The establishment of a prescription drug monitoring program (PDMP) in Missouri has been a slippery proposition for a number of years. A PDMP is one of the many ideas that have been proposed to curb the nation’s opioid epidemic. In the last decade, an electronic PDMP has been enacted by every state, with the exception of Missouri.
In 1990, Oklahoma became the first state to implement an electric prescription database. Between 2003–2012, with the assistance of financial grants, 33 states implemented an electronic PDMP. A PDMP bill has been introduced in the Missouri House of Representatives every year since 2005.
In the early years, the issue was sometimes sponsored by a member of the minority party, which gave it little chance to pass. In addition, it was a relatively new issue. By 2012, however, the issue had begun to get more attention with the onset of the opioid epidemic. It has since created passionate advocates and vocal opposition.
2012
By this time, Missouri was one of two states that had not passed a PDMP (New Hampshire was second last). The House bill moved quickly and passed that chamber by a 143-6 vote in early March. Both versions were bogged down by a Senate filibuster which charged that the government has no business tracking the medications citizens are using. With a few precious days left in the session, the House version passed the Senate after a referendum clause was added that would have sent it to the ballot box for a vote by the people. That effectively killed the bill.
2013
By now, Missouri was the last state without a PDMP. The 2013 House bill didn’t even get a committee hearing that year. The Senate bill got a hearing, but did not receive a vote. Both versions would have been bogged down by a Senate filibuster that would have charged that the government has no business tracking the medications citizens are using. There was a fairly large coalition of stakeholders pushing this bill, so it’s surprising that it seemed to lose momentum. The coalition has since been named the “Missouri PDMP NOW Coalition.”
2014
The bill passed the House by the middle of February. The Senate had three full months to pass it, but they didn’t even hold a hearing on it.
2015
Once again, the House passed their version quickly (before March). This time, the obstructionists in the Senate came to the table to negotiate. Despite being woefully inadequate compared to other states’ programs, the compromise language was a move in the right direction. With little time left, the House made changes to the compromise thereby requiring it be sent back to the Senate. It never made it across the finish line as time ran out. The changes the House made likely would have resulted in a filibuster anyway. This was as close as Missouri has come to having a PDMP.
2016
There was a more concerted effort to derail the bill in the House of Representatives this year, as the folks who oppose the creation of government-sponsored databases rallied their troops. The result was that the bill escaped the House by a 91-68 vote. The Senate held onto the bill for almost two months before scheduling it for a hearing. It was eventually placed on the calendar for floor debate in the session’s final week. It received a half hour or so of debate before it was unceremoniously suffocated.
2017
As has been the case the past couple of years, there are two competing PDMP bills in the legislature. We have been advocating for the version contained in HB 90, and remained silently opposed to the concepts behind the Senate’s version (SB 74). In many cases, the differences between the two bills are subtle, but the House version is better at helping physicians treat their patients and it avoids unknowns, so we - along with the rest of the PDMP coalition - have historically been more closely aligned to it.
Probably the biggest difference between the two programs is that only the House version would allow physicians to actually see their patient’s prescribing data. Under the Senate’s version, a physician would only get a ‘red-light’ or ‘green-light’ notification from the Department of Health and Senior Services (DHSS) as to whether there might be a prescribing discrepancy. While that might give the physician an indication of whether to prescribe or not, it doesn’t do much to actually help treat patients. Not to mention it requires a system far more complex than what we feel is required. The goal is to make patient information as confidential and secure as possible while still allowing for proper treatment for patients. We are actively looking for that sweet spot.
Another huge difference is the Senate bill, once approved by the Senate, would require a vote of the people. This is a procedure trick designed to kill the PDMP. We’re not so sure Missourians wouldn’t vote for it, but ballot questions are incredibly expensive and it’s a road we’d rather not travel.
Both bills allow government agencies (DHSS and Bureau of Narcotics and Dangerous Drugs) to contact law enforcement agencies and/or professional licensing boards when they find “reasonable cause” to believe something is amiss. This language will need finessing. These executive agencies are accustomed to finding violations from a checklist; not in the business of establishing “reasonable cause” from a data set or two. Both bills require dispensers to submit information to the PDMP. The Senate bill allows prescribers to submit information, but neither requires it.
These are big bills that involve multiple stakeholders. They’re not easy to deal with and it is difficult to find compromise that suits everyone at the table. We have been assisting with the nuts and bolts of the recent local efforts to establish county-based PDMPs, and we serve on a number of statewide task forces on this issue. At the Capitol, we will continue to advocate for PDMP language that will survive the legislative process, yet doesn’t dilute the impact of the county-based PDMP presently being enacted across the state.
Biography
Jeff Howell, JD, is MSMA’s General Counsel and Director of Governmental Relations.
Contact: jhowell@msma.org
