The Missouri Legislature's efforts to enact a statewide program have been unsuccessful for more than a decade, so Gov. Eric Greitens signed an executive order to create a program that he said is "a step" toward solving the opioid crisis.
After more than a decade of legislative efforts have proven unsuccessful, leaving Missouri as the only holdout without a statewide prescription drug monitoring program (PDMP), its highest elected official has stepped in to resolve the issue.
On Tuesday, July 17, Gov. Eric Greitens signed Executive Order (EO) 17-18, creating what is described as a “multi-phase prescription drug monitoring program” that would be enacted in at least three stages — though their exact timing remains unclear.
The governor directed the Missouri Department of Health and Senior Services (DHSS) to enter into contracts with “pharmacy benefit management organizations,” sometimes referred to as third-party administrators, to provide it with analyses of “prescriber and pharmacy prescription and dispensing data” for Schedule II through Schedule IV controlled substances.
That would, of course, include opioids, which the governor said in his EO were responsible for the deaths in 2016 of more than 900 Missourians by overdose.
In a news release, the state said the PDMP would use “de-identified data from private-sector partners” to specifically target "pill mills" that “pump out prescription drugs at dangerous and unlawful levels.”
The arrangement will also enable DHSS to “better inform doctors, nurses, pharmacists, other health-care providers, and patients and their families” about pain management best practices to decrease over-prescribing.
The prescription and dispensation information DHSS receives, the state said, shall be kept confidential and disclosed only pursuant to as provided by Missouri State Statute 195.042, enacted in August 1994.
That statute mandates that all complaints, investigatory reports and information be confidential, disclosed only by written consent of the “person whose records are involved” or to “other administrative or law enforcement agencies acting within the scope of their statutory authority.”
Greitens also ordered DHSS to require dispensers to provide controlled substance prescription and dispensation information to it “for the purpose of identifying activity indicating that controlled substances are being inappropriately obtained, prescribed, or dispensed;” for investigations; and for referring “such activity” to law enforcement and professional licensing boards.
Last, the governor called for DHSS to work with private companies, government agencies and other groups “to purchase and utilize innovative technology and software to effectively and efficiently monitor controlled substance prescription information sent to DHSS or its designee … .”
The EO made no specific mention of targeting patients’ private medical information — a point the Associated Press' Jim Salter noted — nor did it appear to come with a “sunset,” after which it would expire, or with a prescribed period of time after which the data collected would expire. These latter two issues have been sticking points this winter and spring with the state Legislature.
In a statement, Greitens asked residents to be “honest and clear about the scale of what we are up against,” calling opioids a “modern plague” visited on “the young, the old, the healthy, the sick, the virtuous and the sinful” alike.
“There is no single program, or law, or executive order that can fix this crisis. This program is a step — and it's a big step,” Greitens said, indicating further steps to address the crisis will come throughout the week, including, on Thursday, July 20, an opioid summit in Springfield on treating addiction in rural areas of the state.
“The only thing we won't do is wait. That's not an option,” Greitens added.
In a statement, Richard Baum, acting director of the Office of National Drug Control Policy, hailed the governor for enacting a statewide PDMP after about 12 years of wrangling in the Legislature.
“In the context of both the ongoing opioid epidemic and the health of Missourians, it’s vital to have safeguards in place to make sure that doctors aren’t over-prescribing opioids that can be misused and patients aren’t doctor-shopping for multiple prescriptions that could be misused or diverted,” Baum said.
This has been a momentous year already for prescription drug monitoring in Missouri.
County PDMPs, in an effort led by St. Louis County, which spans more than 500 square miles and is home to around 1 million people, have stepped in to fill the void left by lack of a statewide PDMP — creating a county framework to cover more than 3 million Missourians as of May, or more than half the state’s 2015 population, according to the U.S. Census Bureau.
But at least one professional organization is reserving judgment on the EO: the Missouri State Medical Association, which in May joined other groups in withdrawing its support from an amended state House of Representatives PDMP bill —concerned it would restrict county efforts.
Jeff Howell, director of government relations for the Missouri State Medical Association (MSMA), told Government Technology that his organization wasn’t aware the EO was coming and doesn’t think many people were aware of it either.
MSMA is still “trying to digest” the governor's edict, Howell said, indicating he believes it's targeting “mail-order pharmacies.”
“It looks to be more a law enforcement tool than it does to be a patient treatment tool. We like to think part of the reason to have a PDMP is to have a clinical tool that subscribers can use to treat patients,” Howell said.
MSMA, he said, doesn’t want to see anything interfere with “an effective program like the one created by St. Louis County.” But, he added: “Everything is kind of still up in the air.”
Dr. Sam Page, a St. Louis County Council member who testified in January to a state Senate committee in support of the House of Representatives bill from state Rep. Holly Rehder, R-Sikeston, also characterized the EO as “generally a law enforcement program” not aimed at supporting physicians.
“It’s what some states do when they can’t do anything else. In all fairness, the governor’s options are limited without the support of the Legislature,” Page told Government Technology. “It’s a step forward, but I hope it doesn’t distract us from a program that would be available for doctors to use for patients who are in their offices and need help.”
Page added that he's concerned the governor's order could unfairly target doctors prescribing pain medication for cancer patients in severe distress, and that it may not yet do enough to go after so-called “pill mills.”
“There will be a pretty big hole in reporting," he said. "Folks who are determined to beat the system will figure it out pretty quickly."
House Bill 90, Rehder’s legislation that foundered in May, would have derived its data from prescribing physicians, similar to the county-level PDMP now led by St. Louis County. The state representative praised Greitens’ forward thinking, saying in a statement that the concept of a “cross-check through private-sector partnerships” has never been done before.
Rehder told Government Technology that the process activated by the governor will complement the PDMP being stood up by counties across the state.
“That is what they were saying, that this will work in conjunction with the traditional PDMP that we’re passing on the county level," Rehder said. "This will be a wonderful addition to a statewide PDMP that the physicians can see."
Editor's note: This article was updated to include a statement and comments from Missouri state Rep. Holly Rehder, R-Sikeston.