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House Public Health met on March 14 to hear a number of bills. This report covers discussions on: HB 1805 (Klick), HB 1488 (Rose), HB 181 (Johnson, Jarvis | et al.), HB 362 (Oliverson | et al.), and HB 1190 (Klick). Part one of the hearing can be found here and part two can be found here.

 

This report is intended to give you an overview and highlight the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

HB 1805 (Klick) Relating to the medical use of low-THC cannabis by patients with certain medical conditions.

  • Klick – Bill adds two conditions to the Texas Compassionate Use Program; chronic pain otherwise treated with an opioid and debilitating medical conditions as defined by DSHS
  • Raises THC limits for low THC cannabis from 1 to 5%
  • Working on a CS to change from a weight cap to a volumetric cap
  • Program currently allows nine conditions to be controlled through the TCUP

 

Michael McKim, Self – For

  • Thanks to Klick on work to expand the TCUP; am a veteran and small business owner in Austin
  • Have suffered with PTSD and previously turned to alcohol; was able to access medical cannabis through the TCUP and has improved my life significantly
  • Veterans in chronic pain are still in need of relief; can only turn to over the counter or opioids
  • Previously supported a bill that covered chronic pain and other conditions, but that version was not passed; urge committee to pass this bill

 

Dr. Jokūbas Žiburkus, Bonet Wilson and Self – For

  • Attending professor at U of H specializing an epilepsy and Alzheimer’s disease
  • Have been supporting expansion/creation of TCUP for six years
  • Have developed education on cannabinoid medications; have studied delivery methods and best way is through inhalation or suppository
  • Operators in the state do not offer these types of products
  • Do not want people to smoke/burn anything, but are devices out there that allow for heated/unheated inhalation
  • Need to be aware that 5% could be raised to 10% or there not be a percentage limit in the near future
  • Mandate for Compassionate Use Review Boards have not been executed; need this for a clear research path; could work with universities on this
  • Tinderholt – Nice to hear there are other devices that do not involve smoking; my district would struggle voting yes on something where people are smoking marijuana
    • Some of these devises have been approved for use in hospitals in other places like Israel

 

David Bass, Self – For

  • Retired veteran; legal use of medical cannabis in the State and this has reduced my PTSD and impacted his life in a positive way

 

Ramona Harding, Self – For

  • Disabled navy veteran; use of cannabis gummies have been lifesaving and expansion of the program will be a positive for many people

 

Elizabeth Miller, Self – For

  • Have a rare disease which effects neurological and gastrointestinal processes; makes it impossible to use edibles
  • In favor of expansion of the TCUP and especially the inhalant delivery system
  • Jones and Miller discuss her disease Ehlers-Danlos syndrome
  • Jones and Tinderholt ask about smoking versus inhaling
    • Notes inhalation is best delivery method especially those with her condition

 

Dr. Matthew Brimberry, Self – For

  • Hospice and palliative care physician and a member of Austin Geriatric Specialists
  • Previous expansions of the TCUP have been very beneficial to palliative care patients
  • Program has further to go; patients have left the program because the price or concentration can lead to GI side effects
  • Ask you raise these caps and include chronic pain treatment
  • Smith – Explain what why we need to raise these caps?
    • Are patients who need way more than the cap; raising by 5% or 10% every time we will never get there
  • Smith – Medically speaking, would you offer a cap? No cap? What is your proposal?
    • Have access to extraordinary concentration of dangerous addictive opioids; should have the same concentration access to this safe and not as addictive medicine
    • Should be up to the physician/patient
  • Smith – So no cap?
    • Thinks should be up to physician’s discretion
  • Smith – Think that process is a standard of care under your profession?
    • Yes – it should be

 

Joyce Hernandez, Self – For

  • Speaks in favor of the bill

 

J Cansigula, Coalition of Texans with Disabilities – For

  • Thanks Klick for this bill; moved to Texas from a state with a more robust compassionate use program
  • Expansion of TCUP will help those with autoimmune issues like myself
  • Deferring further expansions to DSHS is important as well so you do not have to come back and vote on this every two years

 

Chase Bearden, Texas Patients First Foundation – For

  • Lack of TCUP program participation has increased cost and pushed people out of the program; is important to expand program to reduce cost
  • A participant in the program has kept me off of opioids
  • Raising the 5% does not change the amount of THC a person can get
  • Under the by weight system currently doctors can prescribe as much as a person needs, but have to purchase more
  • Edibles/tinctures do not work with all disabilities; could move towards inhalers
  • Appreciate diagnoses for the future to be with DSHS
  • Collier – Was not aware of this by weight system that they would need to buy more; insurance covers this?
    • No insurance no state funds help with this; is not cheap
    • Need to expand program eligibility and number of licensees to get costs down
  • Collier – How many licenses in the state?
    • 3, but 2 who are fully operating
  • Collier – Are they mailing?
    • Main way is delivery, but are barriers that make it more expensive to deliver
  • Collier – Inhalers not in Texas, but other states?
    • Yes; is like with every medication; should allow flexibility for different delivery services
  • Collier – Bill as written would allow for this different delivery method?
    • Are moving that way, but does not specifically mention it
  • Collier – Anything in law that would prevent that?
    • Specifically cannot smoke or burn in current law

 

Klick, in closing

  • This bill is the next step in the TCUP; it follows science and makes medication accessible to patients in need
  • Smith – Any idea of how many patients this bill will support?
    • Cannot say actual patient count
  • Smith – Have misgivings about the evidence base, tracking patients and keeping expansion within bounds of proper versus illicit use
  • Oliverson – Support bill; will do what I can to get it passed smoothly as possible
  • Tinderholt – Can use heating devices now? Can use inhalers people are talking about?
    • Are limitations on those; have limitations far as it being smoked and heated
  • Collier – Nebulizers would not be allowed?
    • Original bill we passed had limitations on smoking the product which is a very similar process
  • Collier – Sounds like when we open it up to other conditions we need to open up to other delivery methods
    • Do not know what the effect of that would be
  • Collier – Is a study being done on that now?
    • Not that I am aware

 

HB 1805 left pending

 

HB 1488 (Rose) Relating to sickle cell disease health care improvement and the sickle cell task force.

  • Rose – Study of sickle cell has been historically ignored by researchers, medical field, and policy
  • Bill ensures Medicaid practitioners can offer healthcare services in line with national clinical practice guidelines, to have education on sickle cell, and to find database opportunities to improve health outcomes
  • Requires Sickle Cell Task Force to include recommendations for improvement of education on sickle cell disease
  • Medical schools and TEA required to incorporate, where appropriate, education related to sickle cell disease
  • Working on a committee substitute and will bring that forward later

 

Dr. Titilope Fasipe, Self – For

  • Pediatric hematologist and have sickle cell disease; overviews sickle cell
  • There has been significant miseducation about the disease even in the medical community
  • Texas was the first state to screen newborns for sickle cell disease in the 1980s, but the last state implemented it in 2006
  • Bill is a call to action to infuse comprehensive sickle cell treatment into society and expands work of the Sickle Cell Taskforce; partnership with TEA and higher education is important
  • Oliverson – Strongly support this bill
  • Oliverson and Fasipe discuss burden of sickle cell on the system versus the positive effects of comprehensive care
  • Jones and Fasipe discuss how knowing information about sickle cell saves lives

 

Andre Harris, Self – For

  • Live with sickle cell disease
  • Bill is a way to hold emergency rooms or hospitals accountable for sickle cell care
  • Currently in a fight with a hospital to keep them accountable for a recent incident in which they did not provide proper care for my disease
  • There are guidelines out there including by the Emergency Nurses Association

 

Dr. Tomia Austin, As One Foundation – For

  • MDs are uneducated and undertrained about sickle cell trait
  • Need to educate/train our physicians

 

HB 1488 left pending

 

HB 181 (Johnson, Jarvis | et al.) Relating to the establishment of the sickle cell disease registry.

  • Jarvis Johnson – Requires DSHS forms a sickle cell registry from the Sickle Cell Task Force
  • Medical community unfortunately does not know much about sickle cell and there is a large stigma for suffers who go to the hospital and seek pain relief
  • Jones – Fiscal note is high, same one as received last session?
    • Find the fiscal note to be a little high/questionable; in Louisiana costs $200k
    • Missed a great opportunity to apply for federal grants to help with the costs; can apply this year
    • Will look into this, but the money should not be the reason this does not pass

 

Dr. Titilope Fasipe, Self – For

  • Estimate greater than 7k with sickle cell in Texas; top three states with sickle cell disease
  • Registry that tracks lifespan data will help healthcare professionals, advocates and policymakers assess the areas of need and develop programs to improve outcome
  • Including those living in the rural communities
  • When you become an adult you are more likely to see fragmented care which can increase healthcare burden on healthcare system
  • Registry will help in those areas of high need

 

Heather O, Self – For

  • National advocate for sickle cell; have sickle cell and have been in Texas for a decade
  • Provides an anecdote of the transition of her care to Texas
  • Data is power and Texas has a foundation to grow with this

 

Andre Harris, Self – For

  • Speaks on his support the bill; glad this is a bipartisan effort

 

Jarvis Johnson, in closing

  • No one should have to go through medical injustice
  • Collier – Asks about the fiscal note
    • Will work on the fiscal note

 

HB 181 left pending

 

HB 362 (Oliverson | et al.) Relating to the use, possession, delivery, or manufacture of testing equipment that identifies the presence of fentanyl, alpha-methylfentanyl, or any other derivative of fentanyl.

  • Oliverson – Would legalize the possession, delivery, or manufacturing of fentanyl testing strips
  • Currently possession of a fentanyl strip is a Class C misdemeanor and manufacturing a Class A misdemeanor
  • Heard policymakers on both sides of this argument; some concerned bill would promote drug use and others say it does not go far enough
    • This strikes the right balance; mere presence of fentanyl is enough to be deadly
  • Number of fentanyl related deaths has risen 89% in the last 12 months
  • Bill will not solve substance abuse, but can work on decreasing the amount of fentanyl related deaths

 

Sarah Reyes, Texas Center for Justice and Equity – For

  • This is a great bill and a step in the right direction to take in the overdose crisis we are in
  • Recommend expanding this bill to other adulterants that carry serious risk
  • Recommended committee to decriminalize drug paraphernalia as a whole as drug testing is only part of the solution
  • Anything we can do to educate regarding substance abuse and overdose is important

Cate Graziani, Texas Harm Reduction Alliance – For

  • Is an important bill, have needed access for these tools for about 10 years
  • Are seeing other substances contributing to overdoses; important to look at nation-wide trends
    • Notes there have been a number of overdoses in the Austin area due to Xylazine
  • Would like to add language that allow for the opportunity to check for other adulterants; do not want to come back every session to authorize testing for drugs one-by-one
  • Support proposals like Senator West’s SB 868
  • Johnson – Depending on how you test, is possible you get a false negative?
    • Not a 100% accurate system, why we need this and more tools that are more accurate
  • Johnson – Need to balance policy condoning usage and getting testing to people
  • Jones – Talked about trends from elsewhere in the nation; do you think this will help with overdoses?
    • Yes is just a part also need Narcan and drug checking beyond fentanyl
  • Jones and Graziani discuss the outreach THRA does
  • Collier – The whole purpose of this is to save lives
    • Agree, this is not condoning behavior, it is about saving the lives of those already using

 

Claudia Delfin, Corazon Harm Reduction – For

  • Have been doing harm reduction education throughout the state
  • Notes drug trends are changing; are more lethal now
  • For this bill because these strips do work; is about saving lives

 

Stephanie Guerra, ViventHealth – For

  • Support the bill, also in favor of language of expanding testing to other adulterants

 

Oliverson, in closing

  • Can order a pack of 5 fentanyl testing strips from Amazon right now for $17, but cannot be shipped to Texas
  • Not opposed to adding other adulterants, but focusing on fentanyl because of its lethality
    • Cannot currently find any Xylazine testing strips in the market
  • Understand some people could fall through the cracks, but this is a no brainer

 

HB 362 left pending

 

HB 1190 (Klick) Relating to the prescribing and ordering of Schedule II controlled substances by certain advanced practice registered nurses and physician assistants.

  • Klick – Current state law prevents advanced practice registered nurses and physician assistants from prescription Schedule II medications; leads to discontinuity of care and higher administrative burdens
  • Bill will allow physicians to delegate Schedule II authority to APRNs and PAs they supervise
  • Is a permissive bill; could not give the authority or could give limited authority
  • APRNs and PAs would be subject to the Prescription Monitoring Program and the 10-day limit on prescription Schedule IIs for acute pain
  • 46 other states and Washington D.C. have allowed this delegation of authority
  • The last two times this bill was heard in committee no one testified against it or registered against the bill
  • This is a common-sense proposal that has support from the Texas Hospital Association, Opioid Treatment Coalition, Texas Association of Physician Assistants, Texas Nurse Practitioners, and others

 

Monee Carter-Griffin, Self and Texas Nurse Practitioners – For

  • Current Texas laws often cause delay of care; bill will allow healthcare teams to work together
  • This bill has passed the committee and the House twice; is common-sense policy
  • Tinderholt – Not saying no, but have concerns about the addictive potential of Schedule II drugs; what do you say to that?
    • We are a part of the healthcare team and work together to decide the best for each patient
    • Are held liable to the same responsibilities/accountabilities as physicians do
  • Tinderholt – Doctor has to opt-in to this?
    • Correct, is between the physician and APRN/PA on what types of medication you are prescribing or what patients you are prescribing to
  • Tinderholt – Does a physician give this delegation for a group?
    • Is individual delegation
  • Tinderholt – That gives me more comfort
  • Jones – What is the oversight on this?
    • Currently, APRNs are allowed to prescribe medications, but not Schedule IIs
    • Is a collaborative effort
  • Jones – Concerned about the opioid crisis?
    • Are at the lowest point of opioid prescribing we have been for the last 15 years
    • Most of the opioid crisis is coming from the illicit market
  • Jones – Would decide on an annual basis?
    • Prescriptive authority is delegated on an annual basis
    • Texas has a provider shortage already; reiterates this is a collaboration of the HC team
  • Tinderholt – This comes down to training, how much more do you have that the average nurse?
    • Is an additional three to five years
  • Tinderholt – This entire conversation has shifted perception of this bill; understand this to be an ongoing collaboration
  • Tinderholt – Punishments for mis-prescribing are significantly high, would be the same for you?
    • Yes; are held to the same rules/standards as physicians
  • Tinderholt – How are similar/different to the training physician assistants receive?
    • Practice similarly in clinical practice
  • Jones and Carter-Griffin discuss the process undergone before this level of prescription is given to patients

 

MD Girish Joshi, of Texas Society of Anesthesiologists – Against

  • Are too many unintended consequences in overseeing a new group of those with prescribing authority; the opioid crisis is a result of this
  • A study shows APRNs and PAs overprescribe narcotics
  • Compares the Texas Medical Board’s power to sanction physicians who overprescribe versus the Texas Nursing Board
  • Healthcare is a team sport, but not everyone on the team has the same abilities
  • Klick – Concerning the study you are mentioned, we are talking about the ability to prescribe, not about pain management practice
  • Klick – Study you mention also show that APRNs and physicians prescribe similarly
    • Is about details in the report; who is going to oversee the oversight?
  • Klick – Nursing Board does, just like TMB for medical practice
  • Collier – Do PAs fall under the TMB? Do
    • Yes, but not over PA opioid prescription oversight
  • Collier – Does this bill not set up the ability to create oversight?
    • Need to have that in place before we give them prescription authority
  • Jones and Joshi discuss that there are significant training differences between and MD and APRN

 

Autumn Spencer, Texas Academy of Physician Assistants – For

  • PAs are the first to be called to the ER and help manage patients; prescribing Schedule II substances once a patient leaves is where we get hung up
  • Bill affirms ability to delegate prescribing authority without site limitations
  • Klick – If you are at an in-patient setting, you can already prescribe these correct?
    • Can order treatments including Schedule IIs on-site, cannot prescribe when they leave
  • Tinderholt – Someone other than the doctor entering this into the system?
    • No
  • Tinderholt – You can issue these exact drugs in a hospital setting?
    • If they have delegated the authority, then yes
  • Collier – If this goes through any pharmacy filling would go through PMP?
    • Have to already do that now since SB 406 in 83(R); also have maximum prescribing for acute pain management
    • Are meeting requirements
  • Collier – Not sure if there will be an increase in referrals to the PMP if this passes?
    • These all go into the patient’s chart
  • Collier – Under bill would a hospital be able to require a doctor to delegate authority?
    • No; the hospital could further restrict if needed
  • Collier – The doctor would be liable if one of their delegates’ wrongdoings?
    • In certain circumstances yes, but code specifies they are not liable just because they were the one who delegated authority
  • Tinderholt – Bill would clear up confusion of when you can/cannot order/prescribe?
    • Yes
  • Tinderholt – Feel if we pass this there will be significant increases in Schedule II prescriptions?
    • Patients will get them either way
  • Jones – Under some circumstances you can order schedule II-VI?
    • Always under physician oversight
  • Jones and Spencer discuss prescriptions versus ordering, the prescription monitoring program and length of PA courses
  • Jones – Physicians may not be held liable?
    • Yes

 

Carla Patel, Texas Nurse Practitioners – For

  • Discusses work as a PA for MD Anderson; often having to wait for someone else to prescribe leaves patients in pain
  • Bill is patient-centered and common sense

 

Dr. Alina Sholar, Texas Physicians for Patients PAC and Tx400 – Against

  • Oppose this bill and others that unravel the legislature’s work to combat the opioid crisis
  • This is a scope of practice bill that expands authority from physicians to NPs and APRNs
  • Guardrails are not barriers to care, but are for the safety of patients
  • We are team players, but someone needs to be the leader
  • Several studies show that mid-level practitioners over prescribe Schedule IIs
  • 80% of illicit sales are from a family member who received an Rx by a mid-level provider
  • Do not know what agency is going to provide oversight; Nursing Board lacks the resource to oversee this
  • Collier – Seems like the bill does have guardrails in place… is permissive
    • If this bill were to pass, would lose that guardrail
  • Collier – Only place I am getting hung up on is
    • Outpatient is a completely different that a hospital
  • Tinderholt – Think if this bill passes there will be an increase in opioid prescriptions?
    • If this bill passes, there will be an increase in Schedule II prescriptions; has been the outcome in every state that has gone this route
  • Tinderholt – Explain about patients not being sure about who they are seeing
    • Is hard for patients to tell who is a doctor versus APRN or a PA
  • Tinderholt – Do not know where I am at concerning this bill; fear increasing crisis we are in
    • Need to look at the data coming out of other states
  • Smith – A reason as to why Schedule IIs are overprescribed even with physician oversight?
    • Is a level of trust between physician and mid-levels and that can be broken; they can write prescriptions outside of the practice
  • Smith – Particular Schedule II drugs it would be oaky to delegate authority for?
    • No
  • Smith – Pressure on physicians to refill these types of prescriptions?
    • Depends on the individual; should know when you should/should not prescribe
  • Smith – Idea on how the TMB oversees investigations?
    • Would be the one to go to if there is a complaint
  • Smith – Unless there is a complaint, will not be any investigation?
    • Correct, true for Nursing Board as well
  • Smith – Information to believe it is that way in other states?
    • Yes
  • Smith – Where did you get your overprescription Medicaid data?
    • Databases outside the complaint system
  • Jones – Physicians know how long they should prescribe these medications for?
    • Yes and they know if you are still requesting pain medication after that time, then something is wrong
  • Jones – Bill is about settings outside of the hospital setting?
    • Correct

 

Lesley Wimmer, Opioid Provider Treatment Coalition – For

  • Support this bill; have controlled measures in place to limit diversion
  • Is extremely difficult to find staff to work in addiction treatment, this bill would help with this
  • Collier – Are good with physician oversight and keeping delegation authority?
    • Yes
  • Jones – Your facilities’ directors are doctors?
    • Correct
  • Jones and Wimmer discuss the facilities’ outpatient structure

 

Dr. Patricia Aronin, Texas Physicians for Patients PAC and Tx400 – Against

  • Is a difference between ordering, while in a hospital setting has large oversight, versus prescribing that lacks same oversight
  • In whole career only had around 20 cases of sending a patient home with a Schedule II narcotic
  • Opioid overdose and toxicity concerns for the expanding senior population; deaths have skyrocketed in recent years
  • Of those admitted to hospital for overdoses, Medicaid is the primary insurer
  • Pharmaceutical reps are more likely for the push to unleash a new group of non-physician prescribers
  • Appropriate pain management is not permanent pain relief that results in death because you were given medication you didn’t need in the wrong amount
  • Tinderholt – Trying to figure out where I stand; usually we hear from people concerned about scope of practice
  • Tinderholt – Seems like you are worried about the patient not scope increase/decrease
    • Correct; what is happening with opioid prescription is frightening
  • Tinderholt – Do not feel like the issues with opioid is malicious?
    • Correct; it is well intentioned as we do not want people to hurt
  • Jones – Request you get me the studies you mentioned
  • Jones and Aronin discuss their concerned about over-prescriptions in management of pain
  • Price – Have been quiet during this bill’s discussion; have heard this issue over multiple sessions
  • Price – People make this black and white, but it is complicated; are presented a lot of conflicting data with varying publication dates
  • Price – Have not heard anyone discuss this from the angle of access to care in rural communities; in some counties there is no healthcare provider or is only an APRN
  • Price – Are many who live in rural communities who have to travel long distances to get a Schedule II
  • Price – This delegated authority was previously in place?
    • Do not believe so
    • Klick – It was
  • Price – Have not heard discussion about the now robust PMP; the issues of today that are not because of mid-level providers

 

Dr. Jason Morrow, Self – For

  • Strongly in favor of the bill
  • Teach at various institutions of higher learning and specialize in palliative care
  • PMP has been in Texas for 10 years and it has changed the game; is a guardrail
  • Notes patients have to wait for symptom relief as his clinic has a wait list; would like nurse practitioner the clinic to help in this care patients

 

Valerie Dezarae Cavazos, Self – For

  • Speaks in favor of the bill; improves patient care/access/efficiency

 

Klick, in closing

  • Tinderholt – Heard about the 10-day rule, do not see in bill, but it can be up to 90 day?
    • Is generally a 10-day now; that is the opioid regime we have in the state currently

 

HB 1190 left pending