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PDMP Debate: Why some physicians aren’t happy with Greitens’ executive order


JEFFERSON CITY, Mo. – Uncertainty and reluctant acceptance seem to be the general attitude of many following Gov. Eric Greitens’ executive order establishing a prescription drug monitoring program.

“That was not a good day,” Rep. Robert Ross said while appearing on This Week in Missouri Politics. “I was extremely frustrated.”

Ross and some other members of the Missouri Legislature have never been fans of PDMPs, something the Republican will tell you is not needed.

“If you look at it, 49 states have a PDMP, but yet in national news every day, across the board, we’re talking about this opioid issue and why it’s a problem nationwide, not just in Missouri. So if 49 other states have an issue and they also have a PDMP… if you look at the statistics from 2015, it shows that the number of opioid-related deaths for the 45 state that actually track this, Missouri actually falls in the middle of the pack at number 22. So the reality is that the standard mode of operation seems that the federal government is going to find a way to surveil law-abiding citizens across the board rather than focusing on what it can actually do to prevent the problem. PDMPs are proven to not work.”

But his issue is also about the Governor’s decision and the question of overreach by the executive branch.

“I disagree with the Governor’s decision in two ways, not just a policy standpoint. We, as a state, do not need to be tracking prescriptions, and I also disagree with the process. Does it require legislative action to be put in place? I believe it does,” Ross said. “This is a give and take between our separated branches of government, and we as the legislative branch must remain vigilant in protecting from executive overreach because if we do nothing, we’re going to see more of this.”

But lawmakers are not the only ones turning a cautious eye on the new order, or quietly bristling at the idea. Many in the medical field are also less than thrilled with the Governor’s decision, as they believe it doesn’t properly address the issue or doesn’t do enough.

The state’s new PDMP will be limited to law enforcement and regulatory boards, which some in the medical field have an issue with, as a more traditional PDMP would allow access to doctors and pharmacists, who are not included in the governor’s executive order.

Without that, they argue, the governor’s version of PDMP is more simply a regulatory tool to be used by law enforcement. They say the missing component is allowing it to be a tool for healthcare professionals, too.

“A real PDMP allows physicians and other prescribers to see patient data so that they can treat those patients and what was done by executive order does not allow for that,” Jeff Howell, the director of government relations at the Missouri State Medical Association said. “Every other state has a PDMP, and it’s supposed to be a clinical tool for prescribers to use so that they can treat patients. That’s what it’s about. It’s about stopping doctor shopping and treating sick people.”

“When you turn it into something that data mines for prescription information to find out who are outliers are and then turn them over to the cops, that’s not a PDMP. That’s a prescriber monitoring program. We’re completely getting away from what PDMPs were established to do, and that’s treating patients.”

Howell says that the Governor’s EO would mean that someone at the Department of Health will be looking at prescribing data and then determine what’s appropriate prescribing and what’s inappropriate prescribing. 

“Some algorithm that no one knows will be used to determine that,” he said. “We can’t just say everyone is over-prescribing because some of them have perfectly clinical reasons to use that treatment.”

“Greitens’ proposal differs from the conventional prescription drug monitoring program approach. Rather than creating a database accessible by providers and pharmacists to identify patients’ interactions with clinicians and opioid prescriptions — similar to the St. Louis County program — the initiative would use data from pharmacy benefit managers like Express Scripts. Patient-identifiable data wouldn’t be included. Rather, the data would identify providers and pharmacies that are outliers in prescribing and/or dispensing controlled substances,” Herb Kuhn, Missouri Hospital Association President and CEO wrote in a blog post. “It is unclear at this time how state government will determine a rate that is excessive. Since pain management, hospice and oncology physicians may all have clinical conditions that justify rates that exceed a set standard, how the rules are written becomes paramount. The stakes are high.”

Kuhn said that they need to make sure that the new PDMP is not a physician monitoring program, but instead “a tool in the states multi-pronged effort to combat the opioid epidemic.”

It still isn’t clear if the proposal will have any effect on the St. Louis County PDMP, which is more of the traditional PDMP, but Rep. Holly Rehder, a major proponent of PDMP legislation for years and carrier of the bill that nearly passed this last session says that the EO PDMP should work in addition to the county PDMP.