SB 132-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN  3:58:45 PM CO-CHAIR ZULKOSKY announced that the final order of business would be SENATE BILL NO. 132, "An Act exempting veterinarians from the requirements of the controlled substance prescription database." 3:58:55 PM The committee took a brief at-ease. 3:59:58 PM CO-CHAIR ZULKOSKY announced the committee would hear invited testimony. 4:00:33 PM JIM DELKER, DVM, Legislative Liaison, Alaska Veterinary Medical Association (AKVMA), shared a conversation he had had with an Alaska State Trooper. He stated that the trooper, with over 20 years of experience working on a drug task force as an undercover agent, had not witnessed any cases of drug abuse involving humans with veterinary prescriptions. Also, he referenced numerous physicians, including emergency care and drug treatment specialists, who sent in letters to attest they had never treated a person with a drug overdose, where the person had obtained the drugs through a veterinarian. DR. DELKER reported that at the request of the legislature, AKVMA met with the Alaska College of Emergency Physicians (ACEP) and the Board of Emergency Physicians to discuss some of the concerns. He described the dialogue between the boards as positive, and despite concerns from the physicians, there were no concrete examples of drug abuse of this type brought forward. He stated that the boards had also discussed the two studies the physicians had referred to in their letters of concern. He shared that one was an unrandomized survey conducted of a small portion of veterinarians in Colorado; these veterinarians had influenced Colorado to keep veterinarians out of the Prescription Drug Monitoring Program (PDMP). DR. DELKER noted the other study was a properly randomized study from Pennsylvania; however, it only took data from a single large referral hospital. He stated that only 6 percent of veterinarians in the country work in a similarly specialized setting and opined that it was unfair to say the study was indicative of the prescribing habits of most veterinarians. He shared that, in their discussion, members from the boards had expressed disagreement with letters of support from former ACEP members, while current members unanimously support the ACEP's letter of concern; however, he stated that this is in direct conflict with the conversations he had with current members, who stated that they had never heard of SB 132, or the letter of concern. He stated that some of these members had submitted their own letters of support for SB 132. DR. DELKER related that veterinarians are frustrated with the task of repeatedly entering data, which "disappears" and cannot be accessed by other physicians or veterinarians. He expressed disagreement with the idea that veterinarians are "out of touch" with the opioid epidemic. He shared a personal experience concerning loss because of opioid addiction, and he suggested that other veterinarians have similar stories. He acknowledged that the opioid crisis is serious and opined that veterinarians want to do their part to help. He asked that their efforts not be wasted but instead result in measurable benefits. 4:06:15 PM TRACY WARD, DVM, President, Alaska Veterinary Medical Association, reviewed the current regulations on PDMP use in the veterinarian field. She explained that all veterinarians who prescribe, administer, or dispense Schedule II or III drugs must query PDMP before doing so. She further explained the "zero reporting" regulations, stating that veterinarians who dispense any Schedule II, III, and IV substances must report to PDMP daily, including on days they do not dispense. She listed the dispense reporting exemptions, which included substances dispensed in an emergency department for a supply lasting less than 24 hours, controlled substances administered to an inpatient of a hospital, controlled substances used at the scene of an emergency, controlled substances used during or within 48 hours before or after a surgery, and writing a non-refillable prescription which lasts no more than three days. 4:08:42 PM The committee took a brief at-ease. 4:09:11 PM CO-CHAIR ZULKOSKY asked Laura Carrillo or Sara Chambers from the Department of Commerce, Community & Economic Development (DCCED) what recommendations and accommodations have been made by DCCED to make the utilization of PDMP more streamlined for veterinarians. 4:11:16 PM LAURA CARRILLO, MPH, Executive Administrator, Alaska Board of Pharmacy, Prescription and Drug Monitoring Program, Division of Corporations, Business and Professional Licensing, Department of Commerce, Community and Economic Development, explained that when the original bill passed in 2017, the Board of Veterinary Examiners (BOVE) had several questions for DCCED, including who to query when prescribing controlled substances for nonhuman patients. She stated that the department advised the board to query the human client and have this posted with the licensure. She shared the board's other concern about animal and human data comingling. She stated that DCCED worked with the Department of Law and the database vendor on ways to clarify the data entry process. In response to this, she stated, DCCED posted guidelines on its website about how to properly input species codes and prevent comingling of data, and the vendor added an animal graphic to help practitioners visually differentiate between human and animal prescriptions. She added that the department continued talks with various boards to adjust issues and instated a biweekly PDMP meeting of chairs to continue the conversation. 4:15:22 PM CO-CHAIR ZULKOSKY asked how DCCED's improvements made the process more user friendly for veterinarians. 4:16:27 PM MCKAYLA DICK, DVM, Past President, Alaska Veterinary Medical Association, explained that as a small animal veterinarian she had seen no changes in PDMP and very little guidance on how to use it in a clinic setting. She stated that "the system just doesn't work" for veterinarians because of the fundamental differences in human and animal data. These differences have led veterinarians to be investigated for clerical issues rather than deliberate misuse of the system. She opined that the changes put into place by DCCED have not been properly conveyed to practitioners and often did not work to solve the issues. 4:17:46 PM HAL GEIGER, PhD, Member, Board of Veterinary Examiners, shared that the private conversations with veterinarians were consistent with their public testimony, which expressed that changes made by DCCED were not helpful, and training had been insufficient. He reported that veterinarians are confused and frustrated with a system which they find to be "completely unworkable." CO-CHAIR ZULKOSKY asked about other efforts the department had made in response to the feedback that the changes were not enough. SARA CHAMBERS, Director, Division of Corporations, Business and Professional Licensing, Department of Commerce, Community and Economic Development, expressed the belief that the department had made all the changes brought to its attention and had provided all information about the changes to the board. She expressed the understanding that it was BOVE's responsibility to disseminate that information. She opined that the board's efforts to do so had "fallen by the wayside," and BOVE had not posted the guidelines on its website or circulated them to veterinarians. She posited that much of the frustration with the system comes from the existential question of whether PDMP is relevant to veterinarians and opined that, because veterinarians believe their participation in PDMP to be [useless], there is less motivation to implement the fixes provided by the department. She expressed the belief that all parties should buy in to PDMP and utilize the tools provided, or statutory changes should be made. 4:22:39 PM The committee took an at-ease from 4:22 p.m. to 4:26 p.m. 4:26:39 PM REPRESENTATIVE SPOHNHOLZ referred to a report from DCCED on the 14 best practices for veterinary use of PDMP and asked Ms. Carrillo to explain how the report was communicated to BOVE. MS. CARRILLO explained that the Bureau of Justice Assistance (BJA) compiled the report, and it was presented at the PDMP training center in January 2022. She stated that the report used studies conducted in other states to derive the best practices. She shared that, to her knowledge, the report was given to BOVE members during a board meeting, and it was included in their meeting packet. In response to a follow-up question, she said the report was presented to BOVE in February of the same year. REPRESENTATIVE SPOHNHOLZ opined that the best practices provided by BJA were very detailed. She referenced a letter sent by Dr. Papacostas to the Senate Finance Committee where he stated that veterinarians now surpass dentists in the prescription of morphine. She requested that Dr. Papacostas explain this information and ACEP's stance on excluding veterinarians from PDMP. 4:32:47 PM NICHOLAS PAPACOSTAS, MD, FACEP, Alaska Chapter American College of Emergency Physicians, confirmed that the statistic was correct and clarified that both veterinarians and dentists prescribe very low rates of opioids in comparison to medical practitioners. He explained that the data was added in the report for context because there was a discussion about exempting veterinarians but not dentists from PDMP. REPRESENTATIVE SPOHNHOLZ asked Dr. Papacostas to describe the findings from the 2019 study published in the Journal of the American Medical Association, which was cited in his letter. DR. PAPACOSTAS explained that Dr. Delker was correct in his testimony; the study had come from a single large veterinary facility. He stated that the point of including this study is because many veterinarians train at referral centers, so the trend of increased opioid prescriptions at those facilities could be indicative of the prescribing habits of veterinarians in smaller, community-based practices as well. REPRESENTATIVE SPOHNHOLZ requested that Dr. Geiger comment on the information presented to BOVE during the February 2022 board meeting concerning the best practices for veterinary prescriptions. She questioned the material presented, the discussions that occurred about implementing these practices, and whether a more nuanced approach to veterinary participation in PDMP is "out of the question." 4:35:50 PM DR. GEIGER stated he was not prepared to speak about this specific meeting, as there were many meetings where suggestions were given by the department. He gave an example of a suggested regulation which would not be possible to carry out. He explained that the majority of testimony the board had heard from veterinarians was that they try to use the PDMP but it "just doesn't quite work" and has not worked since the participation requirement was put into statute. He explained that the requirement is to query the patient, but in the veterinary world, the patient is the animal. REPRESENTATIVE SPOHNHOLZ opined that, because of frustration with the system, many veterinarians have chosen to see the system as a failure rather than trying to find a solution. She cited the earlier comparison to dentists and stated that dentists prescribe fewer opioids a year than veterinarians, yet there has been no push for an exemption from dentists. She posited that this data is in direct opposition to the assertions made during testimony. She requested Dr. Geiger's opinion. DR. GEIGER replied that PDMP works for dentists and human practitioners because PDMP was designed for human patients. He shared that the board received a PDMP report which conveyed no veterinarians had queried the system during a specific timeframe, but during the discussion of the report, numerous veterinarians and their staff reported they had queried the system during the referenced timeframe. He expressed the opinion that this exemplifies the system is not working for the veterinary field. 4:39:58 PM REPRESENTATIVE PRAX expressed the understanding that veterinarians were required through regulation to query their human clients' prescription drug use. DR. GEIGER confirmed this understanding and spoke to veterinarians' frustration around lack of clarity in who to query. 4:41:01 PM DR. WARD confirmed that the query is made to the person physically in the room with the animal patient. REPRESENTATIVE PRAX stated his opinion that this practice seemed like a Health Insurance Portability and Accountability Act (HIPAA) violation and asked whether the information about the human client's prescription history was recorded. In response to a request for clarification, he described a hypothetical situation where someone goes to a veterinarian, discloses his/her own medical history in order to receive medication for the pet, and then later the person switches to a new veterinarian. He asked whether the new veterinarian would be able to see that the pet had previously been prescribed a certain drug and whether this drug would now be a part of the human client's history. DR. WARD explained that before a veterinarian makes a prescription, the human client's drug history would be questioned. She posited that this would not affect the veterinarian's decision on what to prescribe, because veterinarians are not trained in human drug dosage. However, she said, if the veterinarian decides to prescribe a scheduled substance to an animal, this information would be entered under the pet's name. She reported that a reoccurring issue is, when a veterinarian tries to query PDMP for this pet later, the information is often not visible. She added that the same issue happens for medical doctors. She described the process as not affecting public health, as veterinarians cannot interpret the data from medical doctors and [doctors] cannot access the animal data entered by the veterinarians. She confirmed that veterinarians do prescribe more opioids than dentists; however, this amount is less than one percent of all opioids prescribed and does not include the types of opioids human addicts are looking for. She stated that the focus has been on making PDMP easier for veterinarians; however, she pointed out the lack of productive data which results from this practice, which is the main concern for veterinarians. REPRESENTATIVE PRAX opined that veterinary participation in PDMP "fundamentally" accomplishes nothing and potentially violates the HIPAA rights of [the humans who bring in their pets]. DR. WARD expressed agreement with the statement. She stated that "we are accomplishing nothing" in regard to drug prevention and public health, while the process is done at a high cost [to the state]. She reemphasized that the amount of opioids prescribed by veterinarians is small in comparison to the amount prescribed by physicians. 4:45:40 PM REPRESENTATIVE MCCARTY referred to the statistic of opioid prescriptions as being "data on morphine." He questioned whether morphine is prescribed by vets more often. DR. WARD explained that the data describes morphine milligram equivalence (MME), which equates all the opioid class substances to the relative equivalency with morphine; the statistic does include all opioids prescribed. REPRESENTATIVE MCCARTY questioned the data which suggests veterinarians prescribe more opioids than dentists. He cited his knowledge of dentist-related opioid addiction. He asked Dr. Papacostas to provide the data behind the statement on prescription amounts in his letter. DR. PAPACOSTAS explained that the same data is in the white paper in graph form, and it shows that from 2016 to 2018 the amount of opioids prescribed by veterinarians had increased to surpass the amount prescribed by dentists. REPRESENTATIVE MCCARTY sought confirmation from Ms. Chambers that the administration is taking a non-stance on the issue and focusing on complying with the current statute. MS. CHAMBERS responded in the affirmative. REPRESENTATIVE MCCARTY recalled Ms. Chambers previous statement which related that veterinary participation has been a challenge for PDMP, and he remarked that there has been over a "hundred" meetings a year between the different boards on this subject. MS. CARRILLO explained that there have not been "hundreds" of meetings on this specific issue, but it has been discussed, and updates on PDMP have been a standing topic at all BOVE meetings. REPRESENTATIVE MCCARTY shared his understanding that the Division of Corporations, Business and Professional Licensing's main objective with all state boards is to assist with their professional duties to the state and ensure no harm is being done. MS. CHAMBERS confirmed his understanding. REPRESENTATIVE MCCARTY acknowledged the division's effort to follow statute and make the system workable for veterinarians; however, he pointed out that BOVE has related the participation in PDMP is "putting a square peg in a round hole." He shared his belief that testimony points towards an unsolvable issue; therefore, a change of statute is needed. 4:51:57 PM MS. CHAMBERS voiced her belief that many tools are available to the boards, and what boards do with the information directly impacts veterinarians' ability to effectively use PDMP. She expressed agreement that there is room for improvement; however, there are options other than statute change still available. She reiterated that many of the issues have been answered through the resources created by the division. She argued that many veterinarians feel frustrated by the system because they were uninformed of the resources. REPRESENTATIVE MCCARTY opined that the statute put into place in 2017 does not fit a certain group of professionals, and although the division has done its part to make the system work according to statute, PDMP does not work for veterinarians. He alluded that the legislature should follow the suit of other states which have exempted veterinarians. 4:54:09 PM CO-CHAIR ZULKOSKY requested that Ms. Chambers confirm the department had urged BOVE to adopt regulations which address the challenges faced by PDMP. MS. CHAMBERS responded in the affirmative. CO-CHAIR ZULKOSKY questioned Dr. Geiger concerning the board's response to the department, and its request to adopt regulation regarding PDMP. 4:54:51 PM DR. GEIGER explained that the board has received "high level advice" which does not address the realities facing veterinarians. He stated that there are "hundreds" of small, day-to-day problems veterinarians must deal with, such as not having internet access. He posited that getting all the information to veterinarians for each of these issues is not an easy task solved through regulation. CO-CHAIR ZULKOSKY questioned whether the board has pursued making any changes to regulations regarding PDMP, beyond the more nuanced examples which have been given. DR. GEIGER explained that the board did pass regulations trying to make PDMP work. The board took the division's advice and put the resources on the internet; however, the regulations have not been able to get veterinarians the information they need. CO-CHAIR ZULKOSKY asked Ms. Carrillo to supply the committee with screenshots of PDMP for visual clarification, as well as a list of the regulations put into place by BOVE. She questioned the amount of nationwide PDMPs and whether there has been an assessment completed on adapting PDMPs to meet the needs of veterinarians. MS. CARRILLO reported that the vendor used for PDMP has been used by 43 other states. She offered to follow up to the committee with additional information about adaptations for veterinarians. CO-CHAIR ZULKOSKY asked Dr. Papacostas about the tightening of human medical documentation concerning controlled substances, and how this could impact issues in the system. She also asked for a layman's description of the difference between 5 million and 2.9 million MME. 4:59:23 PM DR. PAPACOSTAS explained that PDMP is a tool to identify patients at risk of opioid addiction and get these patients into treatment. He pointed out that it is "disturbing" if the data veterinarians are entering is not visible to physicians. He expressed the opinion that it is individual prescriptions which expose people to opioids, and this is more of a concern than the total amount of opioids being prescribed. He explained that "catching" people misusing or diverting opioids is not the focus of emergency physicians, but rather they want to determine how patients are getting access to drugs, in hopes of intervening, if needed. He restated that the total amount of opioids being prescribed by veterinarians is not huge; however, he expressed the belief that exposure to one prescription can make a difference to a human patient. He voiced his support for removing some of the restrictions on veterinary PDMP participation and called for an investigation into why the veterinary data is not visible. He iterated ACEP's support for including veterinarians into the exemptions for very short-term prescriptions, but it would still support veterinarians entering long-term prescriptions into PDMP. He suggested that sending prescriptions to pharmacists would help veterinarians who struggle with entering prescriptions into PDMP. [SB 132 was held over.]