Missouri opioid Rx-monitoring fight ignites debate over national program

For years, there's been debate over balancing the need to track potentially addicted patients by providing their clinicians with a vast amount of data on their prescription drug habits and maintaining the privacy of those patients' records.

The number of overdoses caused by opioids makes the case for maintaining robust drug-monitoring databases, some experts say.

Now the ongoing fight to track opioid prescriptions in the holdout state of Missouri has once again raised discussion on whether the country would be best served by a national monitoring system—or whether it's too late to implement that idea because the drugs causing overdoses are bought on the street.

Missouri is the only state in the nation without a prescription-drug-monitoring program, which collects information to warn physicians that they may overprescribe opioids and prevent a patient from seeking prescriptions from multiple physicians.

Republican Missouri state Sen. Rob Schaaf, a family physician and a longtime opponent of drug-monitoring programs, recently introduced a bill that would allow a physician to view a patient's medical data only when the state's Department of Health and Senior Services identified cases of doctor-shopping. Critics say a monitoring program just gives physicians more work, while others say it will just track the wrong addictions since drug use has shifted.

Supporters contend a national program expands and streamlines the information available.

“I think that there wouldn't be anyone who would disagree with the idea that it would be better to have a single national system rather than all of these different state systems,” said Dr. Andrew Kolodny, co-director of opioid policy research at Brandeis University.

Kolodny said a uniform national system would solve the problem of states being unable to track interstate drug trafficking.

State prescription drug-monitoring programs, or PDMPs, often differ in the technology they use, as well as the rules and regulations by which they operate. Also, state PDMPs differ on the frequency in which data is collected.

But the move toward establishing a national monitoring program has never taken off because critics feel states may lose the flexibility they need to address their specific drug problems.

“Each of these programs, in doing something different, they also do a lot of innovative things,” said Peter Kreiner, a senior scientist at the Schneider Institute for Health Policy at Brandeis University. “If you had a national program you could imagine the kind of bureaucracy that would be associated with that, and it's unlikely it would be able to innovate in nearly the way state programs can.”

But according to Tom Bizzaro, vice president of health policy and industry relations for health data firm First Databank and a longtime supporter of a national drug-monitoring network, states would be able to keep their individual regulations and rules under a national network by applying standards that are already used by pharmacies for claims reimbursement and electronic prescribing.

“The infrastructure is there,” Bizzaro said. “So we're not talking about having to create a pipeline for that information; that already exists.” Using that infrastructure allows for states to determine who has access to their PDMP, the kind of information that is shared, and what types of drugs would be included.

A total of 41 states engage in some form of interstate data-sharing. But most sharing is still done on a regional basis. A physician in California may be able to easily find that a patient was prescribed opioids in Oregon, but they would not have a clue as to whether the same patient recently received a prescription for pain relievers in New York or Illinois.

Supporters of a national PDMP network believe it would make interstate data-sharing easier. But it could also attract hackers.

“The bigger a database gets the more practical concerns there can be about data security and the ramifications of hacking,” said Nathan Freed Wessler, a staff attorney with the American Civil Liberties Union's Speech, Privacy and Technology Project. “There may well be benefits in terms of efficiency, but in this area, I don't think the efficiency is the most important value.”

Still others feel the whole premise of a national PDMP may be outdated considering current trends in drug use. The rate of overdose deaths by prescription pain relievers has been leveling off over the past few years, while deaths from heroin have skyrocketed from 8% of all drug overdose deaths in 2010 to 25% by 2015, according to the Centers for Disease Control and Prevention.

“The drug problem keeps changing, keeps morphing, and keeps staying ahead of the efforts to address it,” Kreiner said. “Having a slow-moving entity that's trying to help address it is probably not a great idea.”

Increasing scrutiny of opioid prescribing practices in the past few years has helped to reduce prescriptions. That may have led addicts to switch to heroin as prescription medications become sparser.

“It seems like the ship may have already sailed on that,” said Bryce Pardo, a drug policy analyst with research and consulting public policy firm BOTEC Analysis Corp., referring to the database helping curb the overdose epidemic. “It seems like the market is shifting toward heroin, so it seems like we're entering the second stage of this epidemic.”

But Kolodny said the CDC figures do not provide an accurate portrait of what is truly happening in terms of the epidemic. He said the switch from pain relievers to heroin occurred early in the drug epidemic, predominantly among younger adults, but prescription opioids remain a large concern among older Americans.

Bizzaro believes there will someday be a national drug-monitoring program and he's gauging the Trump administration's interest in developing one.

“I think it just makes too much sense to have a national program,” Bizzaro said. “I see it now as more of a political issue than a technical one.”