BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 1977             
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          |AUTHOR:        |Wood                                           |
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          |VERSION:       |April 13, 2016                                 |
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          |HEARING DATE:  |June 29, 2016  |               |               |
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          |CONSULTANT:    |Teri Boughton                                  |
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           SUBJECT  :  Opioid Abuse Task Force

           SUMMARY  :  Requires health plan and health insurer representatives, in  
          collaboration with others, to convene an Opioid Abuse Task  
          Force.
          
          Existing law:
          1)Establishes the California Department of Public Health (CDPH),  
            which among other activities and responsibilities convenes the  
            Prescription Opioid Misuse and Overdose Prevention Workgroup  
            (POMOP).
          
          This bill:
          1)Requires on or before February 1, 2017, health plan and health  
            insurer representatives, in collaboration with advocates,  
            experts, health care professionals, and other entities and  
            stakeholders that they deem appropriate, to convene an Opioid  
            Abuse Task Force (OATF). 

          2)Requires OATF to develop recommendations regarding the abuse  
            and misuse of opioids as a serious problem that affects the  
            health, social welfare, and economic welfare of persons in the  
            state, and requires OATF  to address all of the following:

                  a)        Interventions that have been scientifically  
                    validated and have demonstrated clinical efficacy;
                  b)        Interventions that have measurable treatment  
                    outcomes;
                  c)        Collaborative, evidence-based approaches to  
                    resolving opioid abuse and misuse that incorporate  
                    both the provider and the patient into the solution;
                  d)        Education that engages and encourages  
                    providers to be prudent in prescribing opioids and to  
                    be proactive in defining care plans that include a  






          AB 1977 (Wood)                                      Page 2 of ?
          
          
                    plan to taper and stop opioid use; and,
                  e)        Review and consideration of medication  
                    coverage policies and formulary management and  
                    development of an interdisciplinary case management  
                    program that addresses quality, fraud, waste, and  
                    abuse.

          3)Requires on or before December 31, 2017, OATF to submit a  
            report detailing its findings and recommendations to the  
            Governor, the President pro Tempore of the Senate, the Speaker  
            of the Assembly, the Senate Committee on Health, and the  
            Assembly Committee on Health.

          4)Dissolves OATF on June 1, 2018.

          5)States that a violation of this bill is not subject to a fine  
            or imprisonment, as specified.

          6)Finds and declares that abuse and misuse of opioids is a  
            serious problem that affects the health, social, and economic  
            welfare of this state, and after alcohol, prescription drugs  
            are the most commonly abused substances by Americans over 12  
            years of age.

          7)Finds and declares that almost 2 million people in the Unites  
            States suffer from substance use disorders related to opioid  
            pain relievers and the number of unintentional overdose deaths  
            has more than quadrupled since 1999.   

           FISCAL  
          EFFECT  :  None

           PRIOR  
          VOTES :  
          
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          |Assembly Floor:                     |78 - 0                      |
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          |Assembly Health Committee:          |17 - 0                      |
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          COMMENTS  :
          1)Author's statement.  According to the author, not enough is  
            being done to curb the growth of opioid abuse, and health care  
            providers and parents need tools to help guard against the  
            abuse of opioid medication.  The author cites increasing  






          AB 1977 (Wood)                                      Page 3 of ?
          
          
            patient awareness on proper storage and disposal, limiting  
            initial prescriptions for acute pain, as well as the  
            development and availability of abuse-deterrent opioids, which  
            are formulated to prevent manipulation of the drug for the  
            purpose of misuse, as strategies that should be encouraged to  
            combat opioid abuse.  The CDPH is engaged in efforts to  
            address this epidemic through the grant funded formation of  
            the POMOP Workgroup.   The author is concerned that CDPH  
            efforts have not engaged external stakeholders who may have  
            unique expertise or experience in combating this problem.   
            Additionally, the OATF in this bill could focus on immediate,  
            actionable strategies which complement the DPH workgroup  
            efforts, which are more comprehensive and appropriately  
            focused on longitudinal changes in behavior.  

          2)Opioid abuse. According to a March 2015 federal Department of  
            Health and Human Services issue brief on Opioid Abuse in the  
            U. S., mortality data show that there was a 6% increase in  
            drug overdose deaths between 2012 and 2013. Approximately 37%  
            (16,235) of overdose deaths involved prescription opioids, a  
            number essentially unchanged from 2012. However, the mortality  
            rate from heroin overdose increased each year from 2010 to  
            2013. Deaths from heroin overdoses increased by 39% from 2012  
            to 2013 alone and were approximately 19% (8,257) of all drug  
            overdose deaths in 2013.  According to CDPH in the past,  
            prescription opioids (such as hydrocodone, oxycodone, morphine  
            and codeine) were prescribed for relieving short-term (acute)  
            pain. Today, they are increasingly being used for long-term  
            (chronic) pain management. As a result, sales of opioid pain  
            relievers quadrupled in the past 10 years. By 2010, enough  
            opioid pain relievers were sold to medicate every American  
            adult (about 240 million people) every four hours for an  
            entire month. In California, deaths involving opioid  
            prescription medications have increased 16.5% since 2006. In  
            2012, there were more than 1,800 deaths from all types of  
            opioids - 72% involved prescription opioids. Prescription  
            opioid misuse is a public health problem that can lead to  
            long-term health consequences, including limitations in daily  
            activity, impaired driving, mental health problems, trouble  
            breathing, overdose and death. In 2014, the Association of  
            State and Territorial Health Officials (ASTHO) issued its  
            "President's Challenge" to decrease both the rate of  
            non-medical use and the incidence of unintentional overdose  
            deaths resulting from controlled prescription medications by  
            15% by the end of 2015.

          3)POMOP. CDPH and its state partners convened POMOP workgroup in  






          AB 1977 (Wood)                                      Page 4 of ?
          
          
            the spring of 2014. 
          This workgroup is exploring opportunities to improve  
            collaboration and expand joint efforts among state departments  
            working to address this epidemic. It has identified two  
            priorities: expansion and strengthening of prevention  
            strategies and improvement of monitoring and surveillance.  
            Initial workgroup discussions have focused on information  
            sharing about existing efforts and roles, identification of  
            challenges, and potential opportunities for partnership.  
            Participants in the workgroup include: CDPH, the Department of  
            Health Care Services, Department of Justice, Department of  
            Consumer Affairs, including the California State Board of  
            Pharmacy, the Medical Board of Californian, the Dental Board  
            of California the Board of Nursing, the Emergency Medical  
            Services Authority, The California Department of Education,  
            Department of Corrections and Rehabilitation, and the Division  
            of Workers Compensation.


            POMOP will engage physicians and health care professionals,  
            patients and consumers, and the general public to deliver the  
            following messages: 1) Prescription drugs, including opioids,  
            have an appropriate use. However, there are risks so it is  
            important that doctors and patients discuss the options,  
            benefits and risks when considering prescription drugs for  
            pain management. Both medical use and non-medical use of  
            prescription medications contribute to health complications  
            and deaths; and, 2) Experiencing pain can be devastating and  
            treating it can be complicated. All options need to be  
            considered. Taking unnecessary pills, or taking too many, can  
            kill.  A major milestone occurred in October 2014, when the  
            Medical Board of California revised its guidelines for  
            prescribing controlled substances for pain.

          4)Related legislation. AB 2592 (Cooper), would have created  
            within CDPH a pilot program that would award grants to  
            eligible pharmacies for the purpose of supplying medicine  
            locking closure packages to patients with prescriptions for  
            opioids.  AB 2592 was held in the Assembly Appropriations  
            Committee.


          5)Prior legislation. AB 623 (Wood of 2015), would have  
            prohibited a health plan or health insurer from requiring the  
            use of opioid drug products that have no abuse-deterrent  
            properties in order to access abuse-deterrent opioid drug  
            products; required pharmacists to provide a patient receiving  






          AB 1977 (Wood)                                      Page 5 of ?
          
          
            an opioid drug product information about proper storage and  
            disposal of the drug; and, authorized a provider to prescribe  
            a less than 30-day supply of opioids analgesic drugs.  AB 623  
            was held in the Assembly Appropriations Committee.

            AB 831 (Bloom of 2013), would have required, until January 1,  
            2016, the California Health and Human Services Agency (CHHSA)  
            to convene a temporary working group to develop a state plan  
            to reduce the rate of fatal drug overdoses and appropriates  
            $500,000 from the General Fund to CHHSA to provide grants to  
            local agencies to implement drug overdose prevention and  
            response programs. This bill was held in the Assembly  
            Appropriations Committee. 


            AB 369 (Huffman of 2012), would have prohibited health plans  
            and health insurers that restrict medications for the  
            treatment of pain from requiring a patient to try and fail on  
            more than two pain medications before allowing the patient  
            access to the pain medication, or its generic equivalent,  
            prescribed by his or her physician.  AB 369 was vetoed with  
            the Governor's veto message stating that a doctor's judgment  
            and a health plan's clinical protocols have a role in ensuring  
            prudent prescribing of pain medications, and any limitations  
            on the practice of step therapy should better reflect a health  
            plan or insurer's legitimate role in determining the allowable  
            steps.  


            AB 1826 (Huffman of 2010), would have required a health plan  
            or health insurer that covers prescription drug benefits to  
            provide coverage for a drug that has been prescribed for the  
            treatment of pain without first requiring the enrollee or  
            insured to use an alternative drug or product.  AB 1826 was  
            held in the Senate Appropriations Committee.


            AB 1144 (Price of 2009), would have required health plans and  
            health insurers to report to DMHC and CDI specified  
            information related to chronic pain medication management,  
            including when the health plan or health insurer requires an  
            enrollee or insured to use more than two formulary alternative  
            medications prior to providing access to a pain medication  
            prescribed by a provider, or to use pain medication other than  
            what was prescribed for more than seven days prior to  
            providing access to the prescribed pain medication.  This bill  
            was held in the Assembly Appropriations Committee.






          AB 1977 (Wood)                                      Page 6 of ?
          
          


          6)Support.  LA Care Health Plan writes in support that creating  
            OATF to address widespread opioid abuse is a logical and  
            necessary first step for California.  The California Council  
            of Community Behavioral Health Agencies writes that the  
            creation and operation of OATF could go a long way toward  
            finding solutions to this increasing threat to public health.   
            The County Health Executives Association of California  
            believes this bill is a modest, but important, step in  
            addressing a complicated and rising prescription drug abuse  
            problem. The California Dental Association writes that this  
            bill will begin to address this need for interventions to  
            opioid abuse.  The California State Sheriffs' Association  
            believes OATF's work could prove central to future efforts to  
            deal with this growing problem.  The Medical Board of  
            California indicates that this bill furthers the Board's  
            mission of consumer protection and is in line with the Board's  
            work on this important issue.
          
          7)Opposition. CDPH opposes this bill because CDPH currently  
            convenes POMOP Workgroup in collaboration with over twenty  
            state agencies, and it is expanding this year to include  
            representatives from federal and local entities, foundations  
            and academic partners.  Part of the current planning of the  
            workgroup is outreach to engage health system and health plan  
            partners. CDPH believes OATF duplicates and significantly  
            overlaps with the goals of the ongoing POMOP Workgroup, and it  
            may dilute, divert, or otherwise reduce resources that have  
            been allocated to the Workgroup, potentially limiting its  
            efficacy, and result in policy inaction should recommendations  
            from the groups be misaligned.
          
          8)Suggested Amendments. The author and committee may wish to  
            amend this bill to take advantage of the POMOP workgroup and  
            apply the requirements of this bill to POMOP.  Additionally,  
            the bill could be amended to require an expansion of POMOP to  
            include health care providers, health plans, insurers, and  
            other relevant stakeholders who are not affiliated with  
            existing state departments or state entities.

           SUPPORT AND OPPOSITION  :
          Support:  California Council of Community Behavioral Health  
                    Agencies
                    California Dental Association
                    California District Attorneys Association
                    California Health+Advocates 






          AB 1977 (Wood)                                      Page 7 of ?
          
          
                    California State Sheriffs' Association
                    County Health Executives Association of California
                    L.A. Care Health Plan
                    Medical Board of California
                    Mental Health America of California
          
          Oppose:   California Department of Public Health

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