Legislature(2021 - 2022)BARNES 124
05/13/2022 09:00 AM House LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB190 | |
| SB132 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | SB 132 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | SB 190 | TELECONFERENCED | |
SB 132-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN
9:15:12 AM
CO-CHAIR SPOHNHOLZ announced that the final order of business
would be SENATE BILL 132, "An Act exempting veterinarians from
the requirements of the controlled substance prescription
database." [Before the committee was HCS SB 132(HSS).]
9:15:38 AM
SENATOR ROGER HOLLAND, Alaska State Legislature, as prime
sponsor, introduced SB 132. The most important item, he stated,
is that veterinarians are not trained in the 1996 Health
Insurance Portability and Accountability Act (HIPAA), and one of
the requirements of participating in the Prescription Drug
Monitoring Program (PDMP) is that they must query and review the
personal information of pet owners. This is a financial burden
for veterinarians, he continued, and it's something the state
should not be requiring them to do. Further, he opined that
it's something they should not be allowed to do.
9:16:26 AM
NIKKI ROSE, Staff, Senator Roger Holland, Alaska State
Legislature, on behalf of Senator Holland, prime sponsor of SB
132, provided the sectional analysis for HCS SB 132 (HSS)
[included in the committee packet], titled "CS for Senate Bill
132 Controlled Substance Data Exemption for Veterinarians,"
which read as follows [original punctuation provided with some
formatting changes]:
Sec. 1
AS 17.30.200(k) is amended by
Remove "Dispensing, prescribing, or administering".
Adds "dispensing, prescribing, or administering" to
section (A)
Adds "dispensing, prescribing, or administering" and
adds "or" to section (B)
Adds a new subsection to AS 17.30.200 (k)
(C) "prescribing a controlled substance if the
practitioner is a veterinarian
Sec. 2
AS 17.30.200(t) is amended to read:
(1) the practitioner is a veterinarian licensed under
AS 08.98 who is dispensing a prescription of a
controlled substance in a quantity intended to last
for not more than three days or who did not dispense a
controlled substance during the daily reporting
period; or
(2) a controlled substance is (A) [(1)] administered
to a patient at (i) [(A)] a health care facility; or
(ii) [(B)] a correctional facility; or (B) [(2)]
dispensed to a patient for an outpatient supply of 24
hours or less at a hospital (i) [(A)] inpatient
pharmacy; or (ii)[(B)] emergency department.
Sec. 3
AS 17.30.200(u) is amended by adding a new paragraph
to read:
(6) "practitioner" means
(A) a physician, dentist, advanced practice
registered nurse, optometrist, scientific
investigator, veterinarian, or other person licensed,
registered, or otherwise permitted to distribute,
dispense, conduct research with respect to, or to
administer or use in teaching or chemical analysis a
controlled substance in the course of professional
practice or research in the state;
(B) a pharmacy, hospital, or other institution
licensed, registered, or otherwise permitted to
distribute, dispense, conduct research with respect
to, or to administer a controlled substance in the
course of professional practice or research in the
state.
9:19:08 AM
CO-CHAIR SPOHNHOLZ announced the start of invited testimony on
HCS SB 132(HSS).
9:20:21 AM
MCKAYLA DICK, DVM, Past President, Alaska Veterinary
Association, provided invited testimony in support of HCS SB
132(HSS). She said veterinarians across Alaska are in support
of exemptions from the PDMP because it is a system that is not
working for veterinarians when animals don't have an identifier.
There are key issues with identifiers, she stated, [Alaska] is
lacking veterinarians as well as technicians who can help with
that, and a lot of money is being spent on investigations
throughout that process.
9:21:11 AM
PAM VENTGEN, Executive Director, Alaska State Medical
Association (ASMA), provided invited testimony expressing the
association's concerns with HCS SB 132(HSS). She said ASMA
represents physicians across Alaska and has concerns about
veterinarians being fully exempt from the PDMP. She related
that ASMA does support the amendments to SB 132. She said the
amendment that would exempt veterinarians from having to check
the PDMP when prescribing, and the amendment that exempts
veterinarians from logging into the PDMP on days their clinic
has not dispensed medications, make the PDMP less onerous. The
PDMP is cumbersome for all practitioners and physicians, she
pointed out, and they have complained about that. But, she
continued, Alaska currently ranks highest in the nation in
overdose deaths, so this is not the time to back down on
monitoring of controlled substances. While ASMA supports the
amendments that make [reporting] a little less onerous, she
continued, ASMA doesn't think veterinarians should be totally
exempt from the PDMP.
9:23:25 AM
RACHEL BERNGARTT, DVM, Chair, Board of Veterinary Examiners
(BOVE), provided invited testimony in support of SB 132 via a
PowerPoint presentation, titled "Why It Makes Sense to Exempt
Veterinarians from the Prescription Drug Monitoring Program."
She noted that the presentation, which has not been updated to
reflect the amendments, was prepared by the Alaska State
Veterinary Medical Association (AKVMA) and that as a member of
BOVE she contributed to the presentation.
DR. BERNGARTT turned to the second slide and said SB 132 began
as an act exempting veterinarians but now she understands that
it is called an act relating to the controlled substance
prescription database. She stated that both AKVMA and BOVE
support SB 132. She further noted that the Alaska Board of
Pharmacy supports SB 132 and supports full veterinary exemption
from the PDMP.
DR. BERNGARTT moved to the third slide and provided background
on the PDMP. She said the PDMP was established in 2008 by
Senate Bill 196, but in response to the increasing opioid
epidemic the PDMP was amended in 2017 by House Bill 159 to
include all Drug Enforcement Administration (DEA) permit
holders, including veterinarians. She noted that neither AKVMA
nor BOVE were consulted regarding this amendment. She stated
that under [HCS SB 132(HSS)], veterinarians who prescribe but
script out the prescriptions will be exempt from querying and
reporting, and that burden will be passed on to the pharmacist
to query and report. She further stated that under [HCS SB
132(HSS)], PDMP reporting will be required for all actively
licensed practitioners who hold a federal DEA registration
number and who prescribe, administer, or dispense federally
scheduled II-IV controlled substances in Alaska. So, she said,
those veterinarians who dispense in Alaska will still be
required to query and report. According to the Alaska Board of
Pharmacy, Dr. Berngartt continued, about 65 veterinarians in
Alaska still directly dispense and [HCS SB 132(HSS)] will not
help those veterinarians. Given the shortage of veterinarians
and veterinary time, she added, [that requirement] is a big deal
for those 65 veterinarians.
DR. BERNGARTT proceeded to the fourth slide and stated that the
PDMP is not an effective database for veterinarians or their
patients. The PDMP was established for human medicine, she
pointed out, a query is made on the individual who brings the
animal to the veterinarian and human data is obtained, not
animal data. She said veterinarians are not trained in how to
assess this human data that they are being mandated to view.
Additionally, she noted, veterinarians are not mandated to
assess this human data, they are mandated to view it and
mandated to report. So, while some of that burden will be
removed, she stated, the 65 veterinarians who do directly
dispense will still be stuck in that quandary.
9:27:54 AM
DR. BERNGARTT displayed the fifth slide and said the querying of
human PDMP information is an invasion into an individual's
medical privacy. She related that, by and large, law has
determined that HIPAA regulations do not apply specifically to
the PDMP. However, she continued, veterinarians do not have the
privacy infrastructure that human medical offices have, such as
screen shields and isolated computers. While technically HIPAA
may not apply to PDMPs, she said, there is the expectation of
private human health data by a veterinarian's clients.
Veterinarians, she pointed out, have access to more than just
opiate information because the PDMP has visible information
about all controlled substances, including postpartum depression
medications, sex hormones, Ambien, and Lunesta.
DR. BERNGARTT spoke to the sixth slide. She specified that
veterinarians are already regulated by the DEA and must
participate in the Suspicious Order Monitoring System. When a
veterinarian registers with a veterinary distribution company,
she related, the distribution company is going to take
information about that veterinarian's prescribing habits, such
as how many animals per year the veterinarian sees and the type
of practice, and the distribution company is required to report
any suspicious ordering to the DEA. This DEA oversight, she
said, is to control and prevent diversion from the licensed
professional to drug dealers and users.
9:30:11 AM
CO-CHAIR SPOHNHOLZ inquired about the date that the Suspicious
Order Monitoring System went into place.
DR. BERNGARTT replied that she is unsure but believes it has
been in place for the entirety of her 20 years as a
veterinarian. She said she will get back to the committee with
an answer.
CO-CHAIR SPOHNHOLZ remarked that the timing is important because
a lot of systems have been in place that failed to prevent the
opioid epidemic from happening and the committee is mindful of
keeping Alaskans safe.
DR. BERNGARTT responded that regarding veterinary diversion
where the human has taken the medication prescribed for the
animal, BOVE and AKVMA have reached out to emergency physicians,
other medical health professionals, and substance abuse
coordinators and have received information that veterinary drugs
as a whole are not part of the issue being seen right now in
Alaska with synthetic fentanyl and those types of drugs. She
said veterinarians do not carry those drugs.
9:32:33 AM
DR. BERNGARTT continued her presentation. She turned to the
seventh slide and related that 34 other states have completely
exempted veterinarians from participating in the PDMP. She said
BOVE is asking that Alaska join those 34 states in what makes
sense fiscally, privacy-wise, and resource-wise. Those 34 other
states, she continued, have seen no increased reporting of
doctor shopping and no increased reporting of drug diversion
from veterinarians. Had it been a problem in those states, she
added, they would have addressed it.
DR. BERNGARTT moved to the eighth slide and noted that [between
2016 and 2018] veterinarians [in Alaska] prescribed 0.3 to 1
percent of the total morphine milligram equivalents (MMEs). She
said dentists prescribe even less than veterinarians, so maybe
dentists should be exempt too. She then reframed that statement
to say that it isn't about the total number of MMEs, of which
veterinarians prescribe a very small percentage, but rather that
the drugs veterinarians prescribe are not the drugs that go out
into the population and contribute to addiction and overdose.
Veterinarians, she continued, are not dispensing oxycontin,
methadone, or heroin, which are the drugs of concern in the
opioid epidemic.
9:35:50 AM
CO-CHAIR SPOHNHOLZ maintained that that was an inflammatory
statement because there are no prescribers who prescribe heroin.
DR. BERNGARTT responded that her comments were to the things
that are contributing to the opioid epidemic, and she didn't
mean to insinuate that there were other prescribers who were
prescribing heroin. She said she just wanted to say for the
record that veterinarians are not.
CO-CHAIR SPOHNHOLZ stated that the reason for the PDMP was never
to address illicit drugs, it was to control and monitor typical
controlled substances that are legally prescribed for health
care reasons that helped drive the opioid epidemic. Heroin was
never incorporated into the PDMP, she continued, and she is
cautious about using inflammatory rhetoric.
9:37:02 AM
DR. BERNGARTT resumed her presentation. She moved to the nineth
slide and related that the Board of Veterinary Examiners and the
profession have had to deal with the issue of investigative cost
that has been passed on to veterinarians. She said Alaska's
veterinarians have the highest licensing fees in the US. The
PDMP investigations, she pointed out, haven't shown one instance
of diversion or nefarious conduct, they've simply been querying,
reporting, and [addressing] technical issues. Veterinarians
have testified before BOVE, she related, that they have
repeatedly entered this data but cannot find this data in their
own PDMP screens and then they received letters that they are
being investigated for improper querying and improper reporting.
So, she continued, there is an issue with how the system handles
animal data because it was designed for human data. Dr.
Berngartt further related that there are grants which cover the
cost of PDMP staff to mine the data to figure out who may be in
violation. That information is then passed over to PDMP's
investigations department which does its step, she said, and
that cost is passed directly to the Board of Veterinary
Examiners. Currently there is not a grant that covers the costs
on both sides, she advised, although there possibly may be some
money coming down the pipe to BOVE to help keep licensing fees
static. This would be helpful in relation to attracting and
recruiting new veterinarians to the state of Alaska, she added.
DR. BERNGARTT concluded her presentation by speaking from the
eleventh slide, "AKVMA URGES A YES vote on SB 132," which read
[original punctuation provided]:
An Exemption of Veterinarians from participating in
the PDMP:
Will allow veterinarians to provide the appropriate,
timely, medical management appropriate for each
patient.
Will increase the efficiency of the PDMP system for
its intended purpose, by allowing for accurate
interpretation of data and trends in human medicine.
Will allow continued judicious use of controlled
substances that is already practiced by veterinarians.
Will eliminate unnecessary and disproportionate
business burdens for veterinarians.
9:40:17 AM
REPRESENTATIVE KAUFMAN surmised the existing system presents
risk in that veterinarians and their assistants are not trained
or qualified to look at this private medical data but are doing
so because that is how the system is constructed.
DR. BERNGARTT agreed that this is the case. She said the PDMP
permits veterinarians to delegate the PDMP responsibilities of
querying and reporting to a licensed veterinary technician. She
advised that Alaska has about 430 licensed veterinarians and
about 260 licensed veterinary technicians, so not even one
delegate per veterinarian is physically possible. She further
advised that most of those licensed veterinary technicians are
congregated in the larger metropolitan areas of Anchorage and
Fairbanks, and therefore the actual ability for veterinarians to
delegate is low.
CO-CHAIR SPOHNHOLZ noted that [HCS SB 132(HSS)] requires only
the 65 dispensing veterinarians in Alaska to participate in the
PDMP; the remaining 370 veterinarians who are not dispensing and
are just prescribing are excluded from participating.
9:42:13 AM
REPRESENTATIVE KAUFMAN offered his understanding that there is
little evidence that the veterinary source of medicines is a
pipeline of illicit drug use because the drugs prescribed are
not preferred by those who are abusing substances. He therefore
surmised there is little risk.
DR. BERNGARTT agreed. She said veterinarians don't utilize and
therefore don't prescribe drugs such as oxycodone and Vicodin,
which she understands are drugs that have a high-risk potential
for continued addiction and abuse.
REPRESENTATIVE KAUFMAN commented that he sees little benefit and
a risk of medical data exposure for not much benefit. He asked
why the bill isn't being moved along quickly for the benefit of
all concerned.
DR. BERNGARTT responded that there has not been an identifiable
benefit for veterinary participation in the PDMP; none of the
investigations generated through the PDMP have identified an
instance of veterinary diversion or drug shopping. However, she
continued, there have been identified harms to the veterinary
profession and veterinary clientele through the increased
exposure of private health data, the time cost to veterinarians
to participate in the PDMP, and the investigative costs. She
allowed that [HCS SB 132(HSS)] will relieve the bulk of
veterinarians practicing in Alaska of those duties, but said her
concern is the 65 veterinarians who do dispense and the burden
that could be created to rural and underserved communities that
are served by dispensing veterinarians.
9:45:22 AM
REPRESENTATIVE SNYDER noted that three amendments were added to
SB 132 in House Health and Social Services Standing Committee.
One of the amendments, she stated, provides that non-dispensing
veterinarians who send prescriptions to a pharmacist do not have
to review or enter data into the PDMP, leaving 65 veterinarians
for which there is concern. Another of the amendments, she
continued, does not require any of the veterinarians, including
those 65, to interact with the PDMP if the medication they
prescribe or dispense is for three days or less. Most of the
investigations to date, she further said, have had to do with
the querying problems and not having to inquire if the
veterinarian has not prescribed or dispensed that day, and the
amendment for that will affect all veterinarians, including the
65, and should reduce investigations related to those issues.
As a person in the field of public health, she said the intent
was to find a balance and middle ground to navigate the input
across the spectrum. She agreed additional work on the PDMP is
necessary and that there have been failures in coordination
between the state and the veterinarians. She concurred that
there are concerns with HIPAA, but pointed out that the full
statute includes guidelines and penalties for divulging that
health information and educational materials are supposed to be
provided through the state giving oversight on the PDMP.
9:48:12 AM
REPRESENTATIVE NELSON asked whether it is correct that the
pharmacy association supported the broad exemption that was in
the original version of SB 132.
DR. BERNGARTT answered that's correct, the Alaska Board of
Pharmacy voted to support full exemption of veterinarians from
the PDMP in February 2022.
REPRESENTATIVE NELSON noted that the pharmacy association and a
bunch of veterinarians originally supported SB 132 and asked
whether that has changed with the amendments.
DR. BERNGARTT replied that she personally hasn't had a
conversation with the Alaska Board of Pharmacy or its chair,
Justin Ruffridge. She said she personally feels that the buck
is being passed to the pharmacist for identifying the person to
be queried. The problem of identifying who to query will
remain, she advised, because the person who brought the pet to
the veterinarian may not be the person who picks up the
prescription given there may be multiple household members. The
pharmacist will still have to either query more than one person
or pick one person to query, she pointed out. This gets into
issues of data integrity, she continued, and what type of data
is really being collected as far as being meaningful to the
human health professionals that are trained to analyze and
utilize this data.
9:50:13 AM
JUSTIN RUFFRIDGE, PharmD, Chair, Alaska Board of Pharmacy,
responded to Representative Nelson's question. He stated that
querying and looking at the PDMP for veterinary prescriptions
has been a large and long-time issue for the pharmacy board. A
big issue, he explained, is that there is no unilateral way that
pharmacies are required to input the data for a prescription
from a veterinarian for an animal. To solve the issue, he
continued, regulation is currently being developed for a
specific way to add information into the PDMP. However, he
advised, it will be linked to one owner, so the problem will
still exist in the scenario of multiple owners and people
getting prescriptions.
9:51:47 AM
NICHOLAS PAPACOSTAS, MD, President, Alaska Chapter, American
College of Emergency Physicians (ACEP), provided invited
testimony on SB 132. He thanked the veterinarians who have
worked to use the PDMP, which he understands has been very hard
for them. He said the PDMP has been transformative for
emergency physicians in being able to see the number of
prescriptions and the sources, and therefore how a patient is
exposed to controlled substances. Even though the total volume
that could be prescribed by veterinarians is currently low, he
continued, it is important to ensure that the PDMP is complete
and includes most drugs and prescriptions from veterinary
sources. Many of those who suffer from opioid use disorder
(OUD) or other substance use disorders (SUDs), he related, have
their first exposure via a prescription for a legitimate purpose
or in some cases the prescription of a family member or friend.
DR. PAPACOSTAS stated that overdose death gets the most press,
but more silent is when a vulnerable person takes a tablet of,
say, hydromorphone, for the first time recreationally, which can
potentially spin off a devastating substance use disorder.
Hydromorphone is a very powerful opioid, he said, and it sounds
from the veterinary white paper that it is a commonly prescribed
veterinary opioid. Dr. Berngartt referenced that veterinarians
are not prescribing medications that cause addiction, he
continued, but hydromorphone is a powerful opioid that people in
the emergency room who have opioid use disorder commonly request
by name.
DR. PAPACOSTAS pointed out that the most important function of
the PDMP is to identify vulnerable patients and help them get
treatment, it is not necessarily to catch people doing things
wrong. He stated that ACEP agrees the PDMP is currently
problematic for veterinarians. He said ACEP thinks the
amendments proposed in Section 1 and Section 2 exempting most
veterinarians from checking the PDMP at all and exempting all
veterinarians from checking the PDMP if they provide very short-
term prescriptions of under three days of controlled substances
are good intermediate solutions that balance the regulatory
burden on veterinarians while continuing to capture important
data for patients and public safety.
DR. PAPACOSTAS noted that ACEP's 3/22/22 letter cites a five-
year study between 2014 and 2019 that looked at the states which
do have veterinary monitoring in the PDMP. He said the study
characterized veterinarian shopping or doctor shopping as when
there are four or more prescriptions from different sources for
one animal, and during the study period the instances of such
shopping increased from 900 at the start to 2800 at the end.
The only reason this increase is known, he stressed, is because
the PDMP exists and the states that are tracking the PDMP with
veterinary sources are tracking those sources. States that have
exempted veterinarians are flying blind, he said, and the reason
they've seen no uptick is because they are not watching to see
if there has been any uptick in those problems.
DR. PAPACOSTAS related that the 2022 PDMP legislative report
shows that the trend in overdose deaths from prescription
medication declined between 1999 and 2020, but then in 2020
overdose deaths involving prescription medication spiked to 90.
It has recently come out, he continued, that overdose deaths are
increasing year over year nationally and especially in Alaska,
and therefore ACEP agrees that now is not the time to take the
eye off what is going on with these medications.
9:56:35 AM
REPRESENTATIVE MCCARTY, in relation to the statement about the
states that are flying blind, inquired about the DEA across the
US keeping records about where diversion exists.
DR. PAPACOSTAS replied that he thinks diversion is a very large
volume of opioids. He said he isn't talking about prescriptions
that are necessarily vet shopping that are going to affect an
individual patient suffering from opioid disorder and going from
doctor to doctor or potentially a veterinarian or veterinarians
for a controlled substance. Diversion is specifically the DEA,
he stated, and the DEA is interested in people who are selling
these prescriptions for the purpose of making money, it is not
looking into when one individual patient is exposed to these
medications, so they don't achieve the same function.
REPRESENTATIVE MCCARTY commented that he talks to the DEA to
give his concerns about people who are doctor shopping. He
stated that Dr. Papacostas's answer seems to be incongruent with
other responsibilities of the DEA, such as doctors and
pharmacies doing questionable activities.
DR. PAPACOSTAS responded that yes there is potentially the
responsibility to report, but followed with the question, "What
information are they using if they don't have the PDMP to spot
patterns that they would want to report to the DEA?"
9:58:28 AM
RUSSELL JOHANSON, MD, Board Member, Alaska Chapter, American
College of Emergency Physicians (ACEP), provided invited
testimony on SB 132. He stated he is an emergency room
physician with Mat-Su Regional Medical Center and doesn't know a
single emergency physician in Alaska who disagrees with the
position stated by Dr. Papacostas. He said all physicians have
difficult conversations daily with their patients and it is
important for physicians to know all their sources of opiates.
He related that he's heard a lot of talk about it being onerous
to use the PDMP. However, in his opinion, he continued, it is a
great responsibility to introduce drugs that are quite harmful
and can devastate a community, and therefore a little bit of
work to make sure it is done safely is not too onerous.
[HCS SB 132(HSS) was held over.]
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 132 AKVMA White Paper.pdf |
HHSS 4/19/2022 3:00:00 PM HL&C 5/13/2022 9:00:00 AM SHSS 2/3/2022 1:30:00 PM |
SB 132 |
| SB 132 Testimony PowerPoint ASVMA 2.1.22.pdf |
HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| SB 132 Letters of Support as of 4.13.22.pdf |
HHSS 4/26/2022 3:00:00 PM HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| SB 132 Letters of Opposition as of 4.8.22.pdf |
HHSS 4/26/2022 3:00:00 PM HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| SB 132 Sponsor Statement.pdf |
HHSS 4/26/2022 3:00:00 PM HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| SB 132 Fiscal Note 2.9.22.PDF |
HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| CS for SB 132 Sectional Analysis 5.11.22.pdf |
HL&C 5/13/2022 9:00:00 AM |
SB 132 |
| SB 190 Amendment #2 - Fields 5.13.22.pdf |
HL&C 5/13/2022 9:00:00 AM |
SB 190 |
| CS for SB 132 Sponsor Statement 5.11.22.pdf |
HL&C 5/13/2022 9:00:00 AM |
SB 132 |