At Richard Logan’s pharmacy in Charleston, Missouri, prescription opioid painkillers are locked away in a cabinet. Missouri law requires pharmacies to keep schedule II controlled substances—drugs like oxycodone and fentanyl with a high addiction potential—locked up at all times.
Logan doesn’t stop at what the law requires.
A pharmacist for 40 years, he has also been in law enforcement for more than 20, working as a reserve deputy with two local sheriff’s departments investigating prescription drug abuse. And he applies that mentality to his day job.
After his technicians count out a prescription for controlled narcotics by hand, Logan has them place the pills on a machine that resembles an overhead projector lit from the top instead of the bottom.
“There’s a camera up there,” Logan says, “It actually photographs each pill that we dispense.”
When he has probable cause that a customer is trying to get opioids with a forged or fraudulent prescription, Logan will arrest them on the spot. When he only has a strong suspicion—and if they’re from out-of-state—he’ll escort them out of the pharmacy and direct them to the nearest bridge out of Missouri, about nine miles away.
These run-ins with drug-seekers make Logan anxious to see the state enact a prescription drug monitoring program, or PDMP. This would be a statewide database tracking narcotics prescriptions, which doctors and pharmacists can check to catch signs of abuse or addiction and to intervene if necessary.
In the battle against America’s surging opioid drug addiction, 49 states, the District of Columbia and even Guam have all implemented prescription drug monitoring. Missouri is the only state that has not. A protracted political battle has kept the state from passing a law to establish one. And that’s leaving pharmacists like Logan with few options.
He can only check the prescription history of patients on Medicaid, which already tracks such data. But when a patient pays cash—which is a red flag for Logan—there is no record to check leaving pharmacists to guess whether the patient is in genuine pain, feeding an addiction, or maybe looking for pills to sell.
“We want to take the best care of everybody that we can,” says Logan. “And without a PDMP we are absolutely flying blind."
A debate over privacy
State representative Holly Rehder—whose district includes Charleston, Missouri—has championed establishing a database ever since joining the legislature in 2013.
“I’ve been working on this since my feet hit the floor,” she says.
It’s an issue close to her heart.
Her cousin died of a drug overdose. Her mother was addicted to prescription medications. Her sister used heroin. And for 13 years, her own daughter has struggled with drug abuse—an addiction that began with a legal prescription for Lorcet.
“I’m very candid about it,” Rehder says. “I don’t believe God gave me a microphone to keep my mouth shut.”
She cites these database’s success in limiting drug abuse in other states. They make it harder for pill seekers to “doctor shop”—going from doctor to doctor getting multiple, simultaneous prescriptions for the same drug.
One year after New York state required its prescribers to check the state’s PDMP before writing a prescription, for example, doctor shopping dropped by an estimated 75 percent.
Doctors surveyed in many states, including in Connecticut and Rhode Island, say prescription drug monitoring programs have helped them identify opioid drug abuse and intervene with those patients who need help—all reasons the federal government strongly recommends the programs.
For the third straight year, Rehder’s bill has passed the Missouri House and moved on to the Senate. There, each year, it’s been blocked by her main opponent on this issue, state senator Rob Schaaf, a fellow Republican who strongly disapproves of her bill.
“It’s just the heavy hand of government taking away your liberty,” he says. In 2012, before Rehder joined the legislature, Schaaf led an eight-hour filibuster of PDMP legislation, an act that has loomed over subsequent attempts to pass a similar bill.
Schaaf is a physician by training, making him a surprising opponent to prescription drug monitoring, which is supported by the Missouri Academy of Family Physicians, the Missouri American College of Physicians, and the Missouri State Medical Association, among others.
He argues that drug monitoring may inhibit doctors from prescribing medications that patients really need. His main objection, though, is about privacy.
“The monitoring program would put every citizen’s private drug information on a government database accessible to 30,000 people with usernames and passwords,” he says. “That’s just an outrage.”
Rehder doesn’t buy that argument. The database is electronic medical information, she says, so it would be protected by the same privacy laws protecting all electronic medical records. “It’s not like anyone can go on a phishing expedition in this data.”
But, “there is no data that is secure,” Schaaf counters, citing hacks against the IRS and the VA, and even noting Hillary Clinton’s email scandal.
Rehder argues that 49 other states have faced these same questions about security, and Missouri would be able to follow the best practices they’ve developed. But that’s unlikely to help her bill clear the Senate this year either.
To be fair, Schaaf is not entirely opposed to prescription drug monitoring. He says he would allow Rehder’s bill to pass the Senate if it included a provision that final approval for the database would be put before the voters—a test he doubts the bill could pass.
And for the past three years, he has proposed his own monitoring legislation that would limit access to the database to Missouri’s Bureau of Narcotics and Dangerous Drugs who would then communicate concerns to providers.
Rehder says she can’t support his bill because it would be cumbersome and impractical to implement, and that it’s doctors who should be making decisions with the data.
Meanwhile, Schaaf has called her bill “dead on arrival.”
“Missouri is the only state that doesn't have this. It’s very shameful,” Rehder says. “It’s hurting our population so much.”
The cost of waiting
For pharmacists like Richard Logan, the political gridlock is frustrating to watch when people’s lives are at stake.
“I think this horse has been beaten to death,” Logan says. “It’s something that is absolutely, desperately needed. My fear is in the current environment, it’s not going to happen.”
Logan isn’t the only one who has grown tired of waiting. In March, St. Louis County—which has one of the state’s highest drug overdose death rates—passed its own PDMP. Other counties have signaled they would consider doing the same.
Rehder says this is better than nothing though she prefers a statewide database over a patchwork of county systems.
“We have got to start realizing that this isn't something we can close our eyes and turn our heads to because it’s not going to affect us. It’s affecting us,” she says.
“Our families are being torn apart, lives are being destroyed.”
Twenty miles down the road from Logan’s pharmacy—and also in Rehder’s district—33-year-old Jason Lynch is close to completing a 120-day stay at Mission Missouri, an addiction treatment facility in nearby Sikeston.
Lynch was given his first prescription painkiller by an older student on the school bus when he was just 11 years old.
“I think right from the get-go I was hooked because the next day I was trying to get some extra lunch money to buy some more,” Lynch says.
He’s battled opioid use for 22 years, feeding his addiction with pills prescribed to him by doctors.
“I would research [symptoms] on the internet and say, ‘this is what’s going on with my back.’”
Usually, Lynch says, the doctor would write him a prescription.
“It’s nobody’s fault but my own,” Lynch says of his addiction, but, he adds, getting the pills “should have been a lot harder.”
“You just think about what if those drugs weren’t so available to him,” Rehder says about Lynch’s story. “How could his life have been different?”
Correction: A previous version of this story said St. Louis County passed a PDMP in April. It was passed in March.
This story was produced by Side Effects Public Media, a reporting collaborative focused on public health.