Missouri Gov. Eric Greitens signed an executive order in July, creating a statewide prescription drug monitoring program (PDMP). The move is significant because Missouri is the final state to implement a PDMP and has been criticized for at least a decade for its failure to pass drug-monitoring legislation.
The new PDMP is already mired in controversy because clinical professionals will not have access to patient-specific data. Instead, the Missouri Department of Health and Senior Services will monitor de-identified data for suspicious prescribing patterns and notify law enforcement, which will have a focus on shuttering pill mills, according to Greitens’ announcement.
“If pharmacists and providers can’t access it, then we have done nothing to improve patient care,” says Michael W. Merrigan, clinical assistant professor at Missouri State University. “We don’t need to make struggling patients targets for law enforcement.”
Clinicians lack immediate access
The state department of health will use data from private pharmacy benefit managers (PBMs) to look for patterns of potential diversion. Analyses will be shared with professional licensing boards and law enforcement as required.
What’s concerning to many stakeholders—including the state’s pharmacy and medical associations—is that health professionals will not have point-of-care access to the data to proactively prevent prescriptions for controlled substances from being handed to vulnerable patients or those who are “doctor shopping.” Likewise, providers will not be able to identify patients who should be referred to addiction treatment.
“This makeshift system in Missouri really loses the opportunity for the prescribers to adequately fulfill their roles as the gatekeeper in the supply of controlled medications,” says Michael Barnes, chairman of the board of the Center for Lawful Access and Abuse Deterrence. “Under an ideal prescription drug monitoring program, the prescriber has the opportunity to review the data first for prescribing then periodically after that for represcribing the controlled medication.”
Missouri is paying PBM Express Scripts $250,000 for the prescription data it plans to monitor, Barnes says, but even so, the data will only represent a segment of the state’s total healthcare system. There are other PBMs doing business in the state and many other prescription transactions that aren’t captured by the commercial PBM network, such as cash-paid doctor visits and prescription fills.
Besides, Barnes says, those PBMs already have an implicit obligation to play a role in combating prescription drug overdoses and should be sharing the data with the state in the public interest.
“Everyone contributes in a way to saving lives, and the PBMs should not be charging for this data,” he says.
In 2016, more than 900 Missourians died from an opioid overdose.
Privacy concerns linger
The pivotal point that has hampered Missouri’s PDMP legislation was the issue of patient privacy. Republican State Sen. Rob Schaaf has historically objected to previous policies for that reason. Additionally, physicians also remained concerned about provider autonomy, wondering whether a pain doctor with a clinical reason to prescribe opioids frequently, for example, might be hogtied by an investigation prompted by PDMP data.
“Out of the other 49 states that have PDMPs, those are not, in many instances, ideal either because privacy protections are lacking,” Barnes says. “Specifically, law enforcement can access the data without a referral from health authorities.”
According to the Prescription Drug Monitoring Program Training and Technical Assistance Center, 23 states, including the District of Columbia, allow law enforcement to access PDMP data for active investigations, and 28 allow it through court processes, such as search warrants. California allows access in additional situations as well.
Barnes says many states and drug-enforcement administration authorities (DEAs) are collaborating to target prescribers based on their volume of written prescriptions, without considering the needs of the patients being treated. The prescribing data is being taken out of context, and ethical providers are being subject to unnecessary scrutiny.
“If there was a proposal in Missouri that adequately protected private information for patients and providers in a way that would satisfy the conservative [State Sen. Schaaf], then there would not be a need for this makeshift measure that the governor has put into place with the executive order,” says Barnes.
He says Oregon’s PDMP doesn't allow EA access data without judicial oversight and has even gone to federal court to uphold that rule—something he gives the state credit for.