Missouri is among the 20 worst states for drug overdose deaths, but it was the only state left without a statewide prescription drug monitoring program.
This week, the Missouri Senate attempted to defund one set up by Gov. Eric Greitens.
Greitens ordered the creation of a statewide prescription drug monitoring program, or PDMP, last year amid a growing opioid crisis affecting Missouri and the U.S.
Overdose deaths in Missouri jumped by more than 30 percent between 2015 and 2016, according to the Centers for Disease Control and Prevention. Missouri's rate of overdose deaths is 18th worst in the nation.
"We need to be honest and clear about the scale of what we are up against," Greitens said in a July press release announcing his executive order. "Opioids are a modern plague."
But Greitens' PDMP has been met with opposition from lawmakers — who have resisted creating one for years — and medical professionals who criticize the system he created. As lawmakers work to finalize the state's budget, they may leave additional funds for the program out.
"There's only one thing wrong with it and that’s that it’s not a PDMP," said Faisal Khan, director of the St. Louis County Department of Public Health.
St. Louis County started its own PDMP in April 2017 after years of inaction by the Missouri General Assembly, which Khan called "mystifying." The PDMP covers more than 80 percent of Missouri doctors and pharmacists on a volunteer basis.
Criticisms of Greitens' system rest on the fact that it allows state investigators to track physicians and pharmacists writing and filling prescriptions, but it doesn't give doctors any tools to help prevent overprescription. The PDMP St. Louis County created allows providers to access data to see whether a patient has gotten several prescriptions for opioids or may be struggling with addiction.
Jeff Howell, a government relation specialist with the Missouri State Medical Association, said his organization doesn't support Greitens' program and called it a "witch hunt against physicians."
Sen. Rob Schaaf, R-St. Joseph, is a leading critic of the Greitens PDMP and said he thought the program had the "unintended consequence" of hurting people who need legitimate opioid prescription.
"Doctors are afraid to prescribe narcotics, because they're afraid they're going to be criticized and punished by the state," Schaaf said.
Schaaf, a doctor working in the prison system, said he thought physicians were prescribing fewer opioids and the down-tick was more severe than in other states with PDMPs. According to the Centers for Disease Control and Prevention, the goal behind a PDMP is to change prescribing practices by giving physicians information about patients' histories with opioids.
Schaaf said there was an argument for creating a better-functioning PDMP, but he criticized the entire practice, claiming Missouri's place in the opioid crisis had not worsened in the absence of a PDMP. But between 2015 and 2016, Missouri passed several states in the rate of drug overdose deaths.
To operate Greitens' PDMP, the state established a no-cost contract with Express Scripts, a pharmacy benefit manager. Five state investigators get data from Express Scripts, like type, strength and quantity of drugs physicians are prescribing and pharmacies are dispensing. They look for unusual patterns in the prescriptions.
Investigators can open investigations on physicians and pharmacists and turn them over to state or federal officials for any discipline necessary, said Randall Williams, director of the Missouri Department of Health and Senior Services.
Asked whether a PDMP like that in St. Louis County would better help physicians, Williams said the department encouraged doing both.
Williams said the vast majority of doctors in Missouri are doing the right thing and state health officials don't want to bother them.
"We certainly don't want to audit them, and we don't want to come into their office based on a complaint if it's unwarranted," Williams said.
"With our proactive ... data, we are able to identify people who are egregiously outliers, and that is more than occupying our time," Williams said, adding that if doctors are doing the right thing in their daily practice, "we clearly don't want them to be intimidated or to worry."
Williams said the health department began implementing the program with existing resources. The funds up for debate in the budget would create two additional investigative positions. If lawmakers choose not to allocate that money, the PDMP will continue to operate the way it does now.
The health department plans to release data on the first quarter of operation of the PDMP on July 1, Williams said. Investigators are actively pursuing investigations.
Sen. Jamilah Nasheed, D-St. Louis, said she supported prescription drug monitoring.
"We don't need to be talking about not funding the prescription drug monitoring," Nasheed said. "We need to figure out how different hospitals and clinics can do interoperability in terms of being able to look at records of their patients from one hospital to the next to be able to see how much medicine an individual received."
Sen. Dan Brown, R-Rolla, chairman of the Senate Appropriations Committee, said senators would negotiate with House members when the budget goes to a conference committee. He said senators weren't comfortable with the way Greitens set up the program.
House members had elected to keep that in the budget when they approved it last month. House Budget Chairman Rep. Scott Fitzpatrick, R-Shell Knob, said he preferred Greitens' model to a traditional PDMP.
Khan said Greitens' model is not well received in the 49 other states that allow physicians to access the information housed on the PDMP.
"I can tell you that our peers across the country laugh at what they’ve done, so yes, it is very, very frustrating as a public health official," Khan said.