On March 11, 2015, the Transportation, Infrastructure, and Public Safety Committee of the Missouri Senate passed a committee substitute bill that combined two bills originally filed as Senate Bill 63 (SB 63, sponsored by Senator Sater) and Senate Bill 111 (SB 111, sponsored by Senator Schaaf). The subject of both original bills was the establishment of a prescription monitoring program (PMP) for Missouri, which remains the only state without such a program; we supported SB 63 and opposed SB 111. The American Academy of Pain Management (the Academy) has long been a strong supporter of the type of PMP established by 48 states and the District of Columbia, and has devoted more resources to supporting the establishment and enhancement of these programs than any other pain management organization. This is especially true in Missouri, where the Academy’s current Executive Director has testified nearly a dozen times in committee hearings for PMP bills over the past four years. In light of our unabashed and vociferous support of PMPs, it may seem strange that we find ourselves opposing a Missouri PMP bill that has the best chance of passage since such bills began appearing in the Missouri legislature. That we oppose this bill is a sign of just how far off the rails we believe this bill goes.
Here is a pdf file containing the substitute bill, with 23 notations about our concerns and questions, spanning the ten pages of text constituting the PMP core of this bill. In addition to those specific concerns, we are not at all certain that a PMP constructed and operating in the manner envisioned in this bill is even technically feasible. It has never been attempted in the United States, and the process of designing and implementing such a program will be lengthy and costly, as well as prone to numerous glitches that could have very real negative consequences for the citizens of Missouri whose prescription data are included in this PMP.
Thousands of prescribers query the PMP for every one law enforcement query, and research shows that less than 1% of individuals in a PMP database are true “doctor shoppers”
It is our view that PMPs should be designed and used primarily as public health tools, enabling prescribers and dispensers to obtain complete and accurate information on the prescription controlled substances prescribed for their patients. A secondary use for PMPs focuses on public safety, involving the prevention and detection of drug diversion. That this relative ordering of uses is valid is borne out by the experience of many states, where PMP queries from health care providers outnumber queries from law enforcement and regulatory agencies by a substantial margin—by a ratio of more than 3000:1 in Kansas, for instance. Further, published research indicates that the number of individuals in a typical PMP database who use a large number of prescribers and a large number of pharmacies to obtain controlled substances (commonly labeled “doctor shoppers”) typically is less than 1%. Note that, with the standard that this bill appears to envision, i.e., flagging anyone who has even two prescribers, this number will skyrocket. Thus, we believe that any PMP legislation should focus creating a PMP that primarily allows healthcare providers to deliver better and safer health care to people using controlled substances. We don’t believe this bill does that.
Although we have identified nearly two dozen problems with this bill, three key issues constitute the core of our concerns:
- The PMP cannot be checked before a prescription is written. As currently written, this bill would deny prescribers and dispensers the opportunity to obtain PMP reports on patients they are treating, unless a computer algorithm identifies a cause for concern related to a new prescription. Even when such a cause for concern is identified, it happens after the prescription has been presented at the pharmacy, rather than before the patient leaves the prescriber’s office. We believe that 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, the PMP established by this bill 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.
- People with substance use disorders are treated as criminals instead of being offered treatment. As currently written, if the PMP’s computer algorithm detects “doctor shopping” activity, the only recourse available to the Department of Health and Senior Services is a referral of that patient to law enforcement. Experience with the Kansas PMP has shown that it is likely that as many as 90% of people identified as engaging in this behavior may have substance use disorders, while only 10% are likely to be diverting prescription controlled substances. Thus, the end result of this mechanism is likely to be an increased likelihood that someone with a substance use disorder will be prosecuted and jailed, coupled with a decreased likelihood that they will receive appropriate medical treatment.
- Privacy concerns. For all the concern voiced about the privacy of PMP data over the years, this bill appears to expose not only PMP data, but every bit of a patient’s medical record, to state employees who are not required to have any medical knowledge or experience. This bill grants the agency running the PMP the authority to request copies of medical records for patients whose PMP profiles raise concerns, and mandates that prescribers provide those records. It does not provide any qualifications for those agency employees who would receive and evaluate these records. And, while it is not explicitly stated, the bill appears to anticipate that this evaluation would result in a determination of whether or not the patient has a substance use disorder, and whether or not the case should be referred to law enforcement. If the bill’s authors believe that prescribers and pharmacists, who are schooled in privacy of medical records and related HIPAA requirements, are unfit guardians of that trust, then why do they think state employees who may have no medical training will do any better? If prescribers, who are licensed to diagnose substance use disorders, are denied the opportunity to use PMP data to help them do that, why do the study’s authors think that an agency employee with no specific training or experience requirements, should be allowed to do that? Or even that they are capable of making that judgment call?
We can’t stay silent; we must actively oppose the compromise bill
We are aware of the political realities of this situation. Given Senator Schaaf’s staunch opposition to establishing a PMP like those in 48 other states and the District of Columbia, and the apparent unwillingness of the remaining senators to force a vote on a bill he opposes, it strikes us as unlikely that any PMP bill except this compromise bill will pass this year. Given this consideration, we are left with two considerations: 1) Oppose the compromise bill that would establish a PMP that might not work and might result in the incarceration of people because they have the disease of addiction; or 2) Stay silent, let the bill work its way through the process, and if it passes in an unacceptable form, try to fix it later. We find option #2 completely unacceptable in this case. It is our assessment that such a “fix” after passage would be difficult to accomplish and a long time coming even if it can be accomplished, while people with the disease of addiction are denied proper medical care and subjected, instead, to the legal process. In this case, “just doing something” could turn out to be far worse than doing nothing.
We continue to support House Bill 130, introduced by Representative Holly Rehder. This bill would establish a “traditional” PMP like those in other states. It has passed the House and now awaits a committee assignment in the Senate. We urge the Senate to consider it quickly and to pass it, even if that means forcing an end to Senator Schaaf’s inevitable filibuster.
For the reasons listed above, as well as the additional concerns outlined in our critique of the document, we choose to go on the record in opposition to the compromise bill now awaiting action on the Senate floor.
To take action now, please visit the State Pain Policy Advocacy Network.