altered  because of an                                                               
animal prescription, as  the assessments included a  mix of human                                                               
and animal data.  He stated that  the cost to the public would be                                                               
borne out with an increase in  the shortage of veterinarians.  He                                                               
pointed out  that the Board  of Veterinary Medical  Examiners was                                                               
mandated to  investigate and discipline veterinarians  who failed                                                               
to   correctly   use   the   PDMP,   while   paying   for   those                                                               
investigations.  He  noted that Alaska had  the highest licensing                                                               
fees for  veterinarians in the  United States.  He  urged support                                                               
for HB 184.                                                                                                                     
                                                                                                                                
5:00:21 PM                                                                                                                    
                                                                                                                                
HB 184 was held over.