SB 132-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN    2:39:02 PM CHAIR COSTELLO reconvened the meeting and announced the consideration of SENATE BILL NO. 132 "An Act exempting veterinarians from the requirements of the controlled substance prescription database." She stated her intention to move the bill if public testimony didn't go beyond 3:00 p.m. 2:39:36 PM NIKKI ROSE, Staff, Senator Roger Holland, Alaska State Legislature, Juneau, Alaska, introduced SB 132 on behalf of the sponsor. She paraphrased the following sponsor statement: th Alaska's 25 legislature created the Prescription Drug Monitoring Program (PDMP) in 2008. The legislative intent behind the PDMP was to create a database of prescriptions for controlled substances in the state. The PDMP may create obstacles for individuals seeking opioids to obtain multiple prescriptions from registered providers and may be a useful tool for human doctors in combating the opioid crisis. Under the current statutory framework, Alaska's veterinarians are required to participate in the PDMP, despite the irreconcilable differences between human and veterinary medical practice. PDMPs have been implemented in all 50 states, but 34 states have recognized the unsuitability of veterinary participation in the PDMP and exempted veterinarians. SB 132 would add Alaska to that list. The majority of states exempt veterinarians from PDMP because they have recognized that PDMPs are designed for use in human medicine; and veterinary exclusion from PDMPs does not increase risk to the public. Alaska's inclusion of veterinarians in the PDMP has produced no identifiable benefit; yet the PDMP has created a multitude of verifiable harms to the veterinary profession and the Alaskans they serve. The PDMP is inappropriate and not effective for use with animal patients, as animals do not have identifiers such as a social security number, and veterinarians must view human owners' private health data before treating an animal. Alaska has the highest veterinary licensure cost in the United States. Veterinary participation in the PDMP contributes to this unnecessary financial burden on a profession already experiencing extreme staffing shortages, decreasing availability of veterinary services to Alaskans. Moreso, a recent survey found attempted veterinary doctor shopping across the entire United States is essentially non-existent. Veterinarians are tightly regulated by the Drug Enforcement Agency, the Know Your Customer Act, and the State licensing board. SB 132 seeks to correct an expensive overreach so that Alaskans can have access to treatment for their pets without compromising public safety. 2:42:44 PM MS. ROSE presented the sectional analysis for SB 132 that read as follows: [Original punctuation provided with minor formatting changes.] Sec. 1  AS 17.30.200(o), relating to the controlled substance prescription database, is amended by deleting the Board of Veterinary Examiners from the list of required notification by the Board of Pharmacy when a practitioner registers with the database. Sec. 2  Adds veterinarians to the list of practitioners not required to comply with the controlled substance prescription database under AS 17.30.200(t). Sec. 3  Adds a definition of "practitioner" to AS 17.30.200(u) Sec. 4 Repeals AS 08.98.050(a)(10), which obligates the board of veterinary examiners to require licensees to register with the controlled substance prescription database. 2:43:53 PM SENATOR STEVENS shared that he knew a veterinarian who became addicted to the drugs he prescribed to animals. He asked if the bill had sideboards to ensure that would not happen in the future or if that situation was independent of what the bill does. MS. ROSE explained that this database would not capture that kind of misuse because an individual would not put information about their own drug use into the database. CHAIR COSTELLO suggested that the invited testifiers could talk about how veterinarians must look at pet owners' personal prescription history even though veterinarians have no training in human health matters. 2:45:29 PM SENATOR REVAK mentioned the concern about doctor shopping to feed an addiction and said he didn't want to exacerbate that problem, but he did want to find a solution for veterinarians. CHAIR COSTELLO invited Dr. Tracy Ward and Dr. Rachel Berngartt to give their presentation. 2:46:43 PM DR. RACHEL BERNGARTT, Chair, Board of Veterinary Examiners, Juneau, Alaska stated that she has been an Alaska licensed veterinarian since 2002 working in a wide variety of practice areas and she was speaking in support of SB 132. 2:47:24 PM DR. TRACY WARD, President, Alaska Veterinary Medical Association, Juneau, Alaska stated that she has been a veterinarian for 32 years and has worked in several fields, and she also spent considerable time in the pharmaceutical industry. She is currently a small animal practitioner and in several months will transition to be a shelter veterinarian. SENATOR STEVENS asked Dr. Ward and Dr. Berngartt to address the concern about veterinarians who become addicted to the drugs they prescribe for animals. DR. BERNGARTT explained the process when a veterinarian enters data in the Prescription Drug Monitoring Program (PDMP) and said veterinary addiction is probably outside the PDMP because professionals who are struggling with an addiction are very unlikely to enter their own data into the PDMP. 2:49:27 PM DR. WARD said she believes some of the prepared testimony addresses that concern a little more. DR. WARD stated that both the Alaska State Veterinary Medical Association, which is the professional body, and the Alaska Board of Veterinary Examiners, which is the regulatory body, strongly support SB 132. She and Dr. Berngartt would discuss the reasons. DR. WARD highlighted that just last Thursday the Alaska Board of Pharmacy met and voted in support of this exemption. They agree with the other 34 states that have concluded that including veterinarians dilutes and confuses the database. This vote was significant because this board monitors, maintains, and interprets the data in the PDMP. DR. WARD provided background on Alaska's PDMP, which was established in 2008. In response to the growing opioid epidemic, the PDMP was amended in 2017 to require participation by all federal Drug Enforcement Administration (DEA) permit holders, including veterinarians. Neither the Alaska State Veterinary Medical Association nor the Alaska Board of Veterinary Examiners were consulted when the amendment was proposed. 2:51:26 PM DR. WARD said there are a number of reasons that it makes sense to exempt veterinarians. She would speak about the practitioner concerns and Dr. Berngartt would talk about the regulatory concerns. She highlighted that the PDMP was not intended to be a database for animals so it is not an effective tool for tracking prescriptions for veterinarians or their patients. The primary reason is the database was designed for human medicine. Veterinary patients are animals and they do not have unique identifiers such as a Social Security number and the date of birth is often not known. When the law passed initially, there was some confusion about who the veterinarian would query because the Act talked about querying the patient and the patients in a veterinary practice are animals. It soon became clear that veterinarians were supposed to query the animal owner's prescription data when they prescribed a controlled substance for the animal. This is despite the fact that the information in the PDMP is not useful to veterinarians because they are not trained in human medicine and dosages do not translate from human to animal medicine. The data a veterinarian enters into the PDMP for an animal patient is similarly not useful for a medical doctor. DR. WARD said Senator Revak brought up the next concern which is privacy. Veterinarians are not trained in or bound by the federal Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule. Furthermore, veterinarians often work on shared computers in a large treatment area so many people could see the information that is entered. This is a concern for both veterinarians and their clients. She asked the members if they would want somebody who is not bound by HIPPA to see their private prescription data. She pointed to the list of common medications that veterinarians might see. 2:54:52 PM SENATOR REVAK recalled that when they met he was comforted that she mentioned that the dosages prescribed for animals was comparatively small. This would make it much less likely that an individual would "vet shop" to obtain drugs for their personal use. DR. WARD said that is relevant and she would respond to that later in the presentation. SENATOR STEVENS noted that dosages for large animals such as horses could be quite large, then asked if anybody tracked excessive use of drugs in a veterinary practice. "How can you protect society from someone who may not have scruples?" 2:56:27 PM DR. WARD acknowledged he had valid concerns and noted that the next slide discusses the fact that veterinarians are monitored by the Drug Enforcement Agency and must adhere to controlled substance regulations. She said she also wanted to respond to his comment about large animals. She related that she has experience with cattle, swine, and equine practice and can say that controlled substances are almost never used in food animals because the cost would be prohibitive. Opioids are never used on horses because their gastrointestinal tract would become impacted and the animal would likely die. SENATOR STEVENS thanked her for the response and shared that his knowledge of veterinary science extended to All Creatures Great and Small. DR. WARD addressed the concern about abuse or diversion of drugs by veterinarians. First, the PDMP was not intended to track that information. It is about stopping shopping, not diversion or self-use. If a veterinarian were to purchase a drug for their own use or for diversion that would not be entered into the database. There are, however, strict regulations through the Drug Enforcement Agency (DEA). Any veterinarian who prescribes or dispenses controlled substances is licensed through the DEA and must adhere to strict accountability, record keeping, and medication storage requirements. Those records must be available to the DEA on demand and local law enforcement agencies may also request access. DR. WARD continued to explain that manufacturers and distributors of controlled substances are bound by Know Your Customer type legislation that requires them to maintain a Suspicious Order Monitoring System. These companies must monitor, flag, and report a veterinarian's unusual purchase patterns to the DEA. This is how the majority of veterinary diversion is found. She drew a parallel to a credit card company calling clients to ask about unusual/potentially fraudulent charges on their card. 3:01:13 PM DR. BERNGARTT delivered the second half of the presentation. She reported that 34 other states have exempted veterinarians from participating in the PDMP so Alaska would not be a guinea pig. Increased veterinary shopping or increased risk to the public would already be evident, but that hasn't happened. DR. BERNGARTT made the case that veterinarians are not a source for the drugs that are of primary concern. She spoke to the following from slide 9: • The Board of Pharmacy reported that veterinarians in Alaska from 20162018 prescribed .3% to 1% of total Morphine Milligram Equivalents (MMEs). • Opioid medications prescribed by veterinarians (728,223) were only 0.34% of the total opioid prescriptions (214 million) that were dispensed by U.S. retail pharmacies in 2017. • There is a natural barrier to vet shopping since costs for veterinary care are paid up front by the pet owner. • There have been no identified cases of veterinary shopping in Alaska. 3:04:38 PM DR. BERNGARTT said another reason it makes sense to exempt veterinarians from the PDMP is cost. Speaking as the chair of the Board of Veterinary Examiners, she said the board has seen an exponential increase in the cost of investigations because the PDMP is unwieldy. She highlighted that the state received a grant to cover some of the cost of the PDMP. Costs are distributed between the PDMP and the Board of Veterinary Examiners, but the grant does not cover the board side of investigations. 3:06:23 PM DR. BERNGARTT directed attention to slide 11 that highlights that Alaska has the highest licensing fees for veterinarians in the country. The state also has a critical shortage of veterinarians and veterinary technicians. Juneau, for example, used to have a nine doctor veterinary hospital, and two hospitals that each had two doctors. Currently, no overnight emergency animal services are available in the community. Veterinary technicians are also in very short supply. Further, Alaska has perhaps the highest licensing fees for veterinarians in the country. This makes it difficult to attract veterinarians to the state. Alaska currently has 366 veterinarians who are eligible to prescribe under the PDMP and just 266 licensed technicians. That is less than one technician per doctor, so it is not realistic to think that the technicians could be charged with entering data into the PDMP to provide relief for veterinarians. 3:08:16 PM SENATOR STEVENS referred to the last line on slide 11 that talks about charging veterinarians for the cost of enforcement. He asked if she could place a dollar value on this charge to veterinarians. SR. BERNGARTT explained that the board is self-supporting so the cost associated with the PDMP and investigations comes from the fees charged to veterinarians and veterinary technicians. Over the last several years the investigative fees have become a concern and the only way to cover those additional costs is to raise licensing fees. SR. BERNGARTT concluded the presentation stating that a "Yes" vote on SB 132 will allow veterinarians to: • provide care for their patients; • spend time with their patients instead of needless querying and reporting unusable PDMP data • increase the efficiency of the PDMP by eliminating animal data that is not used • allow more efficient tracking of human data in the PDMP • allow continued judicious use of controlled substances that is already practiced by veterinarians, who are regulated under the DEA • allow veterinarians to continue to do their job • eliminate unnecessary business burdens 3:11:34 PM SENATOR GRAY-JACKSON said she appreciates the concerns of her colleagues but since the bill was introduced last year she has received many emails in support of the legislation. She asked if there was any opposition to the bill because she had heard none. She added that SB 132 makes sense and she signed on as a co-sponsor. DR. WARD replied that the Board of Pharmacy initially expressed concerns similar to those articulated by committee members, but the board recently voted to support the bill. 3:12:31 PM CHAIR COSTELLO opened public testimony for SB 132. 3:12:51 PM DR. MCKAYLA DICK, Past President Alaska Veterinary Association, North Pole, Alaska, stated that she is a veterinarian who supports SB 132. It will allow the PDMP to function as intended, which is to catch drug shoppers. 3:13:25 PM TERRI LYONS, representing self, Wasilla, Alaska, stated that she is a horse owner and there is a huge need for large animal veterinarians in Alaska. She spoke to the difficulties she has when her horse is in need of medical attention in the middle of the night. SB 132 is one thing that can be done to help this desperate situation. 3:14:45 PM CHAIR COSTELLO closed public testimony on SB 132. 3:15:05 PM At ease 3:18:05 PM CHAIR COSTELLO reconvened the meeting and stated she would hold SB 132 for future consideration. 3:18:30 PM SENATOR MICCICHE said the discussion during the at-ease was that he and other legislators amended the Alaska PDMP law in 2017 in the belief that it would help to stem opioid abuse. He said he has come to the conclusion that including veterinarians in the PDMP is not the way to manage this crisis. SENATOR STEVENS said he was not trying to hold the bill up because everything he heard makes sense. However, his personal experience was causing him pause. CHAIR COSTELLO said the veterinary community has worked hard on this legislation and she appreciates that work. She said her office would work to ensure that everyone is comfortable with the bill. CHAIR COSTELLO held SB 132 in committee.