House Committee advances prescription drug monitoring proposal

The Missouri House is again being asked to consider creating a statewide prescription drug monitoring program (PDMP), with the aim of battling the abuse of opioids and other prescription medication.

Representative Holly Rehder presents to a committee House Bill 188, which would create a statewide prescription drug monitoring program in Missouri. Behind her, Senator Tony Leutkemeyer (R-Parkville) listens to the discussion. Luetkemeyer is sponsoring identical legislation in the Senate. (photo; Tim Bommel, Missouri House Communications)

House Bill 188 is sponsored by Sikeston Republican Holly Rehder, who has proposed a statewide PDMP for several years.  Such legislation has passed out of the House several times but was held up in the Senate.

Rehder has been a strong proponent of PDMPs largely because of her family’s experience with opioid and drug abuse.  One of her step-fathers was a drug dealer.  Her daughter, Raychel, became addicted to pain relievers after an emergency room visit when she was 17.  She went on to abuse other substances including methamphetamine before becoming drug-free more than 5-years ago.  Rehder says other members of her family have also struggled with abuse issues.

“I know this issue inside and out, as a parent, as a kid who grew up in it, and it doesn’t matter what your background is, it doesn’t matter how you grow up or how you raise your children.  It’s not a moral failing.  Addiction is a disease,” Rehder told the House Committee on Insurance Policy.

Missouri is the only state in the nation without a PDMP.  Such programs collect and monitor drug prescription and dispensing data to look for, among other things, “doctor shopping;” the visiting of multiple doctors in an attempt to obtain drugs that are commonly abused.

Rehder and other supporters say they don’t view PDMPs as a “silver bullet,” that will end the abuse of opioids and other prescription drugs, but as a tool that will help fight such abuse.

“A PDMP allows providers to see concerning trends in their patients’ narcotic history.  That physician can intervene with options for that patient:  alternative care treatment, medication-assisted treatment – we have many options available now with excellent outcomes, but we need our medical professionals seeing their patients’ history before they get too far down the road,” said Rehder.

Opponents of PDMPs argue that they violate citizens’ rights by collecting personal data and putting it into a government database that, they say, could then be jeopardized by hacking or other breaches.

Doctor John Lilly of Springfield told lawmakers they should put privacy concerns above all others in considering PDMP legislation.

“Your job is not to make my job easier.  Your job is to protect the liberty of the citizens of this state,” said Dr. Lilly.  “I am a U.S. citizen first and a doctor second.  I care about the liberty of these citizens of Missouri.”

Lilly and others speaking against HB 188 argued that data show PDMPs in other states have not been effective in fighting opioid abuse.

Monroe County Commissioner Ron Staggs asked the committee, “After you see the data from 49 states and a death rate that continues to climb why would you want to enact the same thing?”

Proponents say a PDMP wouldn’t just address drug abuse in Missouri.  It could also help pharmacists spot cases in which patients might be prescribed unsafe combinations of medications.

Anne Eisenbeis works at a pharmacy in Moberly.  She told the committee of one such instance that she caught by chance, that a PDMP would have ensured was flagged.

“I had a patient and a friend – a young man – bring in two prescriptions from two different doctors for two almost identical narcotics … had he not brought both physical prescriptions into my store, because in Moberly we don’t have access to the PDMP … he would’ve easily overdosed.  There would’ve been an interaction with these two medications,” said Eisenbeis.  “With a PDMP this would help me prevent this kind of medication error accident.  I would’ve been able to see that he was given another prescription had he gone to another pharmacy.”

In previous years one of the proponents of a PDMP in the Senate has been Senator Dave Schatz (R-Sullivan), who is now the President Pro-Tem of the Senate.  Rehder said she and Schatz worked in past years on compromises that have been worked into HB 188, and having him in Senate leadership bolsters the chance PDMP will become law this year.

The committee voted 13-3 to pass HB 188.  It goes next to another House committee, which could vote on whether to send it to the full chamber for consideration.

Bill to extend Medicaid coverage to chiropractor visits becomes law

One of the legislature’s proposals that has become law will see Medicaid pay for a patient to visit a licensed chiropractor up to 20 times in a year.  Backers say by giving Medicaid recipients more options for treating pain, fewer patients will risk becoming addicted to opioids, and the state will save money by getting away from other, more costly treatments.

House Bill 1516 allows licensed chiropractors to be reimbursed for treatment of conditions currently covered under the MO HealthNet program.  Sponsor John Wiemann (R-O’Fallon) said such services are currently covered by most private insurance carriers and Medicaid parts B and C on a limited basis.  He said more than half of the states in the nation allow Medicaid recipients to receive chiropractic services.

“Ultimately the goal of this legislation is to allow Medicaid recipients access to chiropractic health care providers at a lower cost and in many cases with better outcomes, and overall reduction in opioid abuse,” said Wiemann.

Wiemann said under HB 1516 Missouri will save money as MO Healthnet patients would turn less often to opioid prescriptions and to services from emergency rooms, hospitals, and physicians.

He said the bill is part of a shift happening across healthcare to offer patients more options for treating pain or other chronic conditions.

“Medicine’s moving in that direction, where it’s more collaborative in nature.  It used to be very siloed – the doctors only did this, the nurses only did this … but interdisciplinary medicine is really kind of the wave of the future, and with technology and everything else it just makes sense to make sure we look at all of our options,” said Wiemann.

One of the St. Louis-area chiropractors who testified for HB 1516 when it was in a House committee is Doctor Ross Mattox.  He said pain can stem from many different catalysts, and patients must be given more options to manage it.  While the best answer isn’t always chiropractic care, he said those it can help should have the choice to use it.

“For that large number of people that come in and it is a musculoskeletal problem and it does respond to chiropractic care, you just got that person better without sending them down that really complicated pathway of lots of dollars in the form of referrals and advanced imaging, and the potential for addiction with opioids, surgeries, all that stuff,” said Mattox.

Doctor Quinn James also testified for the legislation.  He said some of his patients are seeking chiropractic care after having used medication.

“When they start coming to us they’re able to start to slowly – through their primary [care provider] also – to be able to reduce the amount of medication that they’re taking, so we’re able to get them off of a lot of the opioid medications after we start treating them,” said Quinn.  He said to date he’s only been able to offer that care to fully insured patients because Medicaid wouldn’t cover chiropractic care.

Wiemann said he expects more legislation to be filed in future sessions that would seek Medicaid coverage for other pain treatment options.  Things like acupuncture and massage therapy could also be candidates for coverage, as a reflection of the shift in medicine to a more all-encompassing approach to treat patients’ pain.

“There’s no doubt in my mind that we will see future legislation that will be pushing for other types of therapies that can alleviate pain without the use of narcotics and opiates – therapies that are known and approved, not some untested and unproven therapies,” said Wiemann, who said he might even carry such bills.  “I don’t have any that I’m looking at right now.  I’m certainly open to looking at ones that are proven to save taxpayers money in addition to providing good medical outcomes.”

Wiemann noted that the Joint Commission on Accreditation of Healthcare Organizations, a nonprofit responsible for accrediting hospitals, began this year requiring hospitals seeking its accreditation to develop strategies to decrease opioid use and minimize related risks, and to offer patients at least one non-drug pain treatment option.

The House voted 137-4 to send HB 1516 to the governor’s office.  Governor Mike Parson (R) signed it into law July 5.  Its provisions become effective August 28.

Democrats propose multi-pronged attack on opioid abuse

Missouri House Democrats say the fight against opioid abuse is about more than passing a statewide prescription drug monitoring program.  They today unveiled a slate of legislation that would attack the problem by addressing a number of other issues.

House Democrat Leader Gail McCann-Beatty and Representative Gina Mitten speak about their caucus’ multi-bill approach to attacking opioid abuse in Missouri. (Photo; Chris Moreland, Missouri House Communications)

“The opioid disorder crisis is multi-faceted,” said House Democrat Leader Gail McCann-Beatty (Kansas City).

Democrats continue to support passage of a statewide prescription drug monitoring program to track the use of prescription narcotics.  Such legislation has advanced farther through the legislative process in each of the past few sessions, but fallen short of passage.  Last year St. Louis Democrat Fred Wessels sponsored such legislation that was combined with a bill sponsored by Sikeston Republican Holly Rehder and fell just short of final passage.  Both representatives will sponsor such legislation again this year.

In addition, Democrats have filed bills that would require pharmacies to post information about methods and locations for the safe disposal of unused medication; require for medical professionals with prescribing authority at least four hours of training on the misuse and abuse of prescription drugs and recognizing addiction in patients; require the Missouri Department of Health and Senior Services to mirror federal regulations for prescribing opioids for chronic pain; require insurance coverage of medication assisted treatment and remove insurer-proposed barriers to addiction services; establish a sterile needle and syringe exchange pilot program; require the Show-Me Healthy Babies program to cover substance abuse treatment for women up to one year post-partum; and expand the use of CBD or hemp oil to include being used as a pain management alternative for those with a history of opioid abuse.

“Substance disorders need to have an all-of-the-above approach and what we’re proposing here is just that.  We’re not only talking about PDMP.  We’re talking about a number of other options; tools that should basically be put in the toolbox of not just the medical community but our entire community,” said Representative Gina Mitten (D-St. Louis).

Mitten is sponsoring the bills that deal with safe disposal of abused prescription medication and additional training for prescribers.

Missouri is the only state in the nation without a statewide prescription drug monitoring program.  Many counties in the state are participating in a program initially launched in the St. Louis region, and Governor Eric Greitens (R) signed an executive order creating a tracking program for some prescription information handled by one benefits provider.

The legislation discussed today by House Democrats is for the 2018 legislative session, which begins January 3.

House asks Senate to come to the table on proposed prescription drug monitoring program

The state House has asked the Senate to debate the changes it made to the House’s proposed prescription drug monitoring program (PDMP).

Representative Holly Rehder (photo; Tim Bommel, Missouri House Communications)
Representative Holly Rehder (photo; Tim Bommel, Missouri House Communications)

A PDMP aims to fight the abuse of prescription drugs by entering into a database information on people’s prescriptions to see who is getting large numbers of drugs that can be abused.  Backers say the program will help identify abusers and cut back on “doctor shopping,” or going to multiple doctors to get multiple prescriptions for drugs.

The House passed House Bill 90 earlier this month that would require pharmacists to report to the database in real time by 2020, require the Department of Health and Senior Services to notify law enforcement if it believes any law or professional standard has been broken, and keep submitted prescription information confidential except when there has been a breach.

The Senate proposed several changes to the House plan.  It would require that information only be kept on the database for 180 days; limit the database to opioids and benzodiazepines (the House proposed including all schedule II, III, and IV drugs); and mandate that doctors check the database before writing prescriptions for specified drugs.

The sponsor of HB 90, Sikeston Republican Holly Rehder, has been pushing for passage of a PDMP for years, driven in part by how drug abuse has affected her family.  She opposes some of those proposed changes and wants to see if the House and Senate can work out differences.

She said those in the medical field she has talked to say the database won’t be effective if information is only kept on it for 180 days.  They want it to be on there for at least two years.

“Typically when you’re looking at addiction, your first two years you have more relapses,” Rehder explained.  “Once you get past that two-year mark you’re doing pretty good.”

Rehder said limiting a PDMP to opioids and benzodiazepines wouldn’t go far enough.

“Ritalin – Adderall is one of the highest drugs of misuse and abuse, so we need to be sure that we have all schedule II through IV (drugs) in my opinion,” said Rehder.

Rehder said she would not fight the change that requires doctors to check the database before writing a prescription.

Representative Justin Hill (photo; Tim Bommel, Missouri House Communications)
Representative Justin Hill (photo; Tim Bommel, Missouri House Communications)

The Senate also proposed letting the legislature decide after six years whether to continue the PDMP, and requiring training for database users.

Lake St. Louis Republican Justin Hill opposes Rehder’s proposal and urged the body to deny her motion.  He said if Missouri is going to have a PDMP it should include the 180-day provision.

“I hope we keep the 180-days in because if we’re talking about addiction and pill shopping, then let’s try it.  Let’s see if it works with 180-days,” said Hill.

Hill would rather Missouri not have a PDMP.  He argues they haven’t worked in other states except to push more people from abusing prescription drugs to heroin.

“49 other states admit that this doesn’t work,” Hill told Rehder.

“No, no, tell me a state that admits it.  You can’t just throw things out like that on the House floor and not have anything to back you up,” Rehder responded.

The House passed Rehder’s motion to seek a conference with the Senate, and now awaits the Senate’s answer.  Fewer than four weeks remain in the legislative session for lawmakers to attempt to reach a compromise.

House perfects prescription drug monitoring program proposal

The Missouri House has given initial approval to a proposed tracking system for prescription drugs that backers hope will fight opioid abuse in Missouri.  Specifically it aims to help stop “doctor shopping;” the practice of going to multiple doctors seeking multiple prescriptions for valuable and addictive medications.

This is the fifth session in which Representative Holly Rehder has sponsored PDMP legislation.  (photo; Tim Bommel, Missouri House Communications)
This is the fifth session in which Representative Holly Rehder has sponsored PDMP legislation. (photo; Tim Bommel, Missouri House Communications)

House Bill 90 would make Missouri the 50th state to enact a prescription drug monitoring program (PDMP).  The electronic registry would take information on those who prescribe, use, or dispense prescription drugs.

The bill had bipartisan support in a 109-40 voteWest Plains Republican Shawn Rhoads, a former police detective, said it is an answer to opioid abuse in Missouri.

“There’s just so many times in a career [someone has] had to go to somebody’s house and tell them that their loved one has overdosed and died because somebody was doctor shopping, selling them drugs, and they’ve overdosed on them.  That is the worst thing that you will ever have to do in a career, and I’m telling you I never, ever, want to do it again,” said Rhoads.  “That’s why, Mr. Speaker, I urge the body to vote for this bill.”

The bill is sponsored by Sikeston Republican Holly Rehder, who has spoken publicly many times about her own family’s experience with addiction.

“I grew up in poverty.  One of my stepdads was a dealer.  My sister married a dealer at 16, was a main line user by the time she was 16,” said Rehder.  “I didn’t use drugs because I was afraid of them.  I saw what they did to those around me.”

Rehder said it was that fear that caused her to raise her children “differently,” but when her daughter was given a prescription for opioid painkillers after cutting her thumb at work, she became addicted.

“From that point forward we had 13 years of addiction,” said Rehder.

Rehder said addictions to opioid painkillers often begin with a legal prescription following an injury, such as when a high school athlete gets hurt.

“An athlete breaks a leg or whatever, they go to the doctor, they get an opiate to help with the pain, and then if that person is predisposed to addiction, they become addicted.”

Before giving the bill first-round approval, the House changed it so that by 2020, pharmacists will have to report information to the registry in real-time.

The sponsor of that change, Representative Lynn Morris (R-Nixa), owns a chain of pharmacies.

“By doing real-time, all my stores are connected real-time, and we know how much importance that is in trying to catch people that are drug shopping every day, and we catch them and we don’t fail to catch them,” said Morris.

Opponents say a PDMP creates a government database and poses a threat to the privacy of anyone using prescription drugs.

Representative Rick Brattin was among those Republicans who opposed the PDMP legislation filed by one of their fellow caucus members.  (photo; Tim Bommel, Missouri House Communications)
Representative Rick Brattin questioned the PDMP legislation offered by a fellow Republican, but voted for the bill on perfection. (photo; Tim Bommel, Missouri House Communications)

Harrisonville Republican Rick Brattin also argued PDMPs must not be effective because they exist in all other states, yet President Donald Trump has launched a task force to fight opioid addiction.

“So that would lend to me that this sort of program does not work and it has no effect, and if it has we would not be issuing a task force for the entire country to tackle the overprescribing of opioids,” said Brattin.

Ash Grove Republican Mike Moon also maintains PDMPs are not effective, and urged his fellow lawmakers to consider whether Missouri should launch one.

“As of 2014 Missouri ranked 24th in the nation related to the number of deaths due to prescription drug overdose, and we’re not participating in the PDMP.  You’d think that Missouri would be number one in the abuse category, but we’re not,” said Moon

Brattin and others offered other changes to HB 90 saying it needed to be strengthened, in part because similar versions have stalled in the state Senate in past years.  Rehder urged legislators to reject them, saying that over the five years she’s handled the issue, stakeholders including law enforcement and medical experts have helped develop the language she’s proposing.  Those amendments were then rejected.

Another favorable vote would send the bill to the Senate, where in past years it has been stopped primarily by Senator Rob Schaaf (R-St. Joseph), who has his own PDMP proposal which cleared that chamber early this month.