Legislature(2017 - 2018)BELTZ 105 (TSBldg)
03/14/2017 01:30 PM Senate LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB4 | |
| SB16 | |
| SB32 | |
| SB64 | |
| SB79 | |
| SB37 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | SB 64 | TELECONFERENCED | |
| *+ | SB 79 | TELECONFERENCED | |
| *+ | SB 37 | TELECONFERENCED | |
| += | SB 4 | TELECONFERENCED | |
| += | SB 16 | TELECONFERENCED | |
| += | SB 32 | TELECONFERENCED | |
SB 79-OPIOIDS; PRESCRIPTIONS; DATABASE; LICENSES
2:11:23 PM
CHAIR COSTELLO announced the consideration of SB 79. She noted
that the bill was introduced on behalf of Governor Walker. SB 79
helps address a major issue facing Alaska, an opioid epidemic.
It is a national epidemic. She provided an example from the New
York Times about a farmer who lost two children to opioids. She
said this type of addiction can lead to heroin abuse and
staggering problems across the country. Deaths related to opioid
abuse have increased three-fold in the past seven years.
She said SB 79 looks at a strategy in Alaska to prevent
prescription pain killer abusers from becoming heroin users. In
2008 the legislature established a controlled substance database
known as the Alaska Prescription Drug Monitoring Program. Last
year the legislature identified ideas to help combat this issue
through managing patient data. She shared another example of a
parent in Juneau who lost a son in January. She maintained that
the state has a moral obligation to address this issue because
of the tremendous impact it is having on Alaska.
She said this is the first hearing of SB 79. The intent is to
hear from the sponsor, take members' questions, take public
testimony, and then hold the bill for further consideration.
2:13:20 PM
DR. JAY BUTLER, Chief Medical Officer, Department of Health and
Social Services, commented that Chair Costello has nicely
outlined the reason for hearing SB 79. He noted the increasing
number of deaths due to opioid overdose, which has mirrored the
increase in the rate of prescribing opioid pain relievers.
Alaska is at a point where many people are dependent on or
addicted to opioids and are more susceptible to heroin and
fentanyl abuse. About 80 percent of those using heroin started
their addiction by using prescription painkillers.
DR. BUTLER spoke of an increase in rates of hepatitis C
associated with drug use and more emergency room admissions. He
emphasized that "all statistics are people with tears wiped
away." He said that, today, most everyone has been touched by
the opioid epidemic.
2:15:13 PM
DR. BUTLER highlighted the need to address overdose, treatment
of addiction, addiction as a chronic health condition, and
prevention, including limiting legal and illegal opioids,
involving law enforcement, curbing overprescribing, and
addressing why people self-medicate. The bill is part of the
larger response and is designed to encourage more evidence-based
prescribing and limit the flood of opioid painkillers into
communities. It intends to increase access to treatment and de-
stigmatization by improving provider knowledge. SB 79 aligns
with guidelines in SB 74 by healthcare boards, as well as with
the Centers for Disease Control Pain Management Guidelines, the
Surgeon General's Report on Alcohol Drugs and Health, and recent
statements from the American Medical Association and the
American Dental Association.
2:16:50 PM
DR. BUTLER said SB 79 provides an option for patients who do not
wish to be prescribed opioids to communicate their preference to
their providers by way of a voluntary, revocable, opioid advance
directive. This was a suggestion from the recovery community. It
also allows patients to request from pharmacists, less than the
total prescribed amount.
He said SB 79 requires that five percent of providers'
continuing education credits be committed to pain management and
addiction. The bill sets limits on the initial opioid
prescription to a seven-day supply. Exceptions can be made by
providers in certain instances.
SB 79 includes changes to the Prescription Drug Monitoring
Program (PDMP), a centralized database where providers can go to
look at a patient's prescription history. The bill authorizes
the Pharmacy Board to issue routine, periodic, confidential
reports to prescribers to provide feedback on their prescribing
practices. He referred to a recent report in the New England
Journal of Medicine that, using the Medicare Part D database,
looked at prescribing habits of emergency room physicians.
People who received opioids in the emergency department were
more likely to have dependency a year later. There was a three-
fold variation in the rate of prescribing opioids, which clearly
demonstrated a lack of agreement among providers as to how to
manage acute pain.
He named states that have been effective in reducing the number
of excessive prescriptions due to the non-punitive reports
issued to providers.
2:20:20 PM
DR. BUTLER spoke of two controversial aspects of the bill. One
requires veterinarians who prescribe opioids to register and use
the PDMP. The second controversial aspect is requiring daily
updates of the PDMP to make it a more useful tool.
2:21:25 PM
CHAIR COSTELLO noted that Public Safety Commissioner Walt
Monegan is present and showing support for the bill.
DR. BUTLER continued to say that 25 states have the requirement
of daily updates of the PDMP.
He stressed that the bill does not place blame. The goal is for
everyone to be responsible for owning the problem and doing
their part to address it.
2:22:52 PM
CHAIR COSTELLO requested the sectional analysis.
2:23:13 PM
DR. BUTLER presented the following sectional analysis for SB 79:
Sec. 1 Adds a new Chapter 55, Voluntary Nonopioid
Directive Act, to AS 13, Decedents' estates,
guardianships, transfers, trusts, and health care
decisions, that provides an option for patients to
execute a Voluntary Nonopioid Directive that would
allow a person in recovery (or for other reasons) to
make clear the person's desire not to be administered
an opioid. A person, guardian, conservator or other
appointed person may revoke a directive at any time.
The person would provide this confidential information
to a health care provider or hospital on a form
provided by the Department of Health of Social
Services. The department would promulgate regulations
on procedures, confidentiality, and exemptions for
emergency or substance misuse treatment. Providers are
not liable for following a directive. Prescriptions
are assumed to be valid; pharmacists are not liable
for dispensing a controlled substance in contradiction
to a directive. The directive does not alter an
advance health care directive, limit opioid overdose
drugs, or limit treatment for substance abuse or
opioid dependence.
CHAIR COSTELLO asked if there are alternatives to opioids that
doctors can use.
DR. BUTLER said there are. He described the evolution over the
past 20 years where opioids have become the first line of
treatment for all pain. He noted the influence of market forces
and the four-fold increase in prescribing and abuse, with no
decrease in the level of pain. Physical dependency is also a
factor.
He shared that there are updated clinical guidelines for back
pain by the American College of Physicians. Now, opioids are
given as the third line of pain relief, starting with something
like Tylenol and physical therapy.
2:26:11 PM
CHAIR COSTELLO noted that the bill will be in committee again
for further discussion.
SENATOR HUGHES thanked Dr. Butler and expressed appreciation of
the Governor's concern about the opioid crisis. She discussed
liberal prescribing practices in the 90s and noted that today
most doctors use opioids as a last resort. She asked how
extensive overprescribing is today.
DR. BUTLER opined that all providers use more opioids today than
five years ago. He said overprescribing is spread across the
profession nationally, but primary care providers prescribe more
than half of all opioids. He pointed out that Oxycodone was
heavily marketed to primary care providers. Heroin users
switched to Oxycodone before 2010 because it was so prevalent
and cheap. In the 90s there was a trend to be "pain free."
He discussed the importance of pain and noted that it is
subjective. It also can be debilitating and needs to be managed.
SENATOR HUGHES asked Dr. Butler if he has access to the PDMP
data to see who may be overprescribing.
2:31:23 PM
DR. BUTLER said he does not. He explained that PDMP monitoring
falls to the Pharmacy Board under SB 74, however, Public Health
can access de-identified data for public health purposes.
SENATOR HUGHES asked if law enforcement has access to the PDMP
with a warrant from the DEA.
DR. BUTLER said yes.
2:32:17 PM
DR. BUTLER continued the sectional analysis of SB 79:
Sec. 2-25 Amend AS 08, Business and Professions, for
the Boards of Dentistry, Medicine, Nursing, and
Optometry to:
Require two (2) hours of pain management and opioid
misuse and addiction instruction;
Disciplinary actions for prescribing or dispensing an
opioid in excess of the maximum dosage allowed by law
or violated a law related to drugs, regardless of any
criminal action;
Set the maximum dosage for initial opioid
prescriptions at a seven-day supply unless, in the
practitioner's professional judgment, it is necessary
for chronic pain management or a patient is unable to
access a practitioner in time to refill the
prescription; and
Require, for a minor under 18 years of age, the
practitioner discuss with the parent or guardian why
the prescription is necessary, and the risks
associated with opioid use.
He provided an example of a 15-year-old who was prescribed
Vicodin.
He continued the sectional analysis of SB 79.
Sec. 26-27 Amend AS 08.80 for the Board of Pharmacy to
Register with the Prescription Drug Monitoring
Database (PDMP) with or without a federal Drug
Enforcement Administration registration number; and
Allow pharmacists to dispense less than the prescribed
amount of a schedule II or III controlled substance at a
person's request; the pharmacists would inform the
prescribing practitioner and the Prescription Drug
Monitoring Database.
2:35:21 PM
Sec. 28 Amends AS 08.98 for the Board of Veterinary
Medicine to:
Register with the Prescription Drug Monitoring
Database if the veterinarian has a federal Drug
Enforcement Administration number; and
Identify resources and educational materials for
veterinarians to identify clients at risk for opioid misuse
or diversion of prescribed opioids.
Sec. 29-36 Amend AS 17.30, Controlled Substances, to
change the frequency pharmacists report to the
Prescription Drug Monitoring Database from weekly to
daily; remove the prohibition on sharing information
with the federal government. The pharmacy board may
provide a confidential unsolicited notification in
summary form to a practitioner's licensing board which
includes the basis for the notification. The
notification must be provided to the practitioner as
well.
Sec. 37 Directs the Department of Health and Social
Services to draft regulations to implement the
Voluntary Nonopioid Directive Act.
Sec. 38 Repeals sunset dates in sections 52 and 73 of
Ch. 25, SLA 2016 (SB 74).
Sec. 39-40 Set an immediate effective date and provide
an effective date for regulations.
2:37:29 PM
CHAIR COSTELLO thanked Dr. Butler and opened public testimony on
SB 79.
2:37:52 PM
DANIEL NELSON, Director of Pharmacy, Tanana Chiefs Conference,
presented concerns about SB 79. He agreed with the overall
intention of the bill and noted a consensus amongst the entire
medical community that opioid addiction is a huge problem.
He addressed specific concerns in the bill. He pointed out that
SB 74 from last year will not be implemented until July 17,
2017, and it contains several provisions that will significantly
positively impact the inappropriate prescribing of opioids. It
would make some things in SB 79 unnecessary. Also, there has
been a lack of participation in drafting the bill by medical and
pharmaceutical communities. Another concern is in Section 31
where there is a removal on the prohibition of sharing the PDMP
information with the federal government, which would undermine
public trust in PDMP. The requirement of daily updates to the
PDMP is unnecessary and onerous. Finally, the voluntary non-
opioid directive is unnecessary; no one is precluded from doing
that now, and the partial filling of controlled substance
prescriptions can be requested now.
MR. NELSON stated support for the mandatory continuing education
course.
CHAIR COSTELLO noted Department of Health and Social Services
Commissioner Davidson was present.
2:41:13 PM
SENATOR GARDNER requested Mr. Nelson repeat the last sentence.
MR. NELSON restated that the mandatory continuing education is
beneficial.
SENATOR STEVENS asked for clarification about partially filling
a prescription at the patient's request.
MR. NELSON explained that a pharmacist can fill a prescription
using a lower quantity drug, at the patient's request.
SENATOR STEVENS asked if pharmacists would be comfortable
overriding a physician.
MR. NELSON said only in that situation.
2:43:28 PM
MICHAEL CARSON, Chair, Mat-Su Opiate Task Force, stated that the
Task Force supports limiting opioid prescriptions to seven days
and imposing stricter rules tied to the PDMP. He thanked Chair
Costello for her introduction and confirmed that fatal overdoses
have tripled in the state due to the increase of heroin abuse;
fentanyl mixed with heroin is a factor. He said 80 percent of
heroin users started with opioids. He concluded that the goal is
to turn off the prescription spigot.
2:45:50 PM
LEIF HOLM, Chair, Board of Pharmacy, voiced concerns with SB 79.
He concurred with Mr. Nelson's testimony. He agreed it is
necessary to find ways to combat the opioid epidemic. He
maintained that the bill unfairly singles out pharmacists and
looks to correct SB 74, which has yet to take effect. He stated
that pharmacists have consistently spearheaded actions against
the opioid epidemic, especially in finding funding sources for
and using the PDMT. He questioned issues related to the partial-
fill provision. He concluded that he opposes the bill in its
current form.
SENATOR GARDNER asked if partial fill and voiding the balance of
a prescription is state law, and what needs to change to allow
retention of the remaining prescription.
MR. HOLM related that since July 2016 partial fills have been
allowed without voiding the balance of a prescription. He stated
support for that.
SENATOR GARDNER asked how the bill could be written to ensure
that a partial fill does not void the remaining amount.
MR. HOLM suggested eliminating the phrase, "the remainder of the
prescription is voided."
2:49:55 PM
BARRY CHRISTENSEN, Co-Chair, Legislative Committee, Alaska
Pharmacists Association, voiced concern with SB 79. He concurred
with the previous testifiers, Mr. Holm and Mr. Nelson. He spoke
of the poor timing, given the passage of SB 74. He shared the
many contributions pharmacists have made to this issue and said
many pharmacists feel that the Governor's press release put a
negative spin on them.
He voiced concern about patients being scared, due to tightening
legislation, to refill medications for chronic pain management.
He shared the risks related to patients suddenly quitting their
pain meds.
GERALD BROWN, Pharmacist, testified in opposition to parts of SB
79. He said many items in SB 79 are similar to those in SB 74.
He suggested not holding the pharmacist in charge liable for
failing to check the database, as written in Section 32. He
pointed out the real control of abuse is when "the pen hits the
paper." He commented on revisiting page 2 of the bill.
CHAIR COSTELLO noted the people available to answer questions
and invited them back the next time the bill is heard. She said
she is keeping public testimony open.
2:55:25 PM
SCOTT WATTS, Pharmacist, testified in opposition to parts of SB
79. He voiced appreciation for what the bill is trying to
accomplish. He suggested that more input from pharmacy
associations would help correct some of the problems in the
bill. He said that daily monitoring of the database can be done
electronically at his pharmacy if the bill passes, however, it
may be more difficult for some pharmacies. He suggested having
some implementation time for that.
He pointed out that prescribers can check the PDMP database in
their offices in advance. He said pharmacists don't always have
the time to check the PDMP database, and they have better
avenues to see about prescribing data and usage. He did not want
to see daily checking of the database being a requirement. They
are willing to maintain and enter the data in PDMP. He said he
liked the ability to decrease the number of pills in the
prescription.
2:57:39 PM
SENATOR GARDNER asked if the database is confidential and
requires logging in every time.
MR. WATTS said correct. Pharmacists are waiting for SB 74, which
allows for an agent to monitor the database.
SENATOR HUGHES asked if there could be software to interface
with PDMP to flag problems.
MR. WATTS said there has been talk of that, but it is expensive.
SENATOR COSTELLO held SB 79 in committee with public testimony
open.