Missouri retained its lonely title as the only state without a statewide prescription drug monitoring program 鈥 for the 鈥 after the legislative session ended Friday.
Patient advocates, politicians, experts and members of the medical community had hoped this would finally be the year Missouri would create a statewide electronic database designed to help spot the abuse of prescription drugs. After all, had pushed for it and, more important, its longtime opponent was no longer in office to block it.
But, because of ongoing fears about privacy violations tangled up with gun control, the bill never got a full Senate vote. And finance site WalletHub last week ranked Missouri for its drug use based on a review of arrests, overdose rates, opioid prescriptions and other measures.
Katie Reichard, a lobbyist with Missouri Primary Care Association who has been working in and around the Missouri legislature for almost 15 years and previously pushed for the issue, said this proposal has bedeviled the state capital as none other while the opioid crisis continues to rage nationwide.
鈥淚鈥檝e never seen anything take seven years to get anywhere, and especially something that鈥檚 going to be put into place to save lives.鈥
Missouri鈥檚 cities, neighboring states and the federal government have been forced to create a patchwork of incomplete workarounds. Those include a voluntary program tracking patients鈥 prescriptions run by St. Louis County that receives federal funding and a statewide monitoring system put into place by former Republican Gov. Eric Greitens that tracks physicians鈥 prescriptions.
And yet, the state cannot seem to legislate a complete fix. 鈥淚t鈥檚 frustrating to watch the rest of the country get this done and watch Missouri be the last one,鈥 said Dr. Sam Page, the St. Louis County prescription drug monitoring program architect and current St. Louis County Executive.
To be sure, the the ability of drug abusers to acquire prescription opioids. But the federal Centers for Disease Control and Prevention has called such statewide patient monitoring databases 鈥渁mong the 鈥 to improve opioid prescribing and protect at-risk patients.
It鈥檚 an embarrassment Missouri can鈥檛 figure out its own statewide system, often referred to as a PDMP, according to St. Joseph pharmacist JulieMarie Nickelson. 鈥淣o one in the pharmacy or medical world really understands it,鈥 she said.
Privacy, Guns And Opposition
While a PDMP bill has been introduced every year in the Missouri legislature since 2005, it was initially championed by the minority Democratic Party, which meant it didn鈥檛 have much of a shot at passing .
Then New Hampshire approved a statewide program in 2012, leaving Missouri as the sole holdout. That pressure, combined with an uptick in awareness of drug abuse, led to a swell of bipartisan agreement.
A statewide PDMP bill passed the Missouri House handily that year, then met its biggest adversary: Republican state Sen. Robert Schaaf, whose district stretched from Kansas City to St. Joseph along Missouri鈥檚 western border.
Since then, Schaaf 鈥 who is also a family physician 鈥 filibustered or insisted on kill clauses that would never pass the House, citing his concerns over privacy and personal liberty issues along with his belief it was an ineffective tool. Year after year, his efforts would defeat PDMP bills.
Schaaf has said the risk of a database of patient information being hacked 鈥 and the government having access to the information 鈥 far outweighed the potential benefits. He also tapped into underlying fears of privacy violations, driven in part by a 2013 scandal over the Missouri Highway Patrol of concealed weapons permit holders to a federal agent.
鈥淚鈥檝e always been opposed to taking private citizens鈥 information and putting it on a government database to which many, many people have access,鈥 he told Kaiser Health News. 鈥淢y understanding is there is no computer information to which the NSA is not privy. How long is it going to be 鈥檛il this is used to pare down the number of people with concealed weapons or weapons at all?鈥
By stoking privacy fears and connecting them to gun rights, Schaaf also helped tap into grassroots far-right opposition that lives . A tweeted by this year鈥檚 anti-PDMP supporters details how the St. Louis County monitoring system could be used in 鈥減assing your personal information on to the federal government, which could use it to infringe on your right to bear arms.鈥
To date, the only reported hack has been of Virginia鈥檚 PDMP database, though it is unclear if the hackers were able to .
Over the years, Missouri鈥檚 PDMP advocates, led by Republican Rep. Holly Rehder, unsuccessfully tried to assuage such concerns by offering amendments to delete records older than three years and ensure medical information could not be tied to. And while Schaaf did an and agreed to stop filibustering the proposal, he effectively killed it with his only stipulation: that all physicians be required to use it. That measure, which took away the inherent voluntary aspect of the PDMP, failed in the House.
鈥淚f they鈥檙e going to take our liberty away for something that鈥檚 never been proven to work, doctors have to use it,鈥 Schaaf told Kaiser Health News.
The former head of the St. Louis County Health Department, Faisal Khan, who in 2017 helped start the voluntary county-based PDMP program that now covers other portions of the state, claims the opposition goes deeper than what he called 鈥渢otally unfounded鈥 privacy concerns.
鈥淭hey view St. Louis County and St. Louis City and St. Louis, in general, as this liberal Democratic bastion that they don鈥檛 want anything to do with,鈥 he said. 鈥淚t鈥檚 the usual nonsense that we鈥檙e seeing around the country at the moment, and it鈥檚 stymying progress in the parts of the state where we need it the most.鈥
But this year, Schaaf had hit his term limit of eight years in office and did not return to the Missouri Senate. Finally becoming like every other state seemed within reach 鈥 until a group of six Republican state senators formed a new conservative caucus and filibustered yet again over the issue, citing the same privacy issues and civil liberties.
鈥淭he conservative caucus has carried his torch on,鈥 Reichard said.
A Series Of Workarounds
Now, because the legislature has refused to move on the issue, cities, states and the federal government must continue to rely on the stopgaps they created to help address the opioid problem ravaging Missouri.
Today, have opted into St. Louis County鈥檚 voluntary prescription drug monitoring system so pharmacists and doctors could check a patient鈥檚 other prescriptions. It now covers 84% of the state鈥檚 population.
Even St. Joseph, one of the areas and where Schaaf lives, joined last year.
For Nickelson, a pharmacist at Rogers Pharmacy in the city of about 76,000 people, the voluntary database means she no longer has to spend upward of 30 minutes on the phone tracking down whether a patient had prescriptions for drugs elsewhere.
鈥淚t鈥檚 really helpful to us as it makes it so we can make sure that patients aren鈥檛 taking medications that interact and can increase risk for an overdose,鈥 she said. 鈥淲e just want to make sure our patients are safe, and we want to make sure medication that鈥檚 not necessary doesn鈥檛 get into the community.鈥
Since her city鈥檚 voluntary PDMP has been in effect, she estimates she sees a handful fewer people each week who were doctor-shopping, a particular risk considering the pharmacy is less than 5 miles from the Kansas border.
Missouri was a premier destination for pill-shopping, Page said, but that鈥檚 changed.
鈥淥ur PDMP is first-class, as any in the country,鈥 Page said. 鈥淲e have gaps, but those will continue to fill in. If the state continues to not move forward with this, then St. Louis County will continue to do the right thing.鈥
And while St. Louis County built its voluntary database in part with $200,000 from the U.S. Department of Justice, interstate sharing of the data with neighboring Illinois, Kansas and Oklahoma didn鈥檛 happen until February. Eight states border Missouri and more states are expected to collaborate with St. Louis County鈥檚 system this year. But data-sharing can occur only among states that have managed to bend or rewrite their regulations to accommodate the one state in the nation without a statewide program.
Tennessee even created and passed legislation to allow it to communicate with the St. Louis County program while Missouri was still haggling over its PDMP bill, according to Spring Schmidt, acting head of the St. Louis County Department of Public Health.
The system that Greitens created when governor, along with Express Scripts, to monitor physicians鈥 prescriptions for unusual patterns led to 50 referrals to the Missouri Healing Arts Board 鈥 the disciplinary board for medical practitioners in Missouri 鈥 for prescribing issues since March 2018, according to Missouri鈥檚 head of Health and Senior Services, Dr. Randall Williams.
Ideally, Williams said, he would love to combine a statewide version of the voluntary PDMP system with Greitens鈥 physician-monitoring one, but he鈥檚 waiting on the legislation.
Reichard can鈥檛 help but wonder why the state won鈥檛 join the rest of the nation in passing it.
鈥淚鈥檓 not saying do what everyone else is doing,鈥 she said. 鈥淏ut if 49 other legislatures are saying 鈥楾his is important, we need to save lives,鈥 I don鈥檛 understand why Missouri can鈥檛 find a way to compromise and do what鈥檚 best for its citizens.鈥
