COLUMBIA — The patients Scott Paalhar doesn’t recognize are the ones who worry him the most.
Paalhar is a pharmacist at D&H Drugstore on Broadway. Working in Missouri, the only state in the U.S. without a central prescription drug database, he has no way to track people who hop from pharmacy to pharmacy, repeatedly filling prescriptions. So when someone unfamiliar comes in with an urgent need for narcotics, it means a lot more work for Paalhar.
“We have customers here who we’ve filled for 50 years,” he said. “We know all our customers by name. But when we get a person coming in for Percocet, never filled for it before, from out of city, that’s a much bigger red flag.”
Other concerns for Paalhar include people who:
- say they don’t have insurance (potentially have already used their insurance, and want to buy the prescription again with cash)
- act as if they’re in extreme pain (potentially exaggerating to tug at the pharmacist’s emotions)
- are unusually chatty (potentially to try to connect with the pharmacist)
- are from out of state (potentially taking advantage of Missouri’s lack of a database).
When he encounters those situations, he said, he takes extra precautions or avoids filling the prescription.
"It’s a really hard thing to do, but I definitely think that the database would help with the bad situations, so to speak,” Paalhar said.
Several bills have been introduced in the Missouri legislature this session to create some type of prescription monitoring program. House Bill 1892, sponsored by Rep. Holly Rehder, R-Sikeston, passed the House and moved onto the Senate in early March.
In the Senate, Rob Schaaf, R-St. Joseph, has sponsored Senate Bill 768, which would route the monitoring of prescription drugs through the Department of Health and Senior Services. But his bill this session was referred to committee in January and has not moved since.
A third bill would create a registry instead of a database.
This is the sixth year in a row that a bill or bills have been introduced to create some mechanism for making it possible to keep track of who's filling prescriptions for controlled substances. Those bills have generally failed after strong opposition from privacy rights groups. Schaaf led that opposition in 2012, organizing a successful filibuster.
Meanwhile, according to the National Institute on Drug Abuse, drug overdose deaths are on the rise. Nationally, from 2001 to 2014, there was a 2.8-fold increase in the total number of fatal prescription drug overdoses, and deadly opioid pain reliever overdoses rose by nearly 350 percent. In mid-Missouri specifically, 2,337 people were hospitalized in 2014 from opioid overdoses. This is an increase of about 136 percent in the decade leading up to 2014, a rate similar to the statewide percentage.
To compensate for the lack of a central database, pharmacists in Columbia have created an informal system of notifications.
“If we do run into a suspicious situation, a lot of times we’ll just call other pharmacies that are close, give them a heads-up that they might be seeing this,” Paalhar said. "I don’t necessarily have a list of pharmacies that I call every time, but I at least try to call the ones up the road, down the road.”
Pharmacist Beth Stubbs, who works at Kilgore’s Medical Pharmacy, described it as an emergency phone tree, where each pharmacist calls the next person on the list. But she said that the system is far from perfect because it’s not always used in the right situations.
“It may not be a situation where you feel like it’s urgent and you have to notify every pharmacy,” Stubbs said. “Maybe it’s just something didn’t look quite right to you, or from somewhere out of town, and at least that takes a little while to get through the entire list.”
Schaaf, who is a medical doctor, is a primary opponent to letting medical professionals access a central prescription monitoring database .
Schaaf proposed a plan that envisions the Department of Health and Senior Services reviewing all prescriptions and using a computer algorithm to report concerns back to the medical provider, who would then be obligated to consider that indication when choosing whether to issue or fill a prescription. Through this method, Schaaf aims to eliminate the potential for privacy violations and human error.
“I really don’t want anybody’s information on a government database, but I’m willing to compromise for them as long as nobody can see that data and all that (pharmacists) get is a computer-generated indication of whether there’s a problem or not,” Schaaf said.
Schaaf proposed another such compromise: He said he “would be glad to let (Rehder’s bill) pass,” but only if it would be put to a public vote. Otherwise, if Schaaf’s bill were to be passed, no referendum would be necessary. He seemed confident that Missourians would support his version without casting a ballot but would vote down Rehder’s bill.
“So my question for Representative Rehder would be, ‘why don’t you let the people vote on it?’” Schaaf said. “And the answer is really clear: She knows very well that people would not vote for that. … My version would protect people’s privacy, and it’s a true compromise.”
But to Rehder, Schaaf’s bill is flawed in that it places new information and decision-making power in the hands of governmental departments instead of doctors and pharmacists. She said any degree of governmental review is the wrong move.
“It’s of the utmost importance that our medical professionals are the ones making those calls as to whether or not you need this medication,” Rehder said. “You don’t want a bureaucrat. … That’s why we want to keep this in the hands of those professionals who have been trained and who we’ve already trusted our private medical information to.”
Schaaf is a founder and chairman of the board of the Missouri Doctors Mutual Insurance Co., or MoDocs, which offers doctors insurance against malpractice. In his campaign finance report from 30 days after the 2014 general election, Schaaf reported that in total, he’d taken $40,000 in campaign funds from MoDocs, as well as $1,400 from Merck Sharp and Dohme Corp., a pharmaceutical corporation, according to the Missouri Ethics Commission.
MoDocs aims to defend doctors against malpractice suits.
Speaking in a general context, Paalhar said having a database would make it easier to identify doctors engaging in medical malpractice.
“Once it gets out there that prescribers are writing C-IIs and narcotics scripts for people, they’re going to be held more accountable for what they’re doing,” Paalhar said. “They’re going to get questioned. You know, ‘why are you doing this?’”
However, Schaaf said the idea of a connection between his affiliation with MoDocs and his views on a prescription drug database is “totally ridiculous.”
“Why would you even think it would be a factor? … I want you to know that my legislation would actually catch every single physician who looks to be overprescribing, and refer them to the Board of Healing Arts,” he said, referring to the state body that regulates the licensure of medical professionals. “I do not believe that the (database) issue has anything to do with medical malpractice whatsoever.”
Opposition to the creation of a prescription drug monitoring database, from Schaaf and other Missouri legislators, typically is framed as a privacy issue. Legislators say they're concerned about the implications of what they view as wider access to sensitive medical information — Schaaf called it a “severe infringement on (people’s) liberty.”
State Rep. Keith Frederick, R-Rolla, says that medical information falls under the Fourth Amendment, which protects citizens from unreasonable search and seizure without probable cause. To him, a database would create an unconstitutional breach because it would be combed by doctors and government workers alike.
“They don’t have probable cause, they’re searching the database for probable cause,” Frederick said. “But they’re voiding your constitutional rights by looking over your prescription usage when they don’t have any probable cause.”
Frederick has endorsed a plan to create a registry list, in which people would be nominated to the list if they had an encounter with law enforcement for drug offenses, if they'd voluntarily sought treatment, or if they were referred by a medical professional or family member. But even then, the person would be able to appeal his or her placement on the list. He sees the creation of an involuntary database for drugs as akin to the government tracking citizens' consumption of alcohol, for example.
“Are we going to create a database for everything that’s potentially harmful for you?” he said. “Is that really the role of the government that we’re going to observe and surveil your entire life, just to find out what you’re doing that might be bad for you?”
Stubbs pointed out that medical information is already protected under federal HIPAA law. In her view, more open access among medical professionals should not be problematic, but it should stay within that realm.
“It’s difficult for me to view it as any type of a privacy issue,” she said. “If you have a real legitimate need for the pain medication or the stimulants or whatever, your doctors are already going to be in the know. Your pharmacist is going to be in the know. And it’s not good to go outside of that reach.”
Rehder explained that the first prescription drug monitoring program was enacted in 1939, and similar programs exist in 49 states.
“I think if there was a privacy rights issue or if there was a constitutional issue, it would’ve been (established) by now,” she said.
While Rehder’s bill enjoys a broad base of support, Schaaf’s does not. The Missouri Prescription Drug Monitoring Program NOW Coalition is the primary organizer for pro-database legislative efforts. It comprises nearly 50 groups, including the American Academy of Pain Management, Pfizer, Missouri Pharmacy Association, the Missouri Substance Abuse Prevention Network and Mallinckrodt Pharmaceuticals. Mallinckrodt spokesman and lobbyist Randy Scherr said he was “not aware of any coalition member that supports” Schaaf’s bill.
“I would suggest quite a few of the coalition members would not find Senator Schaaf’s bill to be very helpful in terms of the problems we’re trying to solve,” Scherr said. “It would not help the health care provider, either the pharmacist or the doctor, to determine the problems that people have and be able to help their patients solve those problems. Because it’s just not structured correctly.”
Rehder’s bill allows medical professionals to have more direct access to the database. Physicians and pharmacists could look up information regarding Schedule II-IV drugs to see if a patient had already filled a similar prescription.
“If the pharmacist recognizes that you’ve gotten five narcotic prescriptions at five different locations, then they can make that decision not to fill your prescription and contact your doctor and say ‘hey, we have a problem,’” she said.
State lawmakers have been sponsoring bills to create a prescription drug monitoring program for several years. Rehder has been the sole sponsor of the legislation for two sessions and a co-sponsor for several years before that — and the bills always stall. Meanwhile, pharmacists are getting frustrated with the lack of progress.
“I fully support it and hope that this year is the year we can get it through to make Missouri no longer also a state that people flock to with out-of-state prescriptions because they know that we can’t track them,” Stubbs, the Kilgore's pharmacist, said.
Missouri as a drug destination
Because Missouri is the only state in the country without a drug database, people from other states come here to covertly fill their prescriptions.
“Surrounding states like Kentucky, or even states as far away as Florida, (are) finding problems with the prescription of opioids that might be carried to Missouri to be filled, so that they don’t fall in any database so they can’t find the repetitive prescriptions,” Scherr said.
Columbia pharmacists are also noticing the trend of people coming to Missouri with out-of-state scripts, and they’re making a point to be on the lookout.
“People try to hide essentially where they filled last,” Paalhar said. “We always take caution for people who are out of city, out of state even. Especially the out-of-state ones. We try to avoid filling those, if we can.”
Florida used to be one of the top narcotics-dispensing states in the country until the state implemented a prescription monitoring program in late 2011. Since then, the rates of both overdose deaths and “doctor shopping” have dropped, according to the Orlando Sentinel.
“There has been a 60 percent decline in oxycodone-related deaths,” Kylie Mason, spokesperson for the Florida attorney general, told The Missourian in an email. “Overall prescription drug related deaths are down more than 15 percent, which represents more than a thousand lives saved. Florida’s Prescription Drug Monitoring Program has been a critical tool in resolving the prescription drug epidemic.”
Rehder said the connection between abusing narcotics and developing a heroin addiction is worsening.
"It’s an easy jump from narcotics," Rehder said. "Heroin is in pill form now. It’s less expensive. And so when you run out of your pills, you can’t get your pills, or you find out that heroin is a lot cheaper and you make that leap, that’s what’s happening. So we need to get on top of this and do all that we can to help curb the abuse."
Pharmacists say a prescription database might also help them discern the drug-seeker from the person truly in pain, genuinely needing relief.
“It’s a tough situation, really,” Paalhar said. “You don’t want to treat people unfairly because they have pain, but at the same time, you don’t want to be adding to the epidemic of overdoses with opioids."
Supervising editor is Katherine Reed.