HB 89-OPIOID PRESCRIPTION INFORMATION  3:31:03 PM CO-CHAIR ZULKOSKY announced that the next order of business would be HOUSE BILL NO. 89, "An Act relating to the prescription of opioids; 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; and relating to the practice of pharmacy." 3:31:35 PM The committee took a brief at-ease. 3:32:09 PM REPRESENTATIVE TARR moved to adopt the proposed committee substitute (CS) for HB 89, labeled 31-LS0421\U, Fisher,4/3/19, as the working draft. CO-CHAIR ZULKOSKY objected for discussion. 3:32:25 PM CO-CHAIR SPOHNHOLZ introduced HB 89, explaining that this was re-visiting a bill that had previously been introduced by Representation Gara in 2018. She stated that the purpose of the proposed bill was to ensure that Alaska did everything possible to reduce access to opioids and the associated unnecessary risks. She introduced a PowerPoint titled "House Bill 89: Opioid Addiction Risk Disclosure." She reported that there had been 100 overdoses from opioids in 2017, and although there had been progress through a prescription drug monitoring program, easier disposal of opioids, and a reduction of use, it was still a problem as 80 percent of addiction to street level heroin began with legally prescribed opioids, whether or not it was their legal prescription. She suggested that it was best to flip the conversation and begin with an introduction to the risks associated with opioids before they were taken. She stated that the proposed bill offered "a couple of opportunities for a patient to be educated about the risks of addiction and dependence on opioids before they can consume it." She allowed that there would be exclusions for emergencies and other times when it was not possible for an informed consent. She offered her belief that education should take place at multiple points as research had indicated that it takes multiple times for an individual to hear a message before the information is internalized. She paraphrased slide 3, "Research and Statistics," which read: A recent meta-analysis of research (Schmidt & Eisend, 2015) published in the Journal of Advertising found that it takes an average of 8-10 exposures for a person to remember a concept. The more often a patient hears a message about the inherent risks of opioids, the more likely they are to have an increased awareness of the potential dangers of physical dependence and addiction. Statistics on Opioid Misuse and Opioid Related Deaths: Drug overdose was Alaska's leading cause of accidental death in 2016 (Alaska Department of Health and Social Services). More than 3 out of 5 drug overdoses involve an opioid (Centers for Disease Control and Prevention, AK DHSS). 4 out of 5 heroin users started out misusing prescription opioids (American Society of Addiction Medicine). New research (Weinheimer, Michelotti, Silver, Taylor, & Payatakes, 2018) on effective pain management: A combination of Ibuprofen 200 mg and Acetaminophen 500 mg is approximately 3 times more effective than 15 mg of Oxycodone. (Dr. Don Teater, Teater Health Solutions). CO-CHAIR SPOHNHOLZ moved on and paraphrased slide 4, "Goals of House Bill 89, which read: Reduce the use of opioids for pain management and increase use of non-opiate pain management tools and medications. Increase communication about the dangers and risks of opioids. Decrease opioid misuse and opioid-related deaths in Alaska. Mitigate the opioid related public health crisis Alaska is currently facing. Provide a positive example to other states in the US that are facing similar public health crises. 3:36:45 PM MIRANDA DORDAN, Intern, Representative Ivy Spohnholz, Alaska State Legislature, paraphrased slide 5, "Section 1: Legislative Findings" which read: Legislative findings hold that the state has a moral, financial, and public health interest in reducing opioid and heroin addiction in Alaska. Medically documented evidence finds that opioid prescription drugs can lead to physical dependence and potential addiction. Studies have shown that a significant amount of heroin users started as opioid drug users. The Opioid Epidemic increases crime in the state, and the presence of heroin dealers in the state poses a public safety threat. Opioid addictions tear families apart, destroy a person's ability to hold a job, and decimate lives. Addiction treatment is costly and hard on families, affecting quality of life. Addiction treatment and additional public safety costs are also expensive for consumers and the state. 3:38:08 PM MS. DORDAN paraphrased slide 6, "Section 2: Dentists," which read: Requires dentists to inform patients of the potential addictive dangers of opioids and any reasonable treatment alternatives using oral and written information before prescribing an opioid. The State Board of Dental Examiners will craft and enforce regulations that satisfy requirements of HB 89. MS. DORDAN directed attention to a handout on the Department of Health and Social Services website as a visual aide with great information for opioid statistics specific to Alaska. 3:40:02 PM CO-CHAIR SPOHNHOLZ pointed out that the bill sponsors did not want to over prescribe the way this should be implemented at the Board level, but to instead, allow each of the Boards to identify for themselves the best way to regulate and manage the information. She emphasized that the sponsors only wanted to ensure that providers in Alaska offered oral and written communication about the risks and alternatives. 3:40:40 PM MS. DORDAN moved on to paraphrase slide 7, "Section 3: Medical, Osteopathy, and Podiatry Providers," which read: Requires Medical, Osteopathy, and Podiatry Providers to inform patients of the potential addictive dangers of opioids and any reasonable treatment alternatives using oral and written information before prescribing an opioid. The State Medical Board will craft and enforce regulations that satisfy requirements of HB 89. 3:41:51 PM MS. DORDAN directed attention to slide 8, "Section 4: Registered Nurses," which read: Requires registered nurses to inform patients of the potential addictive dangers of opioids and any reasonable treatment alternatives using oral and written information before prescribing an opioid. The Alaska Board of Nursing will craft and enforce regulations that satisfy requirements of HB 89. 3:42:24 PM MS. DORDAN shared slide 9 "Section 5: Optometrists," which read: Requires optometrists to inform patients of the potential addictive dangers of opioids and any reasonable treatment alternatives using oral and written information before prescribing an opioid. The State Board of Examiners in Optometry will craft and enforce regulations that satisfy requirements of HB 89. 3:42:56 PM MS. DORDAN indicated slide 10 "Section 6: Pharmacists," which included the changes in the proposed committee substitute, Version U, which read: Requires pharmacists to inform patients of the potential addictive dangers of opioids using oral and written information before dispensing an opioid. The Alaska Board of Pharmacy will craft and enforce regulations that satisfy requirements of HB 89. 3:44:57 PM MS. DORDAN directed attention to slide 11 "Section: Visual Aid," which read in part: DHSS must create a visual aid that providers can hand out to patients when they are being prescribed opioids. MS. DORDAN reiterated that the handout had already been created and was on the Department of Health and Social Services website. 3:46:16 PM MS. DORDAN shared the references and letters of support on slide 12, "Letters of Support:" which included the Alaska Dental Society and Fallen Up Ministries. 3:46:37 PM REPRESENTATIVE JACKSON offered her belief that doctors had taken an oath to do everything within their power to keep their patients healthy and that there was a federal requirement for doctors to explain each drug and its side effects. She asked if the proposed bill was requiring the state to manage doctors for how they inform and educate their patients. 3:47:37 PM CO-CHAIR SPOHNHOLZ explained that the proposed bill was designed to add another layer of education for patients. She shared a personal experience with opioids and noted that the bill proposed to begin the conversation in the health care provider's office. She offered her belief that more conversation would reduce the number of opioids prescribed, consumed, and distributed into our communities. 3:49:34 PM REPRESENTATIVE JACKSON acknowledged awareness for the opioid crisis, with a variety of organizations enforcing education on opioids. She asked for clarification that Co-Chair Spohnholz had been offered medications without any education. CO-CHAIR SPOHNHOLZ replied that she had been offered opioids by a full range of medical professionals. REPRESENTATIVE JACKSON asked if the proposed bill would ensure monitoring through the various Boards that doctors were offering this education. CO-CHAIR SPOHNHOLZ replied that the intent of the proposed bill was to require medical personnel to educate patients about the risks associated and give them printed materials to take home. The proposed bill would give the power to the Boards for enforcement. She emphasized that it was not intended to define in law specific steps that should be taken. She offered her belief that a way to build consensus was to allow the professionals to determine the best way to regulate and enforce. 3:51:51 PM REPRESENTATIVE JACKSON acknowledged that "the idea and the intention is fabulous" but asked if there had been discussions with the various boards for a timeframe. She suggested that enforcement legislation may be necessary if the boards did not comply. CO-CHAIR SPOHNHOLZ shared the history of a prior compromise to allow Department of Health and Social Services to create and distribute information. However, it had been decided that it was time to introduce legislation, as the boards had a limited scope of responsibility and needed a law in order to take on new regulations. She stated that she had been talking with providers to craft a bill that was practical while achieving the public health goal for reduction of opioid dependence. 3:53:49 PM REPRESENTATIVE DRUMMOND directed attention to slide 2 and expressed her surprise regarding the combination of ibuprofen and acetaminophen as three times more effective than 15 mg of oxycodone. She asked if this was a prescription combination or was it available over the counter. CO-CHAIR SPOHNHOLZ explained that the combination was a legal over the counter level for each of those medications. She acknowledged that this combination was so much more effective than opioids. 3:55:44 PM REPRESENTATIVE DRUMMOND directed attention to slide 3 and expressed that she was impressed with the 36 percent decrease in opioid overdoses and a 67 percent decrease in fentanyl overdoses. She asked if each overdose resulted in death. CO-CHAIR SPOHNHOLZ clarified that these were overdose related deaths and not just overdoses. She reported that overdose death had decreased with the broad distribution of naloxone as it allowed emergency responders to reverse an overdose. 3:57:28 PM REPRESENTATIVE DRUMMOND referred to slide 7 and asked about exemptions for palliative and hospice care. MS. DORDAN explained that these exemptions could be offered although ultimately the Board would decide who was exempt. CO-CHAIR SPOHNHOLZ added that, as the delivery of health care was very complex, it was the intention not to define in law exactly where the education should take place and that, instead, the medical professionals make that decision. She noted that the implementation could be addressed later if there were concerns. 3:59:12 PM REPRESENTATIVE DRUMMOND pointed to slide 9 and asked about treatments performed by optometrists which required an opioid. CO-CHAIR SPOHNHOLZ explained that, although it was not routine care, optometrists could perform some minor procedures which could create some pain and necessitate the prescription of pain medication. 4:00:34 PM CO-CHAIR ZULKOSKY removed her objection. There being no further objection, the proposed committee substitute (CS) for HB 89, labeled 31-LS0421\U, Fisher,4/3/19, was adopted as the working draft. 4:01:05 PM CO-CHAIR ZULKOSKY opened public testimony. 4:01:22 PM CO-CHAIR ZULKOSKY said she would keep public testimony open. [HB 89 was held over.]