Missouri Is The Only State In The US Where Doctors Have No Idea What Prescriptions People Are Getting
As medical groups fight to stop people from driving into Missouri to stock up on pain pills, one state senator — who happens to also be a doctor — stands in their way.
It took Jennifer Cartright and her mother about a week to realize her brother wasn’t responding to anyone’s calls.
Brett Mountjoy, 53, had recently lost his job as an ultrasound technician at his local hospital in Duquesne, Missouri. After a decades-long battle with painkiller addiction, his wife had left him, and his daughter had cut off contact. And after watching him languish on methadone treatment for 17 years while he took other drugs on the side, Jennifer and her mother last summer turned to some tough love, too — they had stopped checking in on him every day.
But this was too long for radio silence, even from Brett. On August 5, they made the half-hour drive over to the western edge of the state, and found Brett in his house, where he’d been dead for a week.
Scattered around the home, they found a sea of pill bottles.
“We found bottles from all over,” Cartright said. “We saw pill bottles from lots of different doctors in Missouri for benzodiazepines as well as opiates. There was also amphetamines that we found bottles of. Plus methadone.”
“It had become his job to have to go and go to different doctors.“
Cartright, who had ended her own struggle with addiction 14 years earlier, said the loss of her brother came as the harshest of wake-up calls. She’s now one of the many people in Missouri pushing for a way to cut down on so-called “doctor shopping” among addicts: a new bill that would set up a prescription drug monitoring program, or PDMP, that would allow doctors to see all the scheduled drugs their patients are getting prescribed before they dole out any more. A PDMP, they say, will let doctors spot addiction early on, and decrease the likelihood of dangerous drug interactions, like the benzos (anti-anxiety drugs such as Valium and Xanax) and opioids that killed Brett.
“After Brett died I just knew that if I could spare one person from having to go through what we did as a family and for having to go through the life that Brett had been living, I had to do it,” Cartright said.
Missouri is now the only state in the country that doesn’t have such a monitoring system in place.
As the opioid epidemic sweeping the country sets new records each year for overdose rates, 49 states have set up their own PDMPs to cut down on pill trafficking. But in Missouri, PDMP bills introduced in the last six legislative sessions have lost out, thanks to one senator — also a doctor — who has blocked it year after year.
When asked why, Senator Rob Schaaf of Missouri’s Buchanan County is hardline: patient privacy is at stake. “Just because every other state does something doesn’t mean that Missouri has to do it,” Schaaf told BuzzFeed News. “It’s a severe invasion of our privacy.”
In 2012, beginning a now infamous filibuster on this issue, a fellow Republican senator asked why Schaaf supported cops stopping drivers not wearing seatbelts, but insisted on keeping doctors in the dark about addicts potentially shopping for drugs.
"If they overdose and kill themselves, it just removes them from the gene pool," Schaaf had replied.
He has since gone on to say that the quote has been misinterpreted (“I was talking about liberty,” he told BuzzFeed News), but others question why Schaaf has continued to block a prescription drug monitoring system, even as it has gained the support of all of Missouri’s medical groups, law enforcement officials, and even Mallinckrodt Pharmaceuticals, the St. Louis-based manufacturer of the opioid painkiller, oxycodone. Still others cite the state’s rising drug abuse problem: 18 drug overdose deaths per 100,000 people in 2014, well above the national rate of 14.7 per 100,000.
“My members — that’s nearly 5,000 Missouri physicians — overwhelmingly support having a good monitoring system in place,” said Jeff Howell, director of government relations for the Missouri State Medical Association, which has contributed to Schaaf's campaign. “I just have one member, who also happens to be a senator, who opposes it.”
Pain pill use first started booming in the US after 1995, when the FDA approved the sale of the timed release opioid painkiller OxyContin. Cautious doctors had for decades previously prescribed opioid painkillers most often to deal with short-term issues like surgeries or cancer. But the sales approval kicked off a marketing campaign by OxyContin’s manufacturer, Purdue Pharma, that began to aggressively market opioid drugs as a safe way to ease chronic pain.
Twenty years later, in 2007, Purdue execs would plead guilty to criminal charges that they had intentionally misled the FDA, clinicians, and patients about the risks of OxyContin addiction.
“Overall, 1 of every 550 patients started on opioid therapy died of opioid-related cause,” wrote Thomas Frieden, director of the Centers of Disease Control and Prevention, in an op-ed last year. As many as a quarter of patients prescribed an opioid painkiller for long-term pain become physically dependent, he said, and the typical overdose death came roughly 2.6 years after the prescription started. “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.”
But Missouri’s overdose problem, opponents of the prescription drug monitoring program say, pales in comparison to other states.
“Since we’re the only state that doesn’t have a PDMP, and we’re still only 22nd as far as deaths by opioid abuse, obviously we’re not worse off,” Schaaf said.
Many on the ground argue, however, that the problem can’t be counted up in overdose deaths alone. Instead, law enforcement and medical professionals say, Missouri has become the nation’s pill mill.
In Schaaf’s own district, Buchanan County, which sits on the western edge of the state bordering Kansas and near Nebraska, 52 people were arrested in 2016 for coming into the county with fake or fraudulent prescriptions to fill, said Shawn Collie, head of the sheriff’s drug strike unit. Of those, Collie said, each had an average of 20 scripts with them, and they came in from as far away as Hawaii.
“We’re right on the I-29 and 36 highways,” said Collie, who has testified in favor of a PDMP bill several times. “If you have someone traveling the US doing some type of criminal activity, then at some point they’re probably going to come through our area. When we’ve interviewed people we’ve caught trafficking they say the main advantage was the accessibility to the pharmacies right there on our main road. The accessibility — that’s what we’ve got. It’s easy for them.”
According to the DEA, the relatively small Buchanan County, population 89,000, leads Missouri in the amount of per capita hydrocodone and dilaudid, another powerful opioid, coming in from manufacturers to state pharmacies.
“Once you get into Missouri, you can get to every pharmacy you want and there’s no tracking,” Collie told BuzzFeed News. “We are making the pills a priority. We have to, because of the number of pills coming out of Buchanan County.”
Despite the problem being so bad in his own district, Collie says that Schaaf has not made it a priority. “That’s what kind of has most of us scratching our heads,” Collie said. “He’s never once come to talk to us about it.”
There are approximately 1,200 retail pharmacies, and nearly 6,000 pharmacists currently practicing statewide in Missouri, said Ron Fitzwater, chief executive officer of the Missouri Pharmacy Association, which also supports the PDMP bill. Many of them have similar complaints about not knowing when customers are presenting for their pain, or to abuse or sell pills.
“I repeatedly hear from pharmacists in rural communities about carloads of people who just happen to be passing through Missouri coming in from Florida,” Fitzwater said. “They know it’s not being tracked and they can’t do anything about it.”
“Then it becomes a decision that has to be made at the pharmacy counter— is this a valid script? That’s not a position we want to keep finding ourselves in.”
The efficacy of PDMPs in cutting down drug abuse is well-established, at least when doctors are required to use them. In 2012, Kentucky became the first state in the US to require doctors to check a patient’s drug history before issuing a new painkiller prescription. The state saw a 13% decline in opioid prescriptions, and a 25% decline in overdoses — the first decline in a decade.
Twenty states now require doctors to use PDMPs whenever they’re prescribing a scheduled substance to a patient, and twenty more states require prescribers to use the PDMP in at least some circumstances.
“The fact that there’s a clearly increasing interest in PDMPs among states has everything to do with the opioid epidemic,” Lainie Rutkow, associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, told BuzzFeed News. In 2015, Rutkow’s research group published a study looking at opioid prescribing rates in Florida, where a PDMP law and a pill mill law, which focuses on pain management clinics in particular, were enacted in 2011.
“The implementation of those two laws together was associated with a decrease that was the equivalent of about 500,000 5mg tablets of Vicodin a month,” Rutkow said. “That’s a lot of pills.”
But Rutkow also found in a survey she conducted of 420 primary care doctors nationwide, that roughly a quarter of physicians didn’t know that their states even had PDMPs in place.
“The PDMPs that work really well are mandatory,” said Gary Henson, a board member of a group called Shatterproof that has been advocating for PDMPs across the US. Henson, who lost his son to a drug overdose from mixing benzodiazepenes and opioids (the frequent prescription of these anti-anxiety drugs with opioids led to a five-fold increase in overdose deaths from them from 1999 to 2009), says doctors should be required to see this information in order to do their jobs properly.
“I don’t want other families to go through what I’ve gone through,” Henson said. “We’ve made PDMP a doctor-shopping issue. It’s really a better practitioner issue.”
But after years of pushback, Senator Schaaf is still adamant that he will not support a PDMP bill that allows doctors to see a patient’s full prescribing history. Instead, he argues, he’s pushing for compromise.
Schaaf has proposed an alternate PDMP bill that would collect prescription data, but not allow doctors and pharmacists to actually see it directly. Instead, doctors can send the system prescriptions, which would then return with an assessment of risk.
But none of the state’s medical organizations have supported Schaaf’s alternate version, which they argue still doesn’t give doctors the easy and full access to information they need to help curb the epidemic. It also requires vendors to build an electronic system that no other state currently has in place, an expensive and potentially prohibitive restriction.
Schaaf's bill passed through the state Senate last week.
In the time since Schaaf has been filibustering a statewide PDMP in Missouri, nine counties have passed their own local prescription monitoring databases.
“He has been happy to die on the hill over this issue,” said Holly Rehder, a Republican House member who is sponsoring the original PDMP bill, which will be introduced concurrently in the House and Senate in the next couple of weeks. “But in reality the counties are passing PDMPs. So are we going to do the responsible thing and have a statewide system, or are we going to let it continue to be piecemeal? Either way we’re going to address this epidemic in Missouri. Unfortunately he may make it take a little longer.”
When asked, Schaaf repeatedly said his main concern is over prescribing histories of patients being hacked. Florida’s PDMP database was attacked by hackers in 2013, for example. But Rehder argues that Schaaf’s statements reveal, at best, a stark misunderstanding about the opioid epidemic.
“When Schaaf started his testimony this year he said this is an issue between good and bad people,” said Rehder, whose sister and daughter both fought long battles with opioid addiction. “That’s the problem. He does not understand addiction — this is not an issue between good and bad people.”
For Cartright, who has been writing letters to the Senate and to local newspapers since her brother passed away last summer, Schaaf’s continued obstruction of a full PDMP in Missouri reveals something worse: a deep-seated stigma surrounding addiction. The notion of improving the “gene pool” when people addicted to opioids overdose, she suggested, reflects a staggering lack of compassion for people like her brother, who had helped to set up his town’s first heart institute, even while he struggled with addiction.
“That just makes my blood boil that somebody could say that,” Cartright said. “These are people’s children, these are people’s parents, and it was me too. Now I am a completely important part of society. Recovery is possible and a successful life really can be had. We just need a little more help than we’re getting right now.”