The Phelps County Commissioners signed a User Agreement with St. Louis County on Tuesday, Aug. 14, which when submitted will enact PDMP legislation requiring every pharmacy in Phelps County to provide information on each prescription pharmacies dispense to the St. Louis County PDMP, including mail-order prescriptions.

The PDMP legislation will take full effect in Phelps County towards the end of the year, said Phelps-Maries County Health Department Director Ashley Wann.


“We will be placed on the next implementation cycle, which is every three months, and It’ll be close to the end of the year or beginning of next before it is fully implemented and in use,” said Wann.


Phelps County opted out of including an enforcement clause in the county’s ordinance, which is optional for each of the 66 jurisdictions that have joined the PDMP as of Tuesday, Aug. 14, 2018, according to the St. Louis County Department of Public Health (DPH), the entity that operates and maintains the PDMP.


The St. Louis County PDMP provides quarterly reports to all participating jurisdictions that focus primarily on opiates that are a dominant issue in the county.


In July U.S. Sen. Claire McCaskill (D-Mo.) released a report on the opioid crisis in Missouri, “Fueling an Epidemic a Flood of 1.6 Billion Doses of Opioids into Missouri and the Need for Stronger DEA Enforcement,” which found that 1.6 billion opioid doses made their way into Missouri between 2012 and 2017.


The report identified Phelps County as among the top counties with the highest rates of suspicious opioid orders in the state – orders of “unusual size of frequency based on local ordering patterns.”


Looking at the 45,000 residents that make up Phelps County, 3.6 million opioid pills were prescribed in the county with 81.3 per every man, woman and child, according to the Center for Disease Control and Prevention’s most recent report that looks at the prescribing rate per 100 residents in the county.


The staggering number and complex opioid problem in Phelps County influenced the county in deciding on participating in the PDMP  that was devised to address overdoses from prescription opioids; a driving factor in the 15-year increase in opioid overdose deaths, according to Emily Varner, of the St. Louis PDMP.


Since 1999 the number of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report, The St. Louis County DPH noted.


The number of opioids prescribed parallels the principal goals and purpose of the monitoring program, which is to improve controlled substance prescribing by readily providing crucial information regarding a patient’s history of controlled substances prescribed, along with identifying patients who are at a higher risk of misuse, abuse or overdosing on prescription medications, who could benefit from early intervention by their clinical practitioners.


The program offers an avenue for patients to have access to safe and beneficial treatment in a time when the misuse and abuse of prescription medications are prevalent. Where “prescription drugs are more accessible for high schoolers to acquire than a 12 pack of beer,” said St. Louis Drug Enforcement Agent Ryan Lawyer, who spoke at a Phelps County seminar in May.


The perception of society viewing prescriptions as “good,” is the primary problem leading to the addiction to prescription pills, noted Lawyer.


“We are seeing people who are addicted to opiates, who have never smoked marijuana because in their mind they are never going to take an illegal drug because they are bad for you,” he said.


To help combat the multifaceted problem surrounding prescription pills and the widespread abuse of opiates the PDMP hones in on pharmacies that deal with prescription pills daily.


“We monitor pharmacy compliance and work with those pharmacies. In this past month we sent letters to all of the pharmacies who had gaps in data submission that should be in the PDMP and give them a deadline to fill in that data,” said Varner.


So far no pharmacies in any of the jurisdictions have said no or pushed back on the prescription monitoring program, and the pharmacies keep records through their assigned software vendors and submit the data.


Currently, St. Louis County has enacted an enforcement clause of up to one year in jail or a $1,000 fine or both for pharmacies that don’t comply with the monitoring program.


The program also provides alerts for providers that the online system generates if a patient has three or more subscribers or three or more pharmacies they use to fill prescriptions, which will show up in the patient report for anyone who accesses the information.


The PDMP system shows prescription history, prescribers who write prescriptions for the patient and any dispensatories that fill the prescriptions across every jurisdiction that is part of the PDMP system.


The alert section will also allow authorized users to see the past six months of how many prescribers and pharmacies a patient has, and even up to two years of history, except Phelps County doesn’t have enough data for the extent of two years of patient history, according to Varner.


The PDMP just completed a mass registration where the program allowed all the health systems to mass enroll any and all providers that they wanted to. Over the month of June just fewer than 7,000 users registered in the PDMP. “Primarily physicians, but pharmacists, nurse practitioners, dentists, optometrists, and any kind of health care provider in the healthcare system can register,” said Varner.


And the monitoring program plans to have mass registrations twice a year, once in the summer and once in the winter. “So if the health systems get a new class of medical residents they can get all of their residents enrolled in the PDMP, so they have access to take time off of the physicians and healthcare providers,” she added.


PDMP further sends weekly updates, if a subscriber can’t join the call with all of the health departments, updates on the number of users and jurisdictions, and anything new the monitoring program is going to roll out, and mass registration was a big focus of the most recent conversation.


The monitoring program also provides participating jurisdictions with quarterly, county-level reports on prescribing practices and contain a subset of indicators examined in the annual report focused on schedule II-IV controlled substance prescriptions.


“We look at PDMP utilization so the number of users and how the system is being used across the board, then when we get into the prescribing patterns by your local jurisdiction, so that would be Phelps County compared to the whole system. Then each county has their own jurisdiction report,” said Varner.


At the meeting when Varner introduced the PDMP to the Phelps County Commissioners, Phelps County District 1 Commissioner Larry Stratman questioned if law enforcement could employ the PDMP as a tool for combatting those who sell prescription drugs on the ‘street.’


 “Can this or would this ever be a law enforcement tool,” asked Stratman. “It seems to me that if you have a person out there who sees six different doctors, and obviously they aren’t taking all of that, they are selling some of that, so can the drug task force access the information"?


According to Varner, the answer is yes, but it’s not that simple. There are three types of authorized users. There is direct, full access for medical and pharmaceutical care providers, dispensers or delegates. Next, there is the ability to request data with no direct access, from patients or self-requests. Lastly, there is restricted or limited access from state boards, law enforcement, MO Healthnet and judicial officers.                                                                                                        


Even with authorization as a user, law enforcement must have a court order to request information on patients, prescribers or pharmacies.


“If the judges signed off, then we approve that request, and only that one request is provided back to law enforcement. Every request is separate and individual, and law enforcement only gets approval for each individual case,” said Varner.


She added, “We don’t have a lot of law enforcement usage within the system because it does require that court-ordered subpoena, so half end up rejected.”


The PDMP remains a prevention tool, yet the monitoring program won’t be of any assistance concerning users of recreational street drugs, that people may turn to if a prescriber stops refilling their scripts, a scenario that is all too common according to agent Lawyer.


But the consistent utilization of the PDMP by those authorized in Phelps County will garner greater success in reducing the abuse of prescription medications.


Currently, there are just fewer than 13,000 users in the PDMP. The majority of those are physicians with 7,892 registered for access. There are 3,218 pharmacists, 1,270 delegates, 303 dentists, 104 podiatrists, 44 optometrists and 25 “other” that include law enforcement and regulator or licensing agencies.


 Next year the St. Louis County PDMP is rolling out prescribing summaries that group what type of providers are the frequent high dose prescribers in the area for opiates. The prescribing summaries will have metrics that compare the report summaries to other providers in Phelps County, according to Varner.



Soon the St. Louis County PDMP hopes to go live with interstate data sharing, allotting authorized users to search other states in order to view if patients are seeing practitioners or filling prescriptions across state lines.


As an authorized participant in the PDMP, Phelps County clinicians will soon be able to identify patients who are obtaining opioids from multiple providers, calculate the total amount of opiates prescribed and identify patients who are prescribed other substances that may increase the risk of adverse reactions, according to Varner.


“If you do more with the information the PDMP provides you will have greater success. We are in support of the idea of a state-wide evidence-based program like the evidence-based PDMP we have,” said Varner.


And if Missouri decides to implement a state-level PDMP, changing Missouri’s position of being the lone state without a statewide program, the St. Louis County PDMP will continue to function until the state-level program proves to meet the needs of the St. Louis County PDMP.