Existing law requires a prescriber, with certain exceptions, before directly dispensing or issuing for a minor the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information with the minor, the minors parent or guardian, or another adult authorized to consent to the minors medical treatment.

This bill would extend that requirement for the prescriber by applying it to any patient, not only a minor, under those circumstances. The bill would also require the prescriber to discuss the availability of nonpharmacological treatments for pain, as defined.

Existing law makes an exception to the requirement for the prescriber in the case of a patient who is being treated for a diagnosis of chronic intractable pain, as specified.

This bill would remove that exception and would instead make an exception in the case of a patient who is currently receiving hospice care.

The bill would require the prescriber, after discussing the information, to offer, as deemed appropriate by the prescriber, a referral for a provider of nonpharmacological treatments for pain, and to obtain consent from the patient, a minor patients parent or guardian, or another authorized adult, as specified.

Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), requires a health benefit plan issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined.

This bill would make legislative findings and declarations relating to addiction associated with overreliance on prescription medication for pain management, and providing that nonpharmacological treatments for pain should be considered during the next update to the states essential health benefits benchmark plan.

Existing law requires a prescriber, with certain exceptions, before directly dispensing or issuing for a minor the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information with the minor, the minors parent or guardian, or another adult authorized to consent to the minors medical treatment.

This bill would extend that requirement for the prescriber by applying it to any patient, not only a minor, under those circumstances. The bill would also require the prescriber to discuss the availability of nonpharmacological treatments for pain, as defined.

Existing law makes an exception to the requirement for the prescriber in the case of a patient who is being treated for a diagnosis of chronic intractable pain, as specified.

This bill would remove that exception and would instead make an exception in the case of a patient who is currently receiving hospice care.

The bill would require the prescriber, after discussing the information, to offer, as deemed appropriate by the prescriber, a referral for a provider of nonpharmacological treatments for pain, and to obtain consent from the patient, a minor patients parent or guardian, or another authorized adult, as specified.

Existing federal law, the federal Patient Protection and Affordable Care Act (PPACA), requires a health benefit plan issuer that offers coverage in the small group or individual market to ensure that the coverage includes the essential health benefits package, as defined.

This bill would make legislative findings and declarations relating to addiction associated with overreliance on prescription medication for pain management, and providing that nonpharmacological treatments for pain should be considered during the next update to the states essential health benefits benchmark plan.

Date of Hearing: April 18, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1751

Author:(Gipson) – As Introduced Ver:February 17, 2023

SUBJECT: Opioid prescriptions: information: nonpharmacological treatments for pain.

SUMMARY: Extends existing requirement that applies only to minors to all patients that require a prescriber, before directly dispensing or issuing the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information. Removes the exception for a patient who is being treated for a diagnosis of chronic intractable pain, as specified and instead makes an exception in the case of a patient who is currently receiving hospice care. Requires the prescriber to discuss the availability of nonpharmacological treatments for pain, as defined. Requires the prescriber, after discussing the information, to obtain consent from the patient, a minor patient’s parent or guardian, or another authorized adult, as specified. Specifically, this bill:

Extends the requirement in existing law for a prescriber, before directly dispensing or issuing for a minor the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information with the minor, the minor’s parent or guardian, or another adult authorized to consent to the minor’s medical treatment requirement to apply to all patients, not only a minor, as specified.

Removes existing exception for the prescriber to discuss specified information if a patient is being treated for a diagnosis of chronic intractable pain, and instead creates an exception for a patient who is currently receiving hospice care.

Adds to the list of specified information a prescribing provider must discuss to include the availability of nonpharmacological treatments for pain, as defined.

Requires the prescriber, after discussing the information required in 1) and 3) above, to obtain consent from the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment, to be placed in the patient’s medical record, and to contain all of the following:

The name and quantity of the controlled substance being prescribed or issued to the patient, and the amount of the initial dose;

A statement certifying that the prescriber discussed with the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment, the information required by 1 and 3) above; and,

A space for the signature of the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment; and,

1. Defines nonpharmacological treatments for pain to include, but are not limited to, acupuncture, chiropractic care, physical therapy, occupational therapy, and licensed mental health provider services.
2. Prohibits this bill from requiring health care coverage, or changing existing health care coverage requirements, for nonpharmacological treatments for pain.
3. Makes various findings and declarations including that a growing body of research indicates that certain nonpharmacological therapies are proven to be equally effective to treat certain causes of pain as prescription opioids, without placing patients at risk for addiction or overdose, and that coverage of these treatments should be considered during the next update to the state’s essential health benefits (EHBs) benchmark plan.

EXISTING LAW:

1. Establishes the Department of Managed Health Care to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance to regulate health insurers. [Health and Safety Code (HSC) § 1340, et seq., and (Insurance Code (INS) § 106, et seq.]
2. Establishes as California's EHB benchmark under the federal Patient Protection and Affordable Care Act (ACA), the Kaiser Small Group Health Maintenance Organization, existing California health insurance mandates, and the 10 ACA mandated essential health benefits (EHBs), including but not limited to prescription drug coverage, acupuncture, physical therapy, occupational therapy and mental health. [HSC § 1367.005 and INS § 10112.27]
3. Prohibits, with respect to an individual or group health plan contract or health insurance policy that covers EHBs, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days from exceeding $250; for a product with an actuarial value at or equivalent to a Bronze level, limits cost sharing to not more than $500 for a supply of up to 30 days; and for a high deductible health plan the $250 or $500 limits apply only after an enrollee’s deductible is met. [HSC § 1342.73 and INS § 10123.1932]
4. Establishes various practice acts in the Business and Professions Code (BPC) governed by various boards within the Department of Consumer Affairs which provide for the licensing and regulation of health care professionals. [BPC § 500 et seq.]
5. Requires a prescriber, for minor patients, prior to directly dispensing or issuing a prescription for a controlled substance containing an opioid, to discuss information, including the risks of addiction and overdose associated with the use of opioids, the increased risk of addiction to an individual who is suffering from both mental and substance abuse disorders, and the danger of taking an opioid with a benzodiazepine, alcohol, or another central nervous system depressant. Exempts all treatments of addiction, chronic intractable pain, medical emergencies, or any situation where the prescriber believes the discussion would be detrimental to the minor's health or safety or in violation of the minor's legal rights regarding confidentiality from the discussion requirements. [HSC § 11158.1]
6. Requires a licensed Doctor of Chiropractic to verbally and in writing inform each patient of the material risks of proposed care, defined as a procedure inherently involving known risk of serious bodily harm. Requires the chiropractor to obtain the patient's written informed consent prior to initiating clinical care. Requires the signed written consent to become part of the patient's record. [California Code of Regulations, Title 16, § 319.1]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the opioid crisis is an ongoing epidemic that has devastated communities. This issue is something that needs to be addressed immediately and legislators have to take the steps to reduce the catastrophic impact it has made before it worsens. Californians deserve to be able to receive pain treatment that would not risk their life into a downward spiral. The author concludes that prescribers should offer alternate methods of treatment in order to promote healthier ways to manage pain that will not leave a patient at risk for addiction.
2. BACKGROUND. According to the California Health Benefits Review Program (CHBRP), pain is defined as actual or potential tissue damage that is associated with an unpleasant sensory and/or emotional experience. Pain has a complex categorization system, often classified by length of time and connection of tissue injury. Common classifications of pain include acute and chronic. The prevalence of pain remains a pervasive public health issue in the United States. Despite this, current data on the incidence and prevalence of pain are inconsistent or incomplete.

In recent years, the federal government has passed multiple laws intended to address the country's opioid epidemic. In 2016, both the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act (Cures Act) were enacted. CARA focused primarily on public health and law enforcement strategies, whereas the Cures Act emphasized medical innovation, funding, and addressing mental health and substance use activities. In 2017, the Centers for Disease Control and Prevention officially declared the opioid crisis a public health emergency. In 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was signed into law. The SUPPORT for Patients and Communities Act is a broad law that includes measures to address law enforcement, public health, opioid production and distribution, public education, access to opioid addiction treatment services, and health care financing and coverage. Part of the legislation required the United States Health and Human Services Agency to convene stakeholders to “address the challenges and barriers of developing nonaddictive medical products intended to treat acute or chronic pain or addiction” and publish guidance addressing these challenges. In response, the U.S. Food and Drug Administration published draft guidance to accompany development of nonopioid analgesics for acute pain lasting up to 30 days. The law also directed the Centers for Medicare & Medicaid Services (CMS) to issue guidance to states, or update existing guidance documents, on items and services that may be provided in state Medicaid programs for non-opioid treatment and management of pain. The 2019 guidance published by CMS acknowledged the proven efficacy of exercise therapy, physical therapy, and cognitive behavioral therapy for chronic pain. It also pointed to state's option to provide coverage for acupuncture, massage therapy, chiropractic care, cognitive behavioral therapy, physical therapy, or other Medicaid-coverable services.

• 1. Overview of the Opioid Crisis. In October of 2017, the White House declared the opioid crisis a public health emergency, formally recognizing what had long been understood to be a growing epidemic responsible for devastation in communities across the country. According to the Centers for Disease Control and Prevention (CDC), as many as 50,000 Americans died of an opioid overdose in 2016, representing a 28% increase over the previous year. Additionally, the number of Americans who died of an overdose of fentanyl and other opioids more than doubled during that time with nearly 20,000 deaths. These death rates compare to, and potentially exceed, those at the height of the AIDS epidemic.

Opioids are a class of drugs prescribed and administered by health professionals to manage pain. Modern use of the term “opioid” typically describes both naturally occurring opiates derived from the opium poppy as well as their manufactured synthetics. Common examples of prescription opioids include oxycodone (OxyContin, Percocet); hydrocodone (Vicodin, Norco, Lorcet); codeine; morphine; and fentanyl. Heroin is also an opioid.

• 1. Nonpharmacological Treatments for Pain. According to the author, this bill is intended to increase awareness of, and access to, certain nonpharmacological pain management therapies. Under the bill, this would include acupuncture, chiropractic care, physical therapy, occupational therapy, and mental health.

In 2017, the American College of Physicians (ACP) published updated guidelines in the Annals of Internal Medicine, summarizing the results of studies related to the use of noninvasive methods for treating low back pain in adults. In those published guidelines, which followed research involving controlled trials and clinical studies, the ACP wrote that “patients with acute or subacute low back pain usually get better over time, so they probably will not need medicines. They should discuss other treatment options with their doctors.” Specifically, the ACP described studies indicating that effective treatment options include acupuncture, and spinal manipulation. The ACP also describes how studies show that “before taking medicines, patients with chronic low back pain should try other treatments” including “therapy that addresses physical, psychological, and social issues that may be causing pain,” acupuncture, and behavioral health. The ACP states that “opioids should be considered only if no other treatments work and only if there are more benefits than risks for an individual patient.”

• 1. CDC Guidelines. Additional research and guidance has come from the CDC in a document titled “CDC Guideline for Prescribing Opioids for Chronic Pain”, published in the Morbidity and Mortality Weekly Report. With an intent “to improve communication between clinicians and patients about the risks and benefits of opioid therapy,” the CDC guidelines urge that “appropriate use of long-term opioid therapy must be considered within the context of all pain management strategies (including nonopioid pain medications and nonpharmacologic treatments).” In reviewing the effectiveness of nonpharmacological therapies, the CDC concluded that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”

This bill would require that in a clinical context where a physician or another prescriber may prescribe an opioid medication for a patient, communication occurs to now include an offer, as appropriate, a referral for a provider of nonpharmacological treatments for pain.

1. SUPPORT. The California Chiropractic Association (CalChiro), sponsor of this bill, states that this bill seeks to reduce the over-reliance on prescription opioids by integrating nonpharmacological treatments to pain management care plans and, most importantly, ensures that patients are making well informed decisions before an opioid is prescribed. According to CDC, the data shows 107,477 predicted overdose deaths in the 12-month period ending in August 2022 The sheer magnitude of America’s prescription opioid abuse has evoked visceral responses and calls to action from public and private sectors. The California Health Care Foundation’s (CHCF) Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic states that alternative treatments to opioids, including chiropractic care, have been found to play an important role in the delivery of cost-effective, non-drug services in both acute and chronic stages, as complementary to traditional treatments. The CHCF study notes that some health plans now authorize non-opioid treatment services for select diagnoses and that the cost of these services is offset by savings in opioid prescriptions. Nonpharmacological treatments, such as chiropractic care is a proven safe, long-term, solution to pain that reduces or eliminates the need for opioids and reduces surgical interventions. The Department of Veteran Affairs (VA) has been implementing specific nonpharmacologic therapies recommended by several clinical guidelines. As noted in Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care, a key set of the recommended therapies, spinal manipulation, massage, acupuncture, exercise, and patient education, are the core components of multimodal chiropractic care in the VA. CalChiro believes this bill will allow multidisciplinary teams to begin working together to find pain management options that will bend the curve on opioid addiction.
2. OPPOSITION. The California Medical Association (CMA) writes that this bill would force physicians to inform patients about nonpharmacological treatments for pain, including chiropractic, acupuncture, and mental health services – when prescribing opioids. Additionally, this bill would require physicians to provide redundant patient notifications and get patient signatures through a cumbersome informed consent process. Under this bill, the only exception to the above requirements would be a patient under hospice care. According to CMA, this bill undermines physicians’ expertise and would allow other provider groups to dictate how physicians deliver care to their patients. This bill does not make any attempt to address opioid misuse or abuse in any way outside of adding additional paperwork for patients and physicians. In fact, physicians currently practice safe prescribing techniques with opioids. CMA states that this bill would put overreaching notification and referral requirements on physicians, while also undermining the practice of medicine. CMA concludes that this will unequivocally have a negative impact on patient care.
3. RELATED LEGISLATION.
   1. AB 931 (Irwin) prohibits a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, from imposing prior authorization for the initial 12 treatment visits for a new episode of care for physical therapy. AB 931 is pending in the Assembly Health Committee.
   2. AB 1157 (Ortega) specifies that coverage of rehabilitative and habilitative services and devices under a health care service plan or health insurance policy includes durable medical equipment, services, and repairs, if the equipment, services, or repairs are prescribed or ordered by a physician, surgeon, or other health professional acting within the scope of their license. AB 1157 is pending in Assembly Health Committee.
   3. AB 1288 (Reyes) prohibits a health plan and a health insurer from subjecting a buprenorphine product, methadone, or long-acting injectable naltrexone for detoxification or maintenance treatment of a substance use disorder that is prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder to prior authorization. AB 1288 is pending in the Assembly Health Committee.
4. PREVIOUS LEGISLATION.
   1. AB 2585 (McCarty), Chapter 160, Statutes of 2022, makes related findings and declarations, including that the health care system should encourage the use of evidence-based nonpharmacological therapies for pain management.
   2. AB 888 (Low) from 2019 is substantially similar to this bill and was never heard in Senate Business and Professions and Economic Development Committee.
   3. AB 2487 (McCarty), Chapter 301, Statutes of 2018, authorizes a physician, as an alternative to the mandatory course on pain management, to complete a one-time continuing education course of 12 credit hours in the subjects of treatment and management of opiate-dependent patients, including eight hours of training in buprenorphine treatment, or other similar medicinal treatment, for opioid use disorders.
   4. AB 2741 (Burke) of 2018 would have limited all opioid prescriptions for minors to a maximum of five days, with exceptions, and require a prescriber to discuss risks related to opioid medication with the minor and the minor’s parent or guardian and obtain verbal consent prior to writing the prescription. AB 2741 failed passage in the Senate Business, Professions, and Economic Development Committee.
   5. SB 1109 (Bates), Chapter 693, Statutes of 2018, requires a prescriber to discuss the following with a minor, or the minor’s parent, guardian, or other adult authorized to consent to the minor’s medical treatment, information relating to the risks associated with opioids prior to dispensing or issuing a prescription of opioids to a minor for the first time.
5. DOUBLE REFERRAL. This bill has been double-referred; upon passage of this committee, it will be referred to the Assembly Business and Professions Committee.

REGISTERED SUPPORT / OPPOSITION:

Support

California Chiropractic Association (sponsor)
California Health Coalition Advocacy
California Physical Therapy Association
Occupational Therapy Association of California (OTAC)

Opposition

American College of Obstetricians and Gynecologists District IX
California Medical Association
California Orthopedic Association
California Podiatric Medical Association
California Society of Anesthesiologists
Los Angeles County Medical Association

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097

Date of Hearing: April 11, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1751

Author:(Gipson) – As Introduced Ver:February 17, 2023

SUBJECT: Opioid prescriptions: information: nonpharmacological treatments for pain.

SUMMARY: Extends existing requirement that applies only to minors to all patients that require a prescriber, before directly dispensing or issuing the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information. Removes the exception for a patient who is being treated for a diagnosis of chronic intractable pain, as specified and instead makes an exception in the case of a patient who is currently receiving hospice care. Requires the prescriber to discuss the availability of nonpharmacological treatments for pain, as defined. Requires the prescriber, after discussing the information, to offer, as deemed appropriate by the prescriber, a referral for a provider of nonpharmacological treatments for pain, and to obtain consent from the patient, a minor patient’s parent or guardian, or another authorized adult, as specified. Specifically, this bill:

Extends the requirement in existing law for a prescriber, before directly dispensing or issuing for a minor the first prescription for a controlled substance containing an opioid in a single course of treatment, to discuss specified information with the minor, the minor’s parent or guardian, or another adult authorized to consent to the minor’s medical treatment requirement to apply to all patients, not only a minor, as specified.

Removes existing exception for the prescriber to discuss specified information if a patient is being treated for a diagnosis of chronic intractable pain, and instead creates an exception for a patient who is currently receiving hospice care.

Adds to the list of specified information a prescribing provider must discuss to include the availability of nonpharmacological treatments for pain, as defined.

Requires the prescriber, after discussing the information required in 1) and 3) above, to do both of the following:

• 1. Obtain consent from the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment, to be placed in the patient’s medical record, and to contain all of the following:
     1. The name and quantity of the controlled substance being prescribed or issued to the patient, and the amount of the initial dose;
     2. A statement certifying that the prescriber discussed with the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment, the information required by 1 and 3) above; and,
     3. A space for the signature of the patient, a minor patient’s parent or guardian, or another adult authorized to consent to the minor patient’s medical treatment; and,
  2. Offer, as deemed appropriate by the prescriber, a referral for a provider of nonpharmacological treatments for pain.
     

1. Defines nonpharmacological treatments for pain to include, but are not limited to, acupuncture, chiropractic care, physical therapy, occupational therapy, and licensed mental health provider services.
2. Prohibits this bill from requiring health care coverage, or changing existing health care coverage requirements, for nonpharmacological treatments for pain.
3. Makes various findings and declarations including that a growing body of research indicates that certain nonpharmacological therapies are proven to be equally effective to treat certain causes of pain as prescription opioids, without placing patients at risk for addiction or overdose, and that coverage of these treatments should be considered during the next update to the state’s essential health benefits (EHBs) benchmark plan.

EXISTING LAW:

1. Establishes the Department of Managed Health Care to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance to regulate health insurers. [Health and Safety Code (HSC) §1340, et seq., and (Insurance Code (INS) §106, et seq.]
2. Establishes as California's EHB benchmark under the federal Patient Protection and Affordable Care Act (ACA), the Kaiser Small Group Health Maintenance Organization, existing California health insurance mandates, and the 10 ACA mandated essential health benefits (EHBs), including but not limited to prescription drug coverage, acupuncture, physical therapy, occupational therapy and mental health. [HSC §1367.005 and INS §10112.27]
3. Prohibits, with respect to an individual or group health plan contract or health insurance policy that covers EHBs, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days from exceeding $250; for a product with an actuarial value at or equivalent to a Bronze level, limits cost sharing to not more than $500 for a supply of up to 30 days; and for a high deductible health plan the $250 or $500 limits apply only after an enrollee’s deductible is met. [HSC §1342.73 and INS §10123.1932]
4. Establishes various practice acts in the Business and Professions Code (BPC) governed by various boards within the Department of Consumer Affairs which provide for the licensing and regulation of health care professionals. [BPC § 500 et seq.]
5. Requires a prescriber, for minor patients, prior to directly dispensing or issuing a prescription for a controlled substance containing an opioid, to discuss information, including the risks of addiction and overdose associated with the use of opioids, the increased risk of addiction to an individual who is suffering from both mental and substance abuse disorders, and the danger of taking an opioid with a benzodiazepine, alcohol, or another central nervous system depressant. Exempts all treatments of addiction, chronic intractable pain, medical emergencies, or any situation where the prescriber believes the discussion would be detrimental to the minor's health or safety or in violation of the minor's legal rights regarding confidentiality from the discussion requirements. [HSC § 11158.1]
6. Requires a licensed Doctor of Chiropractic to verbally and in writing inform each patient of the material risks of proposed care, defined as a procedure inherently involving known risk of serious bodily harm. Requires the chiropractor to obtain the patient's written informed consent prior to initiating clinical care. Requires the signed written consent to become part of the patient's record. [California Code of Regulations, Title 16, §319.1]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the opioid crisis is an ongoing epidemic that has devastated communities. This issue is something that needs to be addressed immediately and legislators have to take the steps to reduce the catastrophic impact it has made before it worsens. Californians deserve to be able to receive pain treatment that would not risk their life into a downward spiral. The author concludes that prescribers should offer alternate methods of treatment in order to promote healthier ways to manage pain that will not leave a patient at risk for addiction.
2. BACKGROUND. According to the California Health Benefits Review Program (CHBRP), pain is defined as actual or potential tissue damage that is associated with an unpleasant sensory and/or emotional experience. Pain has a complex categorization system, often classified by length of time and connection of tissue injury. Common classifications of pain include acute and chronic. The prevalence of pain remains a pervasive public health issue in the United States. Despite this, current data on the incidence and prevalence of pain are inconsistent or incomplete.

In recent years, the federal government has passed multiple laws intended to address the country's opioid epidemic. In 2016, both the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act (Cures Act) were enacted. CARA focused primarily on public health and law enforcement strategies, whereas the Cures Act emphasized medical innovation, funding, and addressing mental health and substance use activities. In 2017, the Centers for Disease Control and Prevention officially declared the opioid crisis a public health emergency. In 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was signed into law. The SUPPORT for Patients and Communities Act is a broad law that includes measures to address law enforcement, public health, opioid production and distribution, public education, access to opioid addiction treatment services, and health care financing and coverage. Part of the legislation required the United States Health and Human Services Agency to convene stakeholders to “address the challenges and barriers of developing nonaddictive medical products intended to treat acute or chronic pain or addiction” and publish guidance addressing these challenges. In response, the U.S. Food and Drug Administration published draft guidance to accompany development of nonopioid analgesics for acute pain lasting up to 30 days. The law also directed the Centers for Medicare & Medicaid Services (CMS) to issue guidance to states, or update existing guidance documents, on items and services that may be provided in state Medicaid programs for non-opioid treatment and management of pain. The 2019 guidance published by CMS acknowledged the proven efficacy of exercise therapy, physical therapy, and cognitive behavioral therapy for chronic pain. It also pointed to state's option to provide coverage for acupuncture, massage therapy, chiropractic care, cognitive behavioral therapy, physical therapy, or other Medicaid-coverable services.

• 1. Overview of the Opioid Crisis. In October of 2017, the White House declared the opioid crisis a public health emergency, formally recognizing what had long been understood to be a growing epidemic responsible for devastation in communities across the country. According to the Centers for Disease Control and Prevention (CDC), as many as 50,000 Americans died of an opioid overdose in 2016, representing a 28% increase over the previous year. Additionally, the number of Americans who died of an overdose of fentanyl and other opioids more than doubled during that time with nearly 20,000 deaths. These death rates compare to, and potentially exceed, those at the height of the AIDS epidemic.

Opioids are a class of drugs prescribed and administered by health professionals to manage pain. Modern use of the term “opioid” typically describes both naturally occurring opiates derived from the opium poppy as well as their manufactured synthetics. Common examples of prescription opioids include oxycodone (OxyContin, Percocet); hydrocodone (Vicodin, Norco, Lorcet); codeine; morphine; and fentanyl. Heroin is also an opioid.

• 1. Nonpharmacological Treatments for Pain. According to the author, this bill is intended to increase awareness of, and access to, certain nonpharmacological pain management therapies. Under the bill, this would include acupuncture, chiropractic care, physical therapy, occupational therapy, and mental health.

In 2017, the American College of Physicians (ACP) published updated guidelines in the Annals of Internal Medicine, summarizing the results of studies related to the use of noninvasive methods for treating low back pain in adults. In those published guidelines, which followed research involving controlled trials and clinical studies, the ACP wrote that “patients with acute or subacute low back pain usually get better over time, so they probably will not need medicines. They should discuss other treatment options with their doctors.” Specifically, the ACP described studies indicating that effective treatment options include acupuncture, and spinal manipulation. The ACP also describes how studies show that “before taking medicines, patients with chronic low back pain should try other treatments” including “therapy that addresses physical, psychological, and social issues that may be causing pain,” acupuncture, and behavioral health. The ACP states that “opioids should be considered only if no other treatments work and only if there are more benefits than risks for an individual patient.”

• 1. CDC Guidelines. Additional research and guidance has come from the CDC in a document titled “CDC Guideline for Prescribing Opioids for Chronic Pain”, published in the Morbidity and Mortality Weekly Report. With an intent “to improve communication between clinicians and patients about the risks and benefits of opioid therapy,” the CDC guidelines urge that “appropriate use of long-term opioid therapy must be considered within the context of all pain management strategies (including nonopioid pain medications and nonpharmacologic treatments).” In reviewing the effectiveness of nonpharmacological therapies, the CDC concluded that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”

This bill would require that in a clinical context where a physician or another prescriber may prescribe an opioid medication for a patient, communication occurs to now include an offer, as appropriate, a referral for a provider of nonpharmacological treatments for pain.

1. SUPPORT. The California Chiropractic Association (CalChiro), sponsor of this bill, states that this bill seeks to reduce the over-reliance on prescription opioids by integrating nonpharmacological treatments to pain management care plans and, most importantly, ensures that patients are making well informed decisions before an opioid is prescribed. According to CDC, the data shows 107,477 predicted overdose deaths in the 12-month period ending in August 2022 The sheer magnitude of America’s prescription opioid abuse has evoked visceral responses and calls to action from public and private sectors. The California Health Care Foundation’s (CHCF) Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic states that alternative treatments to opioids, including chiropractic care, have been found to play an important role in the delivery of cost-effective, non-drug services in both acute and chronic stages, as complementary to traditional treatments. The CHCF study notes that some health plans now authorize non-opioid treatment services for select diagnoses and that the cost of these services is offset by savings in opioid prescriptions. Nonpharmacological treatments, such as chiropractic care is a proven safe, long-term, solution to pain that reduces or eliminates the need for opioids and reduces surgical interventions. The Department of Veteran Affairs (VA) has been implementing specific nonpharmacologic therapies recommended by several clinical guidelines. As noted in Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care, a key set of the recommended therapies, spinal manipulation, massage, acupuncture, exercise, and patient education, are the core components of multimodal chiropractic care in the VA. CalChiro believes this bill will allow multidisciplinary teams to begin working together to find pain management options that will bend the curve on opioid addiction.
2. OPPOSITION. The California Medical Association (CMA) writes that this bill would force physicians to inform patients about nonpharmacological treatments for pain, including chiropractic, acupuncture, and mental health services – when prescribing opioids. Additionally, this bill would require physicians to provide redundant patient notifications and get patient signatures through a cumbersome informed consent process. Under this bill, the only exception to the above requirements would be a patient under hospice care. According to CMA, this bill undermines physicians’ expertise and would allow other provider groups to dictate how physicians deliver care to their patients. This bill does not make any attempt to address opioid misuse or abuse in any way outside of adding additional paperwork for patients and physicians. In fact, physicians currently practice safe prescribing techniques with opioids. CMA states that this bill would put overreaching notification and referral requirements on physicians, while also undermining the practice of medicine. CMA concludes that this will unequivocally have a negative impact on patient care.
3. RELATED LEGISLATION.
   1. AB 931 (Irwin) prohibits a health plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2025, from imposing prior authorization for the initial 12 treatment visits for a new episode of care for physical therapy. AB 931 is pending in the Assembly Health Committee.
   2. AB 1157 (Ortega) specifies that coverage of rehabilitative and habilitative services and devices under a health care service plan or health insurance policy includes durable medical equipment, services, and repairs, if the equipment, services, or repairs are prescribed or ordered by a physician, surgeon, or other health professional acting within the scope of their license. AB 1157 is pending in Assembly Health Committee.
   3. AB 1288 (Reyes) prohibits a health plan and a health insurer from subjecting a buprenorphine product, methadone, or long-acting injectable naltrexone for detoxification or maintenance treatment of a substance use disorder that is prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder to prior authorization. AB 1288 is pending in the Assembly Health Committee.
4. PREVIOUS LEGISLATION.
   1. AB 2585 (McCarty), Chapter 160, Statutes of 2022, makes related findings and declarations, including that the health care system should encourage the use of evidence-based nonpharmacological therapies for pain management.
   2. AB 888 (Low) from 2019 is substantially similar to this bill and was never heard in Senate Business and Professions and Economic Development Committee.
   3. AB 2487 (McCarty), Chapter 301, Statutes of 2018, authorizes a physician, as an alternative to the mandatory course on pain management, to complete a one-time continuing education course of 12 credit hours in the subjects of treatment and management of opiate-dependent patients, including eight hours of training in buprenorphine treatment, or other similar medicinal treatment, for opioid use disorders.
   4. AB 2741 (Burke) of 2018 would have limited all opioid prescriptions for minors to a maximum of five days, with exceptions, and require a prescriber to discuss risks related to opioid medication with the minor and the minor’s parent or guardian and obtain verbal consent prior to writing the prescription. AB 2741 failed passage in the Senate Business, Professions, and Economic Development Committee.
   5. SB 1109 (Bates), Chapter 693, Statutes of 2018, requires a prescriber to discuss the following with a minor, or the minor’s parent, guardian, or other adult authorized to consent to the minor’s medical treatment, information relating to the risks associated with opioids prior to dispensing or issuing a prescription of opioids to a minor for the first time.
5. COMMITTEE AMENDMENT. To address concerns that this bill could undermine the practice of medicine and patient care, the Committee should amend this bill to remove the offer for a referral for a provider of nonpharmacological treatments for pain.
6. DOUBLE REFERRAL. This bill has been double-referred; upon passage of this committee, it will be referred to the Assembly Business and Professions Committee.

REGISTERED SUPPORT / OPPOSITION:

Support

California Chiropractic Association (sponsor)
California Health Coalition Advocacy
Occupational Therapy Association of California (OTAC)

Opposition

American College of Obstetricians and Gynecologists District Ix
California Medical Association
California Orthopedic Association
California Podiatric Medical Association
California Society of Anesthesiologists

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097