Tuesday, December 12, 2017

Missouri’s Governor Calls for a Prescription Monitoring Program—But Not the Right One

592px-AP_of_Missouri_State_Capitol_Building (1)Missouri’s long-held status as “only state without a prescription monitoring program” is about to end.

On Monday, July 17th, Governor Eric Greitens issued an executive order directing the Department of Health and Senior Services to implement a prescription monitoring program (PMP) that will be designed to help identify suspicious patterns of prescriptions of controlled substances, including opioids. Given AIPM’s long history of working toward establishing a PMP in Missouri, it would be easy to assume that we’d be pleased with this development; alas, this is not the right PMP for patients or health care providers in Missouri.

As AIPM explained in testimony to no fewer than three legislative committees in 2017 (let alone 2012-2016), optimal PMPs provide healthcare professionals and law enforcement officials with an invaluable tool in their efforts to address two simultaneous and somewhat conflicting public health crises: the abuse of prescription medications and the treatment of chronic pain. For healthcare providers in particular, PMPs provide the opportunity to truly know what controlled substances have been obtained by their patients from other providers.

While Greitens’ executive order was relatively vague, what seems clear is that neither doctors nor pharmacists will be able to access the PMP it envisions as they write and fill prescriptions. Rather, while dispensers would be required to report prescription information, only the state Department of Health and Senior Services would be able to access the data, after which it can file complaints with licensing boards and law enforcement agencies, as it judges to be appropriate.  As we wrote in response to a similar policy proposed in Missouri in 2015, this arrangement totally negates the healthcare benefits of a PMP: a) it does not enable a prescriber to confirm that a patient has a history of safe medication use before writing a prescription, thus decreasing the likelihood that a controlled substance prescription will be issued to patients with a legitimate medical need; b) it does not enable a prescriber or dispenser to review other controlled substances the patient may have gotten from other prescribers, which, when combined with a new prescription, could produce an overdose; and, perhaps most glaringly, c) it does not afford a prescriber or a dispenser the opportunity to uncover signs of a substance use disorder while the patient is still present and available for the necessary follow-on assessment and, if warranted, referral to treatment. Essentially, by prohibiting prescribers and pharmacists from reviewing their own patients’ records, this PMP would seriously diminish the likelihood that someone with a substance use disorder will have that disorder diagnosed and treated properly; and it will increase the likelihood that chronic pain will continue to be under-treated.

AIPM isn’t the only one questioning the PMP that would be created via Gov. Greitens’ executive order. According to Senator Jason Holsman of Kansas City, the executive branch cannot unilaterally allocate spending.  Therefore, even if the governor has the power to create the program, which is unclear, the legislature will still have to fund its implementation.

If not Gov. Greitens’ PMP, what is it that we do want to see in a PMP?  There are currently two options that AIPM is in favor of:

  1. Allow the county-level PMP effort to continue. In December of 2016, we wrote about a unique effort spearheaded by counties in Missouri in response to the legislature’s inability to pass legislation directing the creation of a PMP. This initiative was first launched in St. Louis and, by August 1, will cover 61% of Missouri’s population, including those in three of the state’s four largest metro areas. St. Louis County Executive Steve Stenger has already issued a statement saying that the county-level program will continue to operate with the hope that the governor’s program does nothing to hinder its progress.
  2. Wait for the Missouri Legislature to reconsider PMP legislation in 2018. For two years running, the Missouri legislature has gotten extremely close to passing legislation that would implement a high quality PMP of the sort AIPM would be proud to support, granting access to both prescribers and dispensers so that the PMP may be used as a health care delivery tool rather than a mere tool of law enforcement. While these bills were both derailed prior to passage, most lawmakers in Missouri, with the support of the health care community, are ready to try again next year.

UPDATE 7/20: According to the St. Louis County Prescription Drug Monitoring Program, the counties of St. Francois and Butler are now set to join the county-level program effective September 1st, pushing the percentage of residents that will be covered by the program to 62.8%.

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About Katie Duensing, JD, Director of Legislative and Regulatory Affairs