HOUSE FINANCE COMMITTEE May 11, 2017 1:33 p.m. 1:33:54 PM CALL TO ORDER Co-Chair Foster called the House Finance Committee meeting to order at 1:33 p.m. MEMBERS PRESENT Representative Neal Foster, Co-Chair Representative Paul Seaton, Co-Chair Representative Les Gara, Vice-Chair Representative Jason Grenn Representative David Guttenberg Representative Scott Kawasaki Representative Dan Ortiz Representative Lance Pruitt Representative Steve Thompson Representative Cathy Tilton Representative Tammie Wilson MEMBERS ABSENT None ALSO PRESENT Dr. Jay Butler, Chief Medical Officer and Director of Public Health, Department of Health and Social Services; Stacie Kraly, Chief Assistant Attorney General, Department of Law; Sara Chambers, Acting Director, Alcohol and Marijuana Control Office, Department of Commerce, Community and Economic Development; Kara Nelson, Director, Haven House, Juneau; Taneeka Hansen, Staff, Representative Paul Seaton; Linda Bruce, Attorney, Legislative Legal Services; Valerie Davidson, Commissioner, Department of Health and Social Services; Representative George Raucher, Sponsor; Darrel Breeze, Staff, Representative George Raucher; Representative Lora Reinbold; Representative Andy Josephson. PRESENT VIA TELECONFERENCE Michael Karson, Chair, Matsu Opioid Task Force, Matsu; Carol Carman, Self, Palmer; Ryan Brett, AK Mudslingers, Anchorage; Patti Barber, Self, Mat-Su; Kenny Barber, Self, Mat-Su; Clark Cox, Natural Resource Manager, Department of Natural Resources. SUMMARY HB 6 JONESVILLE PUBLIC USE AREA CSHB 6(RES) was REPORTED out of committee with a "do pass" recommendation and with three previously published zero fiscal notes, FN1 (DNR), FN 2 (DPS), FN3 (DPS); and one new zero fiscal note from the Department of Natural Resources. HB 159 OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES CSHB 159(FIN was REPORTED out of committee with a "do pass" recommendation and with two previously published fiscal notes, one zero note: FN2 (DHS); and one fiscal impact note: FN3 (CED). SB 97 PENSION OBLIGATION BONDS SB 97 was SCHEDULED but not HEARD. Co-Chair Foster reviewed the agenda for the day. HOUSE BILL NO. 159 "An Act relating to the prescription of opioids; establishing the Voluntary Nonopioid Directive Act; relating to the controlled substance prescription database; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; relating to the practice of optometry; relating to the practice of veterinary medicine; related to the duties of the Board of Pharmacy; and providing for an effective date." 1:35:18 PM DR. JAY BUTLER, CHIEF MEDICAL OFFICER AND DIRECTOR OF PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, provided a broad overview of the major provisions in the bill. He relayed that HB 159 was an omnibus bill that enhanced the department's current approach for treating the opioid epidemic by primarily focusing on ways to support people in recovery and reduce the number of newly addicted. The bill included opportunities to avoid opioid prescriptions through advanced directives documented on patient's medical records and for partial refills. He indicated that the bill offered civil liability protection for providers and enforced some of the regulations contained in the federal Comprehensive Addiction and Recovery Act of 2016. The legislation set a standard of care limit of a seven day supply for first time prescriptions for an opioid. The policy was aligned with the Center for Disease Control (CDC), other professional agencies and organizations, and the Veteran's Administration's Opioid Safety Initiative. He related that the initiative made "remarkable progress" in reductions in overdoses and addiction of opioids since 2013. The bill included waivers for judicious use of increased opioid dispensing at the discretion of a professional for situations like palliative care, acute and chronic pain syndromes, etc. Another provision in the bill dedicated a certain portion of required professional continuing education credits for pain management or addiction. He qualified that the education was beneficial even for healthcare providers who did not prescribe opioids due to the "highly prevalent" instances of dealing with patients struggling with addictions or in recovery. The bill "enhanced" the prescription drug database and required veterinarians to register. The bill allowed the Department of Commerce, Community and Economic Development (DCCED) to provide feedback to providers comparing prescribing habits of other providers and required pharmacists to update the database more frequently. He thought that the database implemented with passage of SB 74 Medicaid (Reform; Telemedicine; Drug Database) [Chapter 25 SLA 16 06/21/2016) was a useful tool only with the continued input of quality data. 1:40:21 PM Representative Guttenberg thanked Dr. Butler and the department for doing a "great job." He referred to the update of the prescription drug database. He asked him to address the issues that arose with the implementation of the "Prescription Drug Managers" database established in SB 74 [Prescription Drug Monitoring Program (PDMP)] and whether the database was being regularly updated. Dr. Butler responded that the monitoring program updates were in the process of being increased from monthly to weekly as mandated in SB 74. He relayed that more than 25 states required daily updates and the standard was considered a best practice. However, the more frequent the updates the more burdensome the requirement was for small independent rural pharmacies. He acknowledged the Alaska Pharmacy Association's help in developing a strategy to address the issue by delaying the implementation of the daily updates until mid-2018 to allow a year for pharmacies to adjust to weekly updates before moving forward. The pharmacies with highly automated systems easily complied with more frequent updating requirements but wanted to enable all pharmacies to comply. He thought Representative Guttenberg had raised a good point of looking at how the epidemic grew in Alaska and how the Pharmacy Benefit Manager (PBM) influenced prescribing practices and reimbursement and pointed out that the issue provoked much discussion among the medical community. He drew attention to a book entitled "Drug Dealer M. D." authored by Anna Lembke M. D. Representative Ortiz understood that pharmacies had an initial concern about HB 159. He asked whether the concerns had been addressed. Dr. Butler deferred to the Department of Law (DOL) for a response. He added that the issue also related to provisions in SB 74 that defined who was considered a provider. The intent was that the prescriber checked the prescription drug database and the dispenser "populated" the database to ensure quality data. 1:46:41 PM STACIE KRALY, CHIEF ASSISTANT ATTORNEY GENERAL, DEPARTMENT OF LAW, responded affirmatively. She explained that within the statutory framework of the prescription drug database was a definition section that referred to a definition contained in Title 11 of the criminal code, which applied the Title 11 definition unless otherwise specifically stated in the SB 74 statute. The pharmacists were concerned over the use of the word "practitioner." She clarified that AS 17.30.200 specifically identified that the definition in the criminal code only applied if not addressed in other statutes. She emphasized that the statutes in SB 74 and the amendments in HB 159 were clearly crafted. She believed the definition of practitioner was very concise and delineated between prescriber and pharmacist. She felt that the pharmacists concern was adequately addressed. Representative Ortiz asked Ms. Kraly to provide the page numbers of the bill referring to the definitions. Ms. Kraly clarified that the current bill did not amend the definition section of the database. She delineated that "under the current framework of the statutory scheme" the concerns raised by pharmacists had been addressed. 1:49:41 PM Vice-Chair Gara referred to his previous discussion regarding the adequacy of a three day supply as opposed to the seven day supply in the bill. He requested an answer about the prevalence in the literature recommending a three day supply as adequate for pain and why the seven day supply was chosen. Dr. Butler responded that the seven day period was based on recent studies pointing to the length of time of a first time prescription and the likelihood of chronic use for a year or more. He indicated that the "flashpoint" of an increase in risk for abuse was roughly 5 to 7 days for first time use. He stated that 3 days was the guideline from the CDC and that supplies of longer than seven days was rarely necessary. Vice-Chair Gara ascertained that the bill allowed for a doctor's override from the 7 day restriction due to certain circumstances. He wondered why the legislature should not pay attention to CDC's recommendation and establish a three day limit and allow a longer supply under the doctor's discretion. 1:53:01 PM Dr. Butler indicated the department was not ignoring the 3 day CDC guidelines. He mentioned that one of the analysis that pointed to a 5 to 7 day supply as an increased risk for prolonged use came from CDC data. He believed that a "magic date" did not exist. He offered that the issue fell under the concept of "accountable justification" that described the judicious use of other drugs where a stronger evidence base existed for how to change prescribing behavior to optimize patient safety. He communicated that the concept was not proven with opioids. Vice-Chair Gara provided an example of someone responding well to a three day supply. He wondered why the bill did not impose the limit under the number of days that carried an increased risk of abuse since the doctor could prescribe beyond 3 days at her discretion and the science supported it. Dr. Butler understood Vice-Chair Gara's point. The issue of 3 days versus 7 days had to do with analysis of the risk of addiction and dependency and the dramatic increase in risk that occurred in 5 to 7 days. The 3 day clinical recommendation was "sound" but flexibility for professional judgement was important. Co-Chair Foster acknowledged Representative Pruitt had joined the meeting. Vice-Chair Gara wanted to protect the individuals that kept taking the drug subsequent to pain relief after the third day. Dr. Butler thought Vice-Chair Gara's question addressed the issue of whether opioids were a "first line drug." He remarked that the legislation did not specifically address the issue but was the reason for the continuing education provision dedicated to behavioral pain management and treatment. Over the last ten years, prescriptions for opioids and overdose deaths increased three to four fold without a corresponding decline in chronic pain. Representative Ortiz asked whether Dr. Butler's professional judgement was that the seven day language was in the best interest of the state. Dr. Butler responded that the appropriate number of days was a balancing act. He believed that the risk versus benefit was reasonable. He commented that some of the risk was the under management of pain and a larger administrative burden but it limited the risk for dependency. He reported that the state of New Jersey had limited the number of days to 5 days and was unaware of any state that adopted the three day limit. 1:59:18 PM Representative Wilson felt that only a medical doctor could make educated judgements about prescribing and she was not a doctor. She wondered whether it was already a crime to prescribe too much opioid medication. Dr. Butler agreed that the public official's role was not to dictate individual patient management but felt that advancing patient safety through guidance of how medical care was addressed was acceptable. He noted that prescribing hundreds of opioid pills for "fairly minor surgical procedures" was not a crime. Representative Wilson thought that patient safety should be the number one priority for physicians. She wondered whether addressing the issue of over prescribing via criminal law was a better approach than laws limiting prescriptions made by people without a medical education. Dr. Butler thought that scrutinizing every instance of large opioid prescriptions would be micromanagement of the practice of medicine. He stated that some people adequately managed pain through prolonged use of opioids and he did not want to inhibit access for such use. Conversely, the problem of over prescribing large quantities of opioids was identified as a problem that contributed to the epidemic. He referred to the testimony of a young man that had ultimately become addicted to opioids and heroine from experimenting with the remainder of a previous opioid prescription. He voiced that the criminal justice system controlled the illicit flow of opioids into communities and additional "stop checks" on the legal flow was needed as well. 2:03:18 PM Representative Wilson could not understand why a physician would over prescribe opioids. She believed that the legislature was doing the job a doctor should do and assumed the doctor was incapable of determining the proper dosing amounts. She wanted to understand how her reasoning was incorrect. Dr. Butler offered that the limit was related to the risk analysis and recommendations from professional groups like the CDC, United States Surgeon General, the American College of Physicians, and Veteran's Administration. He thought the provision was "providing guardrails" based on quantifiable information. Representative Wilson could not understand why physicians were not limiting prescriptions "on their own" if it was "not the right thing to do." Dr. Butler explained that the way doctors prescribe medications and some of the drivers of the system had evolved over 25 years. The reimbursement mechanisms and medication marketing had also been drivers of over prescribing. He exemplified that the cost of a pill was lower than some of the other ways to manage chronic pain and pain syndromes. Representative Wilson appreciated what the bill was trying to do. She reiterated that legislators were not doctors and were incapable of making a determination about prescribing. 2:07:21 PM SARA CHAMBERS, ACTING DIRECTOR, ALCOHOL AND MARIJUANA CONTROL OFFICE, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, was impressed with the crafting of the bill. She pointed out that although the bill contained recommendations, doctors were given flexibility. She described the 7 day limit as the "stop and think moment" when a provider could prescribe over the limit but needed to document the transaction. Many physicians were not properly trained in prescribing opioids and unaware of the recent advances in pain management. She liked Dr. Butler's comparison to limiting the use of antibiotics; physicians no longer just handed out antibiotics due to the resistance issues. The bill offered providers an opportunity to receive additional education. She expounded that the four prescribing boards that were affected were also given the authority, in SB 74 and HB 159, to govern, review and discipline its members if continued over prescribing was an issue. She reminded the committee that the boards were comprised of medical professionals qualified to make decisions affecting its profession. 2:10:37 PM Representative Guttenberg thought the previous question made the assumption that all doctors were equal. He remarked that the issue was multi-faceted. He surmised that nothing in the bill restricted a doctor from prescribing over 7 days. He inquired whether the state overrode the doctor patient relationship. Dr. Butler affirmed that the state did not override the provider patient relationship. Representative Guttenberg asked whether the legislature could impose a strict limit on prescribing without an exception or waiver. Ms. Chambers responded that most states had set recommended guidelines. The legislature had the opportunity to set restrictive legal guidelines for overprescribing. She detailed that in HB 159 regulatory authority was left up to the discretion of the professional judgements of the boards based on acceptable standards of care. Representative Guttenberg was not advocating for any restrictive limits. He asked about the authority held by pharmacists and their liability. Ms. Chambers responded that currently the Board of Pharmacists set a threshold for identifying "doctor shopping" through the use of the prescription drug manager. The pharmacist entered the data into the database and the practitioner could review prior to prescribing. She elaborated that the reporting filtered back to a two-fold reporting process. One route of data was streamed to the prescribing board through the Board of Pharmacy; the two boards worked together to see if further investigation was needed. The other element offered the prescriber a report card in comparison to their peers. The reporting offered the provider the opportunity to become self-aware through viewing the practice of their peers. She described the Board of Pharmacy's role as the "delegated governor" of the entire process. 2:16:20 PM Representative Guttenberg ascertained that the physician had the ability to "self-examine" her prescribing practices through the report card. He wondered who else had the ability to monitor the database to identify when something was wrong. Ms. Chambers responded that AS 17.30.200 (d) delineated who can access the database but was quite restricted. She reported that the Prescription Drug Monitoring Program (PDMP) manager reviewed the information at a "higher level" to identify trends and worked with the Control Substances Advisory Committee, the Task Force on Opioids, Board of Pharmacy, DHSS experts, and other professional groups to review "trending." The analyzed data helped shape policy. In Alaska's case, the data was lacking until the SB 74 provisions went "live" in July, 2017. Vice-Chair Gara referred to a remark made by Dr. Butler about the 5 day period of an initial opioid prescription and asked for further clarification. Dr. Butler answered that a CDC study from one of its weekly Morbidity and Mortality Weekly Report (MMWR Weekly) included a graph that depicted the length of time from an initial opioid prescription an individual remained on opioids a year later. He noted that the line was not flat and peaked at the five to seven day period and again at the thirty day periods. Vice-Chair Gara asked Dr. Butler to provide the document. He clarified that the risk of addiction rose steeply at the five to seven day period. Dr. Butler answered in the affirmative and agreed to provide the full report to Vice-Chair Gara. 2:20:32 PM Representative Grenn asked what the goals of the proposed changes in the database were. Ms. Chambers indicated that with the passage of SB 74 the PDMP went from a voluntary basis with low participation rates to a mandatory program for all providers with prescribing authority. She related that in the following months the data would be analyzed for trends in prescribing by occupation, reports on what substances were being prescribed and comparisons that provided more information on further trends. The expectation was that the knowledge gained from the data would instruct further policy and procedural decisions for the professionals as well as legislators. Mandatory reporting to the legislature was a provision in the legislation. 2:23:51 PM Co-Chair Seaton appreciated the legislation. He mentioned that private industry did a very good job of marketing their products to prescribers. The state had an antiquated education system regarding pain management that only considered pain without looking at addiction. He remembered that the state had changed the criteria for rating hospitals and doctors that included adequately managing pain. He explained that the criteria resulted in the dispensing of many prescriptions for drugs to ensure the criteria was met. He asked whether the state had removed or reformed the pain management criteria. He wondered whether the legislature needed to address anything further to remove the incentive for a facility to receive a good rating based on dispensing medications for pain. Dr. Butler appreciated the comments. He offered that previously pain was undertreated so the emphasis over the years, became eliminating pain rather than managing it. He reported that he along with ten other state health officials composed a letter to the Joint Commission and the Center for Medicare and Medicaid Services (CMS) pointing out the "unintentional incentive" of opioid dispensing from the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. He explained that the HCAPS was a survey of patients' perspectives of hospital care and physicians. He added that CMS reimbursement was based on the HCAP score. Initially, the two entities resisted the constructive dialogue but through continued communications and with assistance from the American College of Physicians the HCAP score was changed. The changes recognized that addressing pain was a subjective experience that encompassed emotional and pathological states. 2:29:36 PM Co-Chair Foster OPENED Public Testimony. 2:30:12 PM KARA NELSON, DIRECTOR, HAVEN HOUSE, JUNEAU, supported of the legislation. She particularly favored the "non-opioid directive." She spoke of her own long-term recovery and of her daughter entering treatment only 2 days prior. She thought of herself as an expert in recovery. She relayed a story of a woman who had built a strong recovery framework that was undermined by a prescription from a tooth extraction. The women experienced a temporary relapse and turned to heroin. She felt that a lot of addiction had to do with pain management and shared that was the circumstance regarding her daughter. She advocated for the necessary guidelines contained in the bill and commented that society was moving in the right direction. She spoke of fighting an uphill battle everyday through addiction education and the tools contained in the bill to combat the misconceptions and mishandling of the issue. She thought it was imperative to work aggressively to fight the opioid addiction. 2:35:17 PM Representative Ortiz asked whether Ms. Nelson was familiar with the committee discussion regarding the appropriate number of days for a first time opioid prescription. He asked Ms. Nelson for her perspective. Ms. Nelson reported that based on her work experience and last year's Surgeon General's report on the issue Haven House changed its policy to a three day limit. She personally supported a 3 day policy. She advocated for the continuing education requirements in the bill as a crucial tool in the "battle" against addiction that she characterized as a "war." Vice-Chair Gara asked whether she was aware of doctors who prescribed "more than others." Ms. Nelson answered in the affirmative. However, she noticed that the "tide was changing." She relayed that her work as an advocate for addicts often included attending a doctor's appointment with the individual and noted some doctor's misperceptions and lack of knowledge about addiction. 2:38:34 PM MICHAEL KARSON, CHAIR, MATSU OPIOID TASK FORCE, MATSU (via teleconference), spoke in strong support of the bill. He reported a drastic increase in heroin overdoses and use and cited statistics. He reported the number of overdose deaths due to fentanyl [a powerful synthetic opioid analgesic] and relayed that the drug was 25 percent to 50 percent stronger than heroine. Eighty percent of heroin users began using pain opioid medication and 75 percent of the group received the drugs from friends, grandparents, and parents. He believed that the 7 day limit was imperative and informed the committee that a 10 day supply translated to a one in ten chance of long-term addiction and a 50 percent chance after 30 days. He related that the state of Washington's PDMP reduced medical costs by $33 million and decreased opioid related hospital visits by 24 percent. He remarked on the deadly nature of addiction. Vice-Chair Gara asked for Mr. Karson's appropriate credentials for reference. Mr. Karson replied that he worked in public schools for 35 years, as the Vice- President and addiction specialist for My House, a drop in homeless shelter, and chaired the task force. Vice-Chair Gara thanked Mr. Karson for his work. Representative Guttenberg remarked on the bill's goal of plugging a leaking hole. He asked Mr. Karson to identify another issue where a difference could be made. Mr. Karson referred the committee to an Icelandic study. He stated that Iceland "knew how to reduce teenage substance abuse, but the rest of the world was not listening." He reported that teen tobacco, marijuana, and alcohol use was in the single digits and spoke to the country's work in "upstream" prevention." He delineated that research led officials to discover that youth under stress took two paths: one became risk takers and other became stimulant users. The stimulant users became sedative users. The solution employed was to match the behaviors with activities. The risk takers engaged in activities like rock climbing and snowboarding. The sedative users engaged in music, poetry, and yoga. He emphasized that prevention was imperative. He acknowledged Dr. Butler for his work on pilot projects like "drug-take backs." The bill "turned back the spigot on opioids" but upstream prevention was necessary. He commented that the Icelandic study revealed that no one was listening to drug education. 2:46:03 PM Representative Guttenberg noted that Spain or Portugal had legalized all drugs and had successful results. He wondered if Mr. Karson was familiar with any of the practices. Mr. Karson was unaware of the situation but referred to the method as "harm reduction." He used needle exchanges as an example. The contact that the individual user had with workers at the needle exchange was an important resource for the user seeking treatment. He noted the belief that "addiction was isolation whereas recovery was relationships." He referred to other harm recovery methods such as injection sites or public places where Narcan was immediately available in case of an overdose. The locked boxes of Narcan located on street corners were unlocked by a call to 911 for immediate use. He thought that the Iceland study was the best resource for Alaska due to Iceland's Arctic location. 2:49:07 PM Co-Chair Foster CLOSED Public Testimony. 2:49:17 PM Co-Chair Foster MOVED to ADOPT Amendment 1 (copy on file): Page 11, line 3: Delete "for every 40 hours of education received" Insert "in the two years preceding an application for renewal of a license" Representative Wilson OBJECTED for the purposes of discussion. Co-Chair Foster explained the amendment. The department requested the amendment that corrected an inadvertent error regarding continuing medical education. The original intent of the bill was to require physicians to receive 2 hours of education in pain management and opioid use and addiction in a 2 year licensing period. The current language mandated the 2 hours of education for every 40 hours of continuing education credit. He pointed out that some doctors were required by their professional boards to take up to 200 hours of continuing education that resulted in 10 hours of pain management, opioid use and addiction continuing education, which was not the intent of the department. The amendment reinstated the continuing education mandate for 2 hours in a 2 year licensing cycle. Representative Guttenberg asked whether two hours for the training was enough. Dr. Butler thought the question was challenging. He voiced that the amount balanced administrative demands and benefits and avoided placing "unintended barriers" to seeking continuing education credits beyond the amount required by the Board of Medicine. Representative Guttenberg wanted to ensure the training was useful and academic. Dr. Butler responded that the department offered suggestions of free online material that DHSS had reviewed. Representative Wilson WITHDREW her OBJECTION. There being NO OBJECTION, it was so ordered. Amendment 1 was ADOPTED. Co-Chair Seaton MOVED to ADOPT Amendment 2 (copy on file): Page I, following line 9: Insert a new bill section to read: "* Section 1. The uncodified law of the State of Alaska is amended by adding a new section to read: LEGISLATIVE INTENT. It is the intent of the legislature that the seven-day supply limit for an initial opioid prescription under secs. 5, 16, and 22 of this Act may not be considered as a minimum length of time appropriate for an initial prescription. The United States Centers for Disease Control and Prevention guidelines state that a three-day initial prescription of an opioid is sufficient for most cases of acute pain. The United States Centers for Disease Control and Prevention reported in its March 17, 2017, weekly report that the likelihood of a person's chronic opioid use increases with each additional day of medication supplied after the second day. Practitioners should use their professional judgement in each case and not interpret the seven-day limit as a direction to prescribe the full seven days." Page 1, line 10: Delete "Section 1" Insert "Sec. 2" Renumber the following bill sections accordingly. Page 34, line 10: Delete "secs. 31 and 42" Insert "secs. 32 and 43" Page 34, line 16: Delete "sec. 34" Insert "sec. 35" Page 34, line 17: Delete "sec. 39" Insert "sec. 40" 9 Page 34, line 19: Delete "secs. 34 and 39" Insert "secs. 35 and 40" Page 34, line 24: Delete "secs. 1 and 2" Insert "secs. 2 and 3" Page 34, line 26: Delete "secs. l and 2" Insert "secs. 2 and 3" Page 34, line 28: Delete "secs. 6 - 13" Insert "secs. 7 - 14" Page 34, line 30: Delete "secs. 6 - 13" Insert "secs. 7 - 14" Page 35, line l: Delete "secs. 18 and 20" Insert "secs. 19 and 21" Page 35, line 3: Delete "secs. 18 and 20" Insert "secs. 19 and 21" Page 35, line 5: Delete "secs. 23 - 25" Insert "secs. 24 - 26" Page 35, line 7: Delete "secs. 23 - 25" Insert "secs. 24 - 26" Page 35, line 8: Delete "Section 27" Insert "Section 28" Page 35, line I 0: Delete "Section 32" Insert "Section 33" Page 35, line 12: Delete "Section 33" Insert "Section 34" Page 35, line 14: Delete "Section 35" Insert "Section 36" Page 35, line 16: Delete "Section 36" Insert "Section 37" Page 35, line 18: Delete "Sections 37 and 38" Insert "Sections 38 and 39" Page 35, line 20: Delete "Section 41" Insert "Section 42" Page 35, line 22: Delete "Section 1, 2, 6 - 13, 18, 20, 23 - 25, 34, and 39" Insert "Sections 2, 3, 7 - 14, 19, 21, 24 - 26, 35, and 40" Page 35, line 24: Delete "Sections 31 and 42" Insert "Sections 32 and 43" Page 35, line 25: Delete "secs. 45 - 53" Insert "secs. 46 - 54" Representative Wilson OBJECTED for the purposes of discussion. Co-Chair Seaton spoke to his amendment. He explained that the amendment inserted intent language clarifying that the seven day limit for initial opioid prescription should be considered a minimum. He cited CDC data that discovered that a 3 day supply alleviated most cases of acute pain and the likelihood of chronic opioid use increased with each additional day. A sharp increase in risk occurred on the 5th day, with a second prescription or refill, 700 milligrams of morphine equivalents, or an initial 10 or 30 day supply. He wanted the intent language to clarify that while the provider maintained the discretion to prescribe a seven day prescription, the full amount was not appropriate in every situation and definitely not a mandate. Vice-Chair Gara supported the amendment and reminded the committee that intent language was uncodified law and was not included in statute. He advocated for a "presumptive number" set in statute, which was currently 7 days in the bill and questioned whether it was the proper number. 2:56:24 PM Representative Ortiz asked Dr. Butler whether the amendment "limited the overall intent of the bill." Dr. Butler thought the amendment was very reasonable. He explained that the number of days was not intended to define a length of a prescription but to define when a greater quantity was justified in the medical record. He thought Co-Chair Seaton's amendment was rational and he supported it. Representative Wilson WITHDREW her OBJECTION. Vice-Chair Gara MOVED to AMEND Amendment 2. He offered Conceptual Amendment 1 to delete the language in line 3 that read: The uncodified law of the State of Alaska is amended by adding a new section to read: Vice-Chair Gara explained that he wanted the language to remain in statute. Co-Chair Seaton asked for a brief "at ease" in order to consult with legal services. Vice-Chair Gara WITHDREW his Conceptual Amendment 1 to Amendment 2. Vice-Chair Gara WITHDREW his OBJECTION. There being NO OBJECTION, it was so ordered. Amendment 2 was ADOPTED. Co-Chair Seaton MOVED to ADOPT Amendment 3 (copy on file): Page 8, line 27, following "Surgeons": Insert "or by the National Board of Osteopathic Medical Examiners" Representative Wilson OBJECTED for the purposes of discussion. Co-Chair Seaton reviewed the amendment. He conveyed that the amendment updated a portion of the licensing statute related to Osteopathic Physicians by updating the name of the national examination certification board. The bill listed the board's name as the National Board of Examiners of Osteopathic Physicians and Surgeons. However, the board was currently known as the National Board of Osteopathic Medical Examiners and would be inserted in the legislation along with the existing name. He noted that some osteopaths in the state might still have their license under the previous name of the board. Representative Wilson WITHDREW her OBJECTION. There being NO OBJECTION, it was so ordered. Amendment 3 was ADOPTED. 3:01:08 PM Co-Chair Seaton MOVED to ADOPT Amendment 4 (copy on file): Page 26, line 10, following "older": Insert "or an emancipated minor, a parent or legal guardian of a minor, or an individual's guardian or other person appointed by the individual or a court to manage the individual's health care" Page 26, line 12, following "individual": Insert "or the minor" Page 26, line 18, following "individual": Insert "a parent or legal guardian of a minor, or an individual's guardian or other person appointed by the individual or a court to manage the individual's health care" Page 26, lines 24 - 30: Delete all material and insert: "(c) An individual who is 18 years of age or older or an emancipated minor, a parent or legal guardian of a minor, or an individual's guardian or other person appointed by the individual or a court to manage the individual's health care may revoke a voluntary nonopioid directive at any time in writing or orally." Page 26, line 31, following "individual": Insert, "a parent or legal guardian of a minor, or an individual's guardian or other person appointed by the individual or a court to manage the individual's health care" Page 27, line 7: Delete "who has executed" Insert "or a minor who has" Page 27, line 11: Delete "a controlled substance" Insert "an opioid" Following "individual's": Insert "or a minor's" Page 27, following line 24: Insert a new paragraph to read: "(2) "emancipated minor" means a minor whose disabilities have been removed for general purposes under AS 09.55.590;" Renumber the following paragraphs accordingly. Page 27, following line 26: Insert a new paragraph to read: "(5)"minor" means an individual who is under 18 years of age and is unemancipated;" Renumber the following paragraphs accordingly. Representative Wilson OBJECTED. Co-Chair Seaton presented the amendment. He purported that the amendment was related to the opioid directive for minors. The amendment allowed parents or guardians of minors to issue an opioid directive on behalf of the child. Currently, the directive only applied to individuals 18 years or older, but minors were also prescribed opioids or had already experienced addiction. He explained that in emergency situations a child may be treated without parental consent and the directive would notify the practitioner to avoid opioid use. He added that the amendment clarified the role of legal guardians for non- minors. Previously, legal guardians could revoke a directive but not execute one. The department concurred that a legal guardian should be able to execute a directive therefore, the provision was included in the amendment. Representative Wilson cited page 27, line 24 of the bill or page 2 of the amendment and asked whether the definition of emancipated minor was new. 3:03:45 PM TANEEKA HANSEN, STAFF, REPRESENTATIVE PAUL SEATON, informed the committee that staff from Legislative Legal Services would be able to answer the question. Representative Wilson stated that she supported the amendment as long as the definition of emancipated minor was not altered. She requested that the committee waited to hear from legal services before voting on the amendment. Ms. Kraly responded that the definition was not changed from current statute. She detailed that the language on page 2, lines 13 through 14 of the amendment referenced AS 09.55.590, which was the definition of emancipation. Representative Wilson repeated her question regarding the definition of emancipation of a minor. LINDA BRUCE, ATTORNEY, LEGISLATIVE LEGAL SERVICES, confirmed that the definition was not changing. She indicated that the existing definition was cited in the section. Representative Wilson WITHDREW her OBJECTION. There being NO OBJECTION, it was so ordered. Amendment 4 was ADOPTED. 3:07:03 PM Vice-Chair Gara MOVED to ADOPT New Conceptual Amendment 5 (copy on file): On page 5, lines 23,25,30,31 and page 6, lines 6 and 9 replace "seven-day" with "five-day." Make confirming language changes as needed. Representative Wilson OBJECTED for the purposes of discussion. Vice-Chair Gara spoke to his amendment. He cited the CDC study [Morbidity and Mortality Weekly Report, March 17, 2017 I Vol. 66, No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention] of which he distributed one page [267] (copy on file) that reported the risk of opioid addiction rose sharply after 5 days of the initial prescription and that for most people a 3 day supply was effective. He noted the bill's waiver for an initial prescription that was longer than 7 days. He asserted that the bill should reflect the science that the addiction risk grew sharply after 5 days and proposed the change in the amendment. He emphasized that the change was appropriate due to the waiver for longer periods of time in the bill. He remarked that the intent of the amendment was to include all healthcare prescribers that had prescription authority. Representative Thompson asked whether Amendment 5 altered the intent language in Amendment 2. Vice-Chair Gara answered that the amendment would mesh with Amendment 5 and state that the intent was to prescribe for less than 5 days unless otherwise necessary. He thought the amendment would remain the same but mean fewer than 5 instead of fewer than 7 days. 3:10:44 PM Representative Kawasaki asked whether the amendment included all prescribers. Vice-Chair Gara responded in the affirmative. Representative Kawasaki noted that the CDC had recommendations for chronic pain and separate guidelines for cancer or palliative care. He observed that the bill referenced the limited supply for a person with chronic pain and wondered whether how that affected a person with cancer or palliative care. Vice-Chair Gara deferred the question to Dr. Butler. He recounted that the doctor had the authority to prescribe for longer than the limit depending on the situation in either the bill or amendment. Dr. Butler responded that the waiver provided the protections as defined in the CDC guidelines. He commented that the CDC guideline was "a guideline and not a specific study." He expounded that a summary of the available data in 2015 was used to develop the guideline published in early 2016. The discussion regarding 5 or 7 days was not available in 2015. He concurred with the CDC guideline that pointed to the 3 day supply as being optimal and that a 7 day supply was rarely necessary. He referred to the CDC line graph he referenced earlier and characterized the line as a line of increasing risk containing "a couple bumps that were steeper at 5 and 30 days" but did not represent a "sudden quadrupling of the risk." 3:14:32 PM Representative Ortiz asked whether Amendment 5 was drafted without consultation with DHSS. Vice-Chair Gara answered in the affirmative and commented that the amendment was based on the department's testimony and the CDC information. He noted that he spoke with the department. Representative Ortiz asked Dr. Butler how he felt about Conceptual Amendment 5. Dr. Butler understood that the administration did not support the amendment. He felt that the amendment containing the intent language [Amendment 2] struck the balance between risks and benefits. Co-Chair Seaton clarified that Dr. Butler was talking about a line graph, which was not handed out and requested distribution of the document. [MMWR dated March 17, 2017 Vol. 66, No. 10 CDC page 267] He conveyed that the CDC guideline reference that Dr. Butler previously discussed was from the Morbidity and Mortality Weekly Report, March 15, 2016, Vol. 65, - US Department of Health and Human Services/Centers for Disease Control and Prevention (copy on file). He read from the March 17, 2017 handout: The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids have been prescribed… Co-Chair Seaton queried why the committee should not embrace the most recent CDC data that demonstrated an increased risk after 5 days of use and adjust the legislation. Dr. Butler remarked that the graph was a helpful visual aid but the department focused on the textural interpretation of the report. He furthered that the main structural advantage of retaining the 7 day supply was the conceptual ease for the provider keeping track of calendar days. He speculated that 5 days was a bit more complicated. 3:19:21 PM  Vice-Chair Gara asked whether the concern over a doctor's had the ability to perform simple math was on balance with the CDC stated guideline that after 5 days addiction grew sharply. Dr. Butler was not remarking on the ability of providers to prescribe for 5 days versus 7 days. He articulated that he wanted to make the guidelines as easy as possible for busy providers. Representative Kawasaki asked whether the consequence of prescribing an opioid past the 7 day limit was that the provider was required to document and justify the event in the patient's chart. Dr. Butler responded in the affirmative. Representative Kawasaki wondered whether the prescriber would feel that she had to prescribe lesser amounts to avoid reporting. Dr. Butler thought he raised a good question and was not sure whether the reporting was significant to a prescriber or not. 3:23:11 PM Representative Ortiz understood Vice-Chair Gara's concern but was not comfortable with further accessing the relevance of the issue. He felt that the department thoroughly vetted the issue before the decision was made. Co-Chair Seaton referred to the 2 charts on the CDC handout [MMWR, March 17, 2017 Vol. 66, No. 10 - CDC, page 267 (copy on file)] he cited earlier and asked for an explanation of the second chart the depicted the number of prescriptions in the first episode of opioid use. Dr. Butler referred to the first chart that depicted the days' supply of first opioid prescription. He explained that the solid line denoted the 1 year probability and the vertical line denoted the probability of continuing use [1 to 100 percent] by the number of days' supply in the horizontal axis. He noted the steeper upswing between 5 to 7 days and a slight leveling off and did not feel the increase was much more dramatic at 5 days than seven. Co-Chair Seaton interpreted that the risk at five days was roughly 7 percent and 7 to 8 days was over 15 percent and asked whether he concurred. Dr. Butler interpreted the data a 10 percent risk at 5 days and 13 to 14 percent at 7 days. Vice-Chair Gara was "really confused" about the department's balancing of risks and rewards. He interpreted the data to read a sharp rise in the risk of addiction from 10 percent to 15 percent from 5 to 6 days. He cited the text and read: …increases most sharply in the first days of therapy particularly after five days. Vice-Chair Gara voiced that the graph concurred with the narrative. He reiterated his skepticism that the burden of choosing a limit based on prescribing around calendar days was worth the increased risk of addiction. He felt that the danger to the public was demonstrated to be much higher at 7 days and even higher at 10 days, roughly 20 percent. Dr. Butler did not intend to imply that Vice-Chair Gara's interpretation was "way off." Vice-Chair Gara asked whether Dr. Butler thought the 5-day limit was bad policy. Dr. Butler replied in the negative and would not object to the amendment. 3:30:20 PM VALERIE DAVIDSON, COMMISSIONER, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, attempted to provide more clarity. She relayed that there was nothing in the bill that precluded the provider from writing a prescription for less than 7 days. The bill required the provider to justify in the medical record why the script was written for more than 7 days. She shared that the department had worked with providers to find an amount of time that did not pose an administrative burden and 7 days was agreed upon. She was uncertain how providers would react to the amendment. Representative Wilson thought the issue had been properly vetted. She had not heard objections from providers regarding the current 7 day limit. She did not support the amendment. Co-Chair Seaton asked whether a doctor could prescribe a refill for an initial opioid prescription. Dr. Butler answered in the affirmative and added that the refill was possible due to the waiver. Co-Chair Seaton clarified that he was asking about a refill on an initial 3 day or 5 day prescription. He indicated that the objective of HB 159 was to halt the opioid epidemic that was partially caused by over prescribing. He reiterated his inquiry regarding whether a refill on a 3 or 5 day prescription was allowed under the bill. He wanted to place "downward pressure on initial prescriptions" and strike a balance between need and the 5 and 7 day options. He deduced that if a refill was allowable, without a further prescription, the distinction between the 5 and 7 day was irrelevant. 3:36:18 PM Commissioner Davidson responded that the way the bill was written the 7 day limit applied to the initial prescription. She added that the refill was considered a second prescription and fell outside of the scope of the seven day limit. The bill allowed a patient to request a partial fill of a prescription. She indicated that the bill attempted to "reset" the standard practice of automatically prescribing much larger amounts i.e., 30 days. She restated that the bill recognized instances where a longer dose was necessary by providing the waiver and the required justification. Vice-Chair Gara understood that a doctor could already prescribe less but the bill was necessary to create a standard. Commissioner Davidson responded, "That is correct." Vice-Chair Gara reasoned that the question was what the standard should be. He noted that the CDC data was released subsequent to the bill's introduction. He asked whether she had spoken to the providers about the spike in risk that occurred after 5 days. Dr. Butler shared that he used the same graph in a slide when he spoke to providers about the bill. None had spoken out about the issue. Vice-Chair Gara cited statistics that the state experienced 90 deaths due to opioid addiction and two thirds were linked to prescription use. He reiterated that the risk for abuse sharply increased after five days. He stressed that even though providers did not weigh in on the issue the legislature could make the "policy call." He asserted that the bill needed to include a guideline and that the guideline should be 5 days; the point before prescription opioid abuse rose sharply. 3:41:06 PM Representative Wilson MAINTAINED her OBJECTION. A roll call vote was taken on the motion. IN FAVOR: Gara, Grenn, Thompson, Seaton OPPOSED: Wilson, Kawasaki, Ortiz, Pruitt, Tilton, Foster. Representative Guttenberg was absent from the vote. The MOTION to ADOPT Amendment 5 FAILED (4/6). Amendment 5 FAILED to be ADOPTED. Co-Chair Foster asked Vice-Chair Gara to discuss the fiscal notes. Vice-Chair Gara had a question regarding Amendment 2. He reiterated that the amendment provided intent language clarifying that the provider could prescribe an initial opioid prescription for less than seven days. He asked if the language, "The uncodified law of the State of Alaska is amended by adding a new section to read:" was deleted on lines 3 and 4 would the intent language remain in the statue books. LINDA BRUCE, ATTORNEY, LEGISLATIVE LEGAL SERVICES, asked whether he meant that by removing the uncodified lead-in the language would be codified law. Vice-Chair Gara explained that he wanted the intent language to remain in statute. Ms. Bruce did not believe that as drafted the Amendment 2 language would appear in the statute. Vice-Chair Gara restated his question regarding removing the lead-in language and adding a new section if Amendment 2 would remain in statute. Ms. Bruce responded in the negative. She clarified that a section number was necessary and substantive language needed to replace the intent language. 3:45:42 PM Vice-Chair Gara reviewed the Department of Commerce, Community and Economic Development fiscal note FN 3 (CED) appropriated to the Division of Corporations Businesses and Professional Licensing in the amount of $27.5 thousand for legal and printing costs for new regulations. The second fiscal note DHSS FN 2 (DHS) was zero. 3:46:58 PM AT EASE 3:47:11 PM RECONVENED Co-Chair Foster noted that Fiscal 1 was no longer relevant. Co-Chair Seaton MOVED to report CSHB 159(FIN) out of Committee with individual recommendations and the accompanying fiscal notes. Representative Wilson OBJECTED. Representative Wilson felt that the legislature was attempting to be doctors and the bill was "beyond the scope of where we belong." She believed that overprescribing should be a crime. The bill only contained suggested guidelines and included ways to maintain the overprescribing practices. She believed that the decisions were better left up to the medical professionals and their boards and allow them to deal with the problem. 3:49:59 PM Representative Pruitt disagreed with his colleague from North Pole. He thought that the medical community was slow to respond to the crisis. He felt that the problem "ballooned" rapidly. He believed that the epidemic warranted government intervention for the public's protection. He supported the legislation and thanked the sponsor for introducing the bill. Representative Kawasaki thanked the administration for bringing the legislation forward. He commented that the United States had 28 thousand deaths due to prescription opioids last year; half were procured legally. The black market for opioids was still a major part of the problem but the legislation addressed part of the issue. Representative Grenn appreciated the department's efforts and felt that the bill sent a "strong message" of awareness to all parts of the state. He approved of Dr. Butler's three pronged approach: working with patients, physicians, and prescribing. Representative Guttenberg thought the issue crossed multiple lines. He elucidated that the medical community was self-regulating and was inattentive to "broad public policy." The pharmacists were prescribing drugs and filling prescriptions and the pharmaceutical companies were manufacturing and marketing drugs under their own agendas. He believed that the factors made addressing the problem difficult. 3:55:49 PM Co-Chair Seaton addressed the previous testifier, Michael Karson's comments. He believed that the state was "tinkering around the edges attempting to get something under control." He thought the state had a problem to solve when 85 percent of addiction was started with prescription opioids and warned that the bill was only part of the solution. He agreed with Mr. Karson's comments regarding prevention and upstream solutions and felt they offered a "better" solution. He advocated for a holistic approach to the problem. He thanked all who worked on the bill. Vice-Chair Gara agreed with all of Co-Chair Seaton's comments and also thanked the department. He maintained that physicians remaining silent during a power point presentation containing the 5 or 7 day data was not enough "evidence" to standby the 7 day period, especially when prescribers opinions were not directly solicited. He considered the issue unresolved. He urged the department to revisit the issue with providers to determine whether it was worth choosing the 5 day limit "to save extra lives." Representative Wilson MAINTAINED her OBJECTION. A roll call vote was taken on the motion. IN FAVOR: Gara, Grenn, Guttenberg, Kawasaki, Ortiz, Pruitt, Thompson, Foster, Seaton OPPOSED: Tilton, Wilson The MOTION PASSED (9/2). CSHB 159(FIN) was REPORTED out of committee with a "do pass" recommendation and with two previously published fiscal notes, one zero note: FN2 (DHS); and one fiscal impact note: FN3 (CED). 3:59:14 PM Co-Chair Foster indicated that due to time constraints the committee would not hear SB 28 today. 3:59:35 PM AT EASE 4:17:27 PM RECONVENED HOUSE BILL NO. 6 "An Act establishing the Jonesville Public Use Area." 4:17:36 PM REPRESENTATIVE GEORGE RAUCHER, SPONSOR, thanked the committee for hearing the legislation. He provided information about the legislation. The bill provided an opportunity to make a public use area for the community of Sutton in conjunction with the Matanuska/Susitna Borough, Department of Natural Resources (DNR), Alaska Mental Health Trust Authority (AMHTA), and all of the user groups. The bill simply authorized a public use area that allowed the community to design a management plan in the future. Co-Chair Foster OPENED public testimony. CAROL CARMAN, SELF, PALMER (via teleconference), testified in support of the legislation. She relayed information about a man who had been shot and killed in the Jonesville mine area about one year earlier. She shared that the area was popular with campers, four wheelers, and shooters. The area lacked management and was littered with trash, unsafe with frequent shooting incidences, experienced stray gunfire, and out of control, which created safety issues for residents living in the area. She shared another story about an individual shooting into a crowd around a bonfire. The area was heavily used. She discussed that the police needed to have the ability to take preventative measures instead of merely responding to negative events after they took place in the area. She remarked that the legislature passed bill's dealing with honoring indigenous people and African American soldier's efforts to build the Alaska Highway during World War 2 and opined that HB 6 was "passed over." She urged the committee and legislature to pass the legislation. 4:23:47 PM RYAN BRETT, AK MUDSLINGERS, ANCHORAGE (via teleconference), spoke in favor of the legislation. He provided information about the organization and noted that the group conducted an annual Jim Creek/Knik River area cleanup where over 1000 people participated. He reported a large decrease in trash. He shared that the same issues in the Sutton area were present in the Jim Creek/Knik River area prior to management. He had personally seen bonfires and out of control activities in the unmanaged area in Sutton. He believed the bill would have a positive impact on the area and all user groups. He spoke to protecting the community of Sutton. He reported that his organization was conducting a Jonesville area cleanup in June. The annual cleanups provided more exposure to the issue. He asked the committee to pass the bill. Representative Tilton thanked Mr. Brett for coordinating the cleanups and for the way he ran the organization. 4:26:45 PM PATTI BARBER, SELF, MAT-SU (via teleconference), testified in support of the legislation. She stated that the area was popular and needed direction to contain the uncontrolled use. She spoke to the burned out vehicles, trash, and bullets in the area. She related that the community of Butte had the same problems until the Knik River Public Use Area was established. She believed that creating the Jonesville Public Use area would educate the public about using the area safety and advocated for funding in the future. 4:27:56 PM KENNY BARBER, SELF, MAT-SU (via teleconference), spoke in support of the bill. He believed it was a positive effort and hoped for financial support of the area in the future. 4:28:54 PM Co-Chair Foster CLOSED public testimony. Vice-Chair Gara addressed the four zero fiscal notes from the Department of Natural Resources, Department of Public Safety, and the Department of Fish and Game. Representative Kawasaki asked for discussion regarding the two fiscal notes from DPS. 4:31:20 PM AT EASE 4:31:33 PM RECONVENED 4:31:47 PM CLARK COX, NATURAL RESOURCE MANAGER, DEPARTMENT OF NATURAL RESOURCES (via teleconference), introduced himself and asked Representative Kawasaki to repeat his question. Representative Kawasaki noted that the DNR fiscal note from the Division of Mining, Land and Water discussed that troopers were unlikely to provide enforcement in the area. Mr. Cox explained that the departments gauged HB 6 to the Knik River Public Use area when creating the fiscal notes. The Knik River area was very successful due to the funding appropriated when the area was established. The appropriation afforded one DNR staffer and funding for troopers for enforcement. Representative Kawasaki indicated that Mr. Cox's response clarified his question. He remembered that previously a fiscal note attached to the establishment of the Knik River Public Use Area was roughly $400 thousand in 2007. The major portion of the funding was for creation of the management plan. He asked how DNR would prioritize the planning work for Jonesville with a zero fiscal note. Mr. Cox answered that the Knik River planning took several years with ample funding and the Jonesville area would take much longer with a zero fiscal note. Representative Kawasaki cautioned the Jonesville Public Use Area's supporters that without funding the proposal and management plan would take a long time to implement. He noted that troopers and a half-time ranger was necessary for the Knik River area. 4:36:22 PM DARREL BREEZE, STAFF, REPRESENTATIVE GEORGE RAUCHER, noted the letter in member's packet from the commissioner of DNR, Andrew Mack (copy on file) and pointed to the second paragraph that stated without additional funding the process was expected to take 5 years. He related that the sponsor acknowledged that the plan would take time. He favored taking five years to work with the community, borough, and users to develop a management plan that met the needs of all of the users. Representative Wilson asked whether the sponsor was expecting the borough to play a large role in developing the plan to present to DNR and participate in fundraising efforts unlike the development of the Knik River area. Representative Raucher answered in the affirmative. He referred to Page 2, lines 10 through 11 of the bill: …the commissioner may designate incompatible uses and shall adopt and may revise a management plan for the Jonesville Public Use Area…. Representative Raucher expounded that the bill did not stipulate that DNR should write the management plan. The Matsu Borough was committed to developing the public use area and was willing to help write the management plan and help facilitate the public process among user groups. There was currently a 30 page plan developed from surveys and previously meeting and working with user groups every other week. The same process would be used to continue building the comprehensive plan to present to DNR for their review and approval. Representative Wilson thanked the representative for working with local government, the community, and user groups. She thought that everyone would understand that the project would not happen overnight. 4:41:40 PM Co-Chair Seaton MOVED to report CSHB 6(RES) out of Committee with individual recommendations and the accompanying fiscal notes. There being NO OBJECTION, it was so ordered. CSHB 6(RES) was REPORTED out of committee with a "do pass" recommendation and with three previously published zero fiscal notes, FN1 (DNR), FN 2 (DPS), FN3 (DPS); and one new zero fiscal note from the Department of Natural Resources. Co-Chair Foster reviewed the agenda for the following meeting. ADJOURNMENT 4:43:41 PM The meeting was adjourned at 4:43 p.m.