Some in public health now argue that monitoring programs to cut off prescription opiate misuse, will push addicts to use heroin and fentanyl.
This article was published on Monday, July 26, 2021 in Kaiser Health News.
By Eric Berger
Kathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction.
The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.
He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started "doctor-shopping" at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.
If the state had had a monitoring program, doctors might have detected Mullane's addiction and, Arbini thinks, her son might still be alive. She said it's been embarrassing that it's taken Missouri so long to agree to add one.
"As a parent, you would stand in front of a train; you would protect your child forever — and if this helps, it helps," said Arbini, 61. "It can't kill more people, I don't think."
But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF.
Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri's new toll could cause more people to overdose and leave the state with buyer's remorse.
"If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others' mistakes and not repeat them," said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.
Before Missouri's monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.
State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.
In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.
The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.
Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it's important to mandate that prescribers review a patient's information in the database. "We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis," she said.
But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.
He and his colleagues in the intensive care unit at Carney Hospital in Boston don't use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.
"Rather than pulling out a piece of paper and being accusatory, I find it's much better to present myself as a caring provider and sit down and have an honest discussion," Wood said.
When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.
But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation's second-largest increase in drug overdose deaths.
When efforts to establish Missouri's statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.
Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has "saved lives across the state." Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, according to the CDC.
The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.
Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can't obtain them and instead buy street drugs that are more potent and contain impurities.
But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.
"We absolutely are not prepared for that in Missouri," said Winograd, of NoMODeaths. "Substance use treatment providers will frequently tell you that they are at max capacity."
Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.
For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.
Tipton, who has worked at the clinic for 17 years, said that before the COVID-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it's mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse.
Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.
Inez Davis, diversion program manager for the Drug Enforcement Administration's St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because "doctor shoppers and those who commit prescription fraud now have one less avenue."
Winograd said it's possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. "I don't think that's the answer," she said. "We need to move in the direction of decriminalization and a regulated drug supply." Specifically, she'd rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.
State Rep. Justin Hill, a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri's opioid problem any worse than many other states'. He also worries the monitoring program will lead to an increase in overdose deaths.
"I would love the people that passed this bill to stand by the numbers," Hill said. "And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board."
“I would love the people that passed this bill to stand by the numbers. And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.”
Missouri State Rep. Justin Hill, (R-St. Charles)
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Missouri lawmakers and health and law enforcement officials had warned that the lack of monitoring made it easier for patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates.
A monitoring program can lead to an increase in overdose deaths because people addicted to prescription opioids suddenly can't obtain them and instead buy street drugs that are more potent and contain impurities.
A monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment.