HB 174-EXTEND DISASTER EMERGENCY: OPIOID EPIDEMIC  3:50:59 PM CHAIR SPOHNHOLZ announced that the final order of business would be HOUSE BILL NO. 174, "An Act extending the governor's declaration of disaster emergency to address the opioid epidemic; and providing for an effective date." 3:51:17 PM JAY BUTLER, MD, Chief Medical Officer/ DPH Director, Central Office, Division of Public Health, Department of Health and Social Services, declared that there were challenges with the opioid epidemic, as there had been a fourfold increase of death from opioids in the past 20 years. He said that the Department of Health and Social Services was awarded a five year grant to support opioid overdose prevention programs in 2016. He said that this included distribution of naloxone, the lifesaving drug administered for an opioid overdose. He shared that there was a nasal spray form which was now part of the rescue kits in Project HOPE, Harm reduction, Overdose Prevention, and Education. He said that Project HOPE had prioritized partnerships with the staff of organizations which did not have medical direction, but were most likely to be present when an overdose occurred. The department had explored ways to provide the kits under a standing medical order, but the authority to declare the standing order required a disaster declaration. He added that although there were a number of mechanisms to achieve the authority, this seemed to be the way to do it as quickly as possible and take advantage of the federal resources that had been made available. Governor Walker issued the declaration on February 14, with an anticipated legislative concurrent resolution to extend the declaration longer that the than the 30 day duration defined by Alaska statute. He emphasized that no state general funds were requested to support Project HOPE, as it was supported entirely by the federal grant. Since that declaration, 12 partner organizations had received training to dispense the medication and provide the kit, and nearly 1300 kits had been dispensed. He reported that Legislative Legal Services had a different interpretation for the meaning of a concurrent resolution and had determined that instead a bill was required to extend the declaration and continue distribution of the kits under the standing order. 3:54:50 PM DR. BUTLER paraphrased the Sectional Analysis [Included in members' packets], which read: Sec. 1 includes findings on the extent of the public health threat; acknowledgement and description of the Governor's disaster declaration; and the need for the legislature to extend the declaration to address the epidemic. Sec. 2 extends the February 14, 2017, disaster declaration for one year to February 14, 2018. Sec. 3 makes the effective date retroactive to March 15, 2017, when the disaster declaration expires. REPRESENTATIVE JOHNSTON asked if the bill was mainly to distribute [naloxone], and if there was any other way to accomplish this. DR. BUTLER explained that naloxone was an FDA (US Food and Drug Administration) approved drug which could be acquired with a physician's prescription. To work with the partners in the program and distribute the overdose kits, it was necessary to have a standing order under the authority of his prescribing license, although the best way forward appeared to be as part of a disaster declaration. REPRESENTATIVE JOHNSTON asked if DHSS was looking for further federal grants. DR. BUTLER replied that this disaster declaration would primarily achieve the goal of the standing order for the naloxone distribution, although other grants and other funding sources were being reviewed. REPRESENTATIVE JOHNSTON asked if the proposed bill was necessary to apply for the grants. DR. BUTLER said they could have applied for the grants without the proposed bill. 3:57:54 PM REPRESENTATIVE KITO asked what would happen after the deadline in the disaster declaration of February 14, 2018. DR. BUTLER replied that an extension would be necessary if it was decided to continue distribution under the standing order. REPRESENTATIVE KITO asked if there was a designated time frame for the grant. DR. BUTLER replied that this was a 5 year grant, effective October 1, 2016, the beginning of the federal fiscal year. REPRESENTATIVE EASTMAN asked about the number of heroin overdose deaths in 2015. DR. BUTLER reported that there were 38 deaths when heroin was associated or morphine was detected in post mortem. He said that although it was not uncommon for there to be multiple drugs, multiple opioids could be recognized at death. He pointed out that the trend was increasing significantly, and mirrored other parts of the U.S. and Canada. REPRESENTATIVE EASTMAN asked about the number of deaths in 2016. DR. BUTLER opined that this was in the mid-40s. REPRESENTATIVE EASTMAN asked when the final numbers would be released. DR. BUTLER replied that he hoped to have the final numbers by the end of March. REPRESENTATIVE SULLIVAN-LEONARD asked if the statistics were heroin related only or opioid and/or heroin related. DR. BUTLER replied that these were related to heroin, although there were more than 80 opioid associated deaths. He explained that prescription opioids were frequently used interchangeably, and about 80 percent of heroin users reported that they started with prescription opioids. CHAIR SPOHNHOLZ asked about the best tool for utilization after a year, as proposed HB 174 would expire after one year. DR. BUTLER said that he was not sure of the best mechanism. He said that current state law did not provide the authority for the state medical officer to issue standing orders, which had been the reason for the earlier disaster declaration. He declared that the proposed bill was a short term fix for a possibly longer term administrative fix. 4:03:42 PM STACIE KRALY, Chief Assistant Attorney General, Statewide Section Supervisor, Human Services Section, Civil Division (Juneau), Department of Law, said that she concurred with the testimony of Dr. Butler, that the proposed bill was a response to the emergency nature of the event. She offered her belief that an additional statutory fix would be necessary, although it would not require extension of the proposed bill. She relayed that it would be necessary to find the authority for Dr. Butler to issue the standing orders. She said that there had been an oversight in the passage of Senate Bill 23 last year, which created the mechanism for the distribution of naloxone, as it did not allow for the chief medical officer to issue standing orders, although there was intent for that to be fixed. CHAIR SPOHNHOLZ suggested that the proposed bill was an intermediate remedy. MS. KRALY expressed agreement. REPRESENTATIVE EASTMAN asked what would be done if the proposed bill did not pass. MS. KRALY replied that, as there would not be any standing order for the authority to issue the kits, a statutory change would be necessary for the authorization. REPRESENTATIVE EASTMAN asked what could be accomplished with memorandums of agreement instead of a statutory change. MS. KRALY offered her belief that, without licensed physicians to step in and provide oversight and standing order services, the memorandums of understanding or agreement "would not get us very far." She declared that it was necessary for a licensed physician to issue the standing order, and without that, there would be a large gap period for administering the kits. REPRESENTATIVE EDGMON asked about the zero fiscal note in light of page 2, line 6 of the proposed bill which discussed the establishment of a statewide overdose response program. He asked "how much teeth" this would have. DR. BUTLER replied that this was a valuable tool for saving a life, but it did not cure addiction. He stated that the broader response needed to include access to care and the de- stigmatizing of addiction. He explained that addiction was a condition of the brain which needed to be managed as a chronic health condition. He added that it was necessary to address ways to manage pain, some of the drivers for self-medication, and the amount of opioid pain relievers in the community. He reported that the fiscal note focused entirely on the aforementioned Project Hope. He stated that this would be a long term emergency response, similar to a major natural disaster, with an incident command structure to coordinate the prolonged recovery phase. REPRESENTATIVE EDGMON said that he was supportive of the effort and the proposed bill, but that he was skeptical in the broader sense that the necessary resources to effectively combat substance abuse in Alaska were being made available. DR. BUTLER acknowledged that Representative Edgmon had captured the complexity of the issue, although, he pointed out, alcohol still killed more Alaskans than opioids. He added that alcohol deaths had not been on the same dramatic increase. He stated that there was not a similar tool for alcohol related mortality. 4:13:16 PM VALERIE DAVIDSON, Commissioner, Office of the Commissioner, Department of Health and Social Services (DHSS), acknowledged that the proposed bill would not solve the problem. She explained that Department of Health and Social Services was taking a multi-faceted approach with application to "every federal dollar that we possibly can" and that they had secured four federal grants designed to do different things. She explained that the grant mentioned in the proposed bill would be for administration of an immediate lifesaving intervention for people during active overdose. She reported that there were additional federal grants about education and prevention, to ensure understanding for the dangers of opioids, as well as allowing for treatment services. She relayed that the Alaska State Legislature had made funds available in 2016 to provide treatment for women with children. She said that Central Peninsula Hospital had received a grant to provide for immediate detoxification services. She reported that DHSS had applied for a $2 million grant to allow for medication assisted treatment to "assist folks to be able to stay clean" combined with available therapy to "get to the root of the problem" "which was why people are self-medicating." She declared that there was not any magic treatment or magic pill. She stated that DHSS was also pursuing a [Section] 1115 behavioral health waiver, which would allow for a complete redesign of the behavioral health system as it was recognized that there were gaps in the continuum of care. She reported that there were ongoing studies for determining "the best place for us to be able to provide those services, what are we missing, can we intervene sooner." She shared that Alaska had been disproportionately impacted by a federal law which precluded facilities with more than 16 beds to seek reimbursement from Medicaid. She reported that DHSS had received guidance from the Centers for Medicare and Medicaid Services for working through this with an amended [Section] 1115 waiver. REPRESENTATIVE KITO asked for explanation to the limitation on 16 beds for treatment. COMMISSIONER DAVIDSON, in response, explained that previously individuals experiencing severe mental illness were institutionalized. The U.S. Congress recognized that housing those with serious mental illness was not an efficacious way to support people, and, instead, to treat people in the least restrictive environment. There was an unintended consequence that facilities with more than 16 beds providing for substance use disorders were impacted. She pointed out that this was possible in the Lower 48, as there was a larger economy of scale, but, as this was not economically feasible in Alaska, it impacted the ability to provide more treatment services. REPRESENTATIVE KITO suggested that, as smaller facilities had higher incremental costs, hopefully Alaska could address this issue. REPRESENTATIVE EASTMAN compared the number of heroin deaths to a murder epidemic in Alaska. He said that he was familiar with the declaration process, and that the disaster act was designed to allow cases of urgent need to bypass the normal appropriations process, and allow the administration the opportunity to act decisively without the accompanying bureaucracy in the budgeting process. He offered his belief that the declaration in the proposed bill would allow the governor greater access to funding. He questioned whether the proposed bill was offering this temptation. COMMISSIONER DAVIDSON explained that the original disaster allocation by the governor was "actually drafted extremely narrowly and limited the resources available to the state to those of the federal grant." She stated that the zero fiscal note [Included in members' packets] accompanying the proposed bill was due to the limits to available federal resources of the original disaster declaration. REPRESENTATIVE EASTMAN, directing attention to the limited resources and the stop gap solution of the proposed bill, asked what would be the next options. COMMISSIONER DAVIDSON replied that the current challenge was that the Chief Medical Officer did not have the authority in state statute to provide the standing order. She explained that DHSS was trying to ensure that its community based partner organizations without medical directors or physicians able to write a standing order could instead use the standing orders of the Chief Medical Officer limited to immediate distribution of the naloxone kits, and ensure that as many kits as possible were distributed as quickly as possible. She offered as a longer term solution to provide the Chief Medical Officer with the authority to issue standing orders when necessary. REPRESENTATIVE EASTMAN asked about the liability incurred with any mishaps when naloxone was administered. DR. BUTLER said that he would not be taking this on beyond the protections afforded under Senate Bill 23, which focused on establishing the guidelines around the training. He said that, as Emergency Medical Services personnel had medical supervision and were already carrying the kits, they were not a focus of Project HOPE. REPRESENTATIVE SULLIVAN-LEONARD offered a personal story and reflected on the progress of the work in the Matanuska-Susitna Valley. She reminded the committee that there were also epi- pens for allergic reactions, and that more training and more education would have a greater effect on the epidemic. 4:26:18 PM CHAIR SPOHNHOLZ opened public testimony. 4:26:52 PM TERRIA WALTERS, President, Founder, Fallen Up Ministries, offered a personal story, and stated that she was in long term recovery. She spoke about using a calculation for those who had lived because of the administration of [naloxone], instead of calculating the deaths. She declared support for HB 174, noting that the lack of resources in the state ensured that many individuals would continue to use drugs and take the risk for overdose. She reiterated that the availability of naloxone meant that an overdose could be revived. She reported that Fallen Up Ministries was conducting a detoxification project which would serve 25 patients, and would be used for data collection. She shared that she had been clean and sober for almost 12 years. She estimated that 129 people died of drug overdose daily, declaring that this was a disaster. 4:31:44 PM MARK WEAVER, Vice President, Fallen Up Ministries, shared his background with local opioid task forces and declared his support for HB 174. He offered some of his personal experiences. He opined that a gap in the disaster declaration would "just be ridiculous." He compared [naloxone] to a defibrillator or a fire extinguisher. He stated that once a life had been saved, the individual could be directed toward available resources for breaking "the entrapment of addiction." He noted that many people who did not live in downtown locales were struggling. He declared his desire to help the community. He added that most of his group were volunteers. 4:35:16 PM SERENA ESPINOZA, Vice President, Real About Addiction, Board Administrator, Fallen Up Ministries, reported that she was also a member of the local opiate task forces. She stated that she had seen too many accidental overdose deaths, and that there would have been a chance at recovery if there was access to [naloxone]. She declared that it was necessary to distribute naloxone and have continued access to it. She offered her belief that non-profit treatment facilities, medical providers, emergency responders, families of addicts, and recovery advocates would play an important role in saving the lives of Alaskans if there was immediate access to the [Project} HOPE kits. She added that the medication disposal bags would also play a large role in prevention by keeping opiates out of the hands of youth. She stated her support for the proposed bill. 4:37:49 PM KARA NELSON, Director, Haven House, Juneau, shared some background of Haven House and stated that she was in long term recovery. She said that Haven House, as a recovery residence, was in partnership with Project HOPE, and offered help to many women in the community. She shared that they were providing peer support services as volunteers. She stated her support of HB 174 and the extension for the declaration of disaster to address the opioid epidemic. She reiterated that this was a place of hope for the many organizations and individuals that allowed them to come together and move forward. 4:41:36 PM JOHN GREEN, Mat Su Opiate Task Force, shared that his daughter had died in jail of complications from detoxification. He reported that getting into recovery was full of obstacles and barriers, which included required proof of income and waiting lists. It was daunting for a parent to find recovery help for their child. He stated his support of HB 174. He shared that although there was a perception that those for recovery were soft on crime, the option to get into recovery was better for the community and public safety because once an addict had recovered, they became a productive member of society and would not continue their criminal behavior. He referenced a concern that naloxone would make addicts more careless, comparing that to having air bags in cars and people driving into trees to see if they worked. He emphasized that no one wants to overdose and die. He stated that naloxone offered people a chance to live and get into recovery, thereby helping other addicts toward sobriety. 4:45:14 PM CHAIR SPOHNHOLZ closed public testimony. She said that this bill was an extremely urgent and important piece of legislation, even as it was a small piece of an overall, much broader strategy. She added that the emergency declaration would expire in the next day. 4:46:40 PM REPRESENTATIVE EDGMON moved to report HB 174 out of committee with individual recommendations and the accompanying zero fiscal note. 4:46:59 PM REPRESENTATIVE EASTMAN objected. He said that he had reviewed the disaster declaration, and he offered his understanding that it was intended to limit authority to only the federal program. He asked for clarification. MS. KRALY explained that the emergency declaration had been very narrowly drafted within the construct of the statutory authorization. She said that there was a companion statute which allowed the department to use the framework to craft a public health emergency. She stated that they took this authorization and that the presented documentation provided the fiscal analysis along with the declaration which identified how the money was limited to the federal grant. She pointed out that this was narrowly crafted to make clear that there would be no additional fiscal impact. She directed attention to AS 26.23.020 and said that the documentation in the packet, along with the declaration, encompassed that detail. REPRESENTATIVE EASTMAN said that he only had the fiscal note and the declaration of disaster which authorized certain things. He offered his belief that the actual statute read that all state resources were now at the governor's disposal. He asked if this was the correct declaration. MS. KRALY replied that the statutory authorization did offer a broad array of authority to address an emergency. She explained that the opioid disaster finance plan had limited the funding to the $4.1 million from the federal grant. She said that it had been made clear to the governor's office and to the leadership of both bodies that no additional authorizations under the statute were being sought. She offered to supply this additional documentation. CHAIR SPOHNHOLZ asked if Representative Eastman had the fiscal note, which she opined did address the issue. REPRESENTATIVE EASTMAN asked if there was anything other than the fiscal note. MS. KRALY reported that a budget document had also been created. REPRESENTATIVE EASTMAN maintained his objection. 4:52:00 PM A roll call vote was taken. Representatives Spohnholz, Kito, Sullivan-Leonard, Johnston, and Edgmon voted in favor of HB 174. Representative Eastman voted against it. Therefore, HB 174 was reported out of the House Health and Social Services Standing Committee by a vote of 5 yeas - 1 nay.