This article first appeared in the St. Louis Beacon, Jan. 20, 2012 - Jason Eccker rarely counsels a cocaine addict, and he can't remember the last time he encountered someone addicted to methamphetamine. He started working at a residential treatment facility in south St. Louis about a year ago, and since then, opiate addictions have become the most common maladies among clients 25 and under.
A waiting list for long-term care at Harris House has grown from four to 16 weeks in the last year, and the facility has plans to expand.
The increase in opiate addictions follows a local trend in which more people are overdosing each year from heroin. Heroin today is more potent than in the past and is frequently sold in pill form rather than in a syringe, which makes it less intimidating. In St. Louis city and county, 126 people died of heroin overdoses in 2010 and at least 178 people died in 2011, according to local medical examiners. Worries over a heroin epidemic have sparked parents to create educational events and support groups, and area law enforcement agencies have organized efforts against the drug.
While increasingly popular, heroin still only represents part of the problem. People addicted to opiates eventually switch to heroin because it's cheaper, Eccker said. But they often start with prescription painkillers like Percocet and Oxycontin, which are capable of producing similar euphoria.
"There's sort of the innocence of thinking it's a prescription pill (and) not a problem because it's a legal drug. And then they end up on (heroin), one of the most dangerous illicit street drugs," Eccker said.
The problem is not unique to St. Louis. More people in the United States die from overdosing on painkillers each year than heroin and cocaine combined, according to the Centers for Disease Control and Prevention.
Many states have turned to prescription drug monitoring to prevent people from abusing and selling pills. Missouri is one of only two states -- New Hampshire is the other -- without a monitoring program or any laws to establish one. In recent years, Missouri House members have proposed legislation to establish a monitoring program several times and seen their efforts fail. Opponents talk about privacy issues and cost.
Advocates say not having a monitoring program makes it easier for drug addicts or dealers to visit five different doctors and complain of the same backache. Or for a doctor to operate a pill mill, over-prescribing drugs to those willing to pay. Monitoring programs vary from state to state, but generally they allow doctors, pharmacists and law enforcement to view a central database of prescription records.
Monitoring -- or lack of it -- in Missouri
State Rep. Keith Frederick, R-Rolla, an orthopedic surgeon, was trained as a pharmacist before entering medicine. He calls the current system, in which law enforcement and inspectors visit doctors' offices and pharmacies to examine records, "disruptive to practices, and slow." People who make appointments only to acquire painkillers can clog up the medical system and force patients with legitimate medical problems to wait, he said.
Frederick sponsored a monitoring bill in 2011 that passed in the House but died in the Senate. A similar piece of legislation in 2007 never advanced out of committee.
"I am a conservative and in many ways oppose government really micromanaging your life, but I think this is an area where the benefits outweigh the risks," Frederick said.
State Sen. Rob Schaaf, R-St. Joseph, said databases are "fraught with holes." He is a physician with a family medical practice in his hometown. A database allowing access to law enforcement, doctors and pharmacists -- depending on the rules -- could be compromised and violate doctor-patient privilege, he said.
"People are going to lie to get drugs no matter what," Schaaf said. "That doesn't meant the rest of the system, the 99 percent of the people who use them properly, should give up their right to privacy just to stop people from doing bad things."
Schaaf said instead of implementing a database, the government "should just enforce the laws it has."
Regulatory groups such as the Board of Healing Arts and Board of Pharmacy rely on complaints and routine inspections to catch people, but the system can be ineffective.
The case of Dr. Janet Akremi highlights its lapses. Akremi operated a practice in Boonville, Mo., where for years, authorities say, she regularly prescribed painkillers like Oxycontin to patients, often times without conducting any examination. The Bureau of Narcotics revoked her license to prescribe controlled substances. But she retains her medical license almost three years after the Board of Healing Arts filed a complaint against her for improperly increasing dosages of addictive painkillers.
One patient Akreimi started treating for "chronic pain syndrome" in 2004 told the doctor on several occasions that her painkillers had been stolen and requested more, according to the board's complaint. Despite the apparent substance abuse, Akremi continued to prescribe painkillers for several years, increasing dosages without examining the patient.
According to a record of the hearing. when the Administrative Hearing Commission questioned her practices, Akremi said, "I think that the right to make decisions about care belongs to the patient. How is that for a radical notion?"
The case is still pending, and no hearings have been scheduled.
It is difficult to determine whether prescription drug monitoring would prevent prescribing abuses. Regulatory groups were aware of Akremi's questionable practices years before she was stripped of her prescribing privileges. But a name that appears with unusual frequency in a prescription drug database might attract the attention of regulators.
Drug Enforcement Agency spokesperson Scott Collier said law enforcement in Missouri would not use a database to bust patients who doctor shop or produce fraudulent prescriptions but to find those who engage in trafficking conspiracies.
"Right now, we may get lucky at a particular pharmacy, but we are unaware of the other places they may have been. And unless we catch them or get lucky again, we won't find the patterns," Collier said.
Collier sees privacy concerns as a red herring from opponents of the monitoring system. Prescription records are already accessible to Missouri law enforcement. But without a database, officials must travel to individual pharmacies to examine their logs -- an inefficient system. In many states, law enforcement does not have carte-blanche access to the database; it must first receive permission from the courts or some other authority.
"In the absence of (a monitoring database) you're creating a sort of natural gravity for those with addiction issues or other nefarious schemes to come here and get those prescriptions from pharmacies," Collier said.
Experience in other states
An evaluation of a monitoring program in Maine, a state with a high rate of prescription drug abuse, found that patient information remained confidential, according to a University of Southern Maine study conducted in 2007. The study also found that the monitoring program had not made doctors less willing to prescribe medications for legitimate purposes, which had been a concern.
There is not one uniform model for monitoring programs. Pennsylvania has one of the oldest programs, established in 1973. It does not allow access by patients, pharmacists or doctors -- only to law enforcement officials.
In Vermont, all those categories have access, except for law enforcement.
Vermont Health Commissioner Harry Chen said lawmakers are considering amending the law because of concerns over increased opiate abuse.
"At the time when you start out with a program like this, you want to be fairly cautious," said Chen, who was a legislator when the bill passed in 2006. "I think everyone was concerned about the privacy issues. We really tightly controlled law-enforcement access."
Chen worked as a physician in an emergency room, where doctor shopping is common because emergency-room physicians rarely have ongoing relationships with patients. His instinct was to take patients at their word, but the database provided a useful glimpse at their histories.
"If you were to find out from the prescription database that they've been to five doctors and gotten prescription narcotics from each, you're obligated to question why they were in your emergency room," Chen said.
Some question whether monitoring programs are worth the start-up and annual costs. A comparison of states with monitoring programs to those with none found that deaths due to opiate-related overdoses increased at comparable rates, according to a study by the Centers for Disease Control and Prevention.
Frederick said the monitoring program he proposes for Missouri is modeled after those states that received most of their initial funding from federal and private grants. A program launched in New Jersey earlier this month cost $244,000 to set up and is expected to cost $177,000 annually for the next three years, according to the state's Division of Consumer Affairs. The state received a $350,000 federal grant for the program.
Drug Policy Alliance, an organization supporting reform of drug laws, opposes monitoring programs as a law enforcement tool. Grant Smith, a lobbyist for the organization, instead suggests Good Samaritan laws, which protect people from arrest if they call 911 to report an overdose. He also calls for increasing the use of Naloxone, a drug that halts the impact of opiates on the brain and revives a person. He says these responses are more effective ways to prevent drug-related deaths than policing.
"If there is going to be (a monitoring system), it should be put in place exclusively for medical professionals to monitor the commerce and the prescription of controlled substances," Smith said.
Here in Missouri, Frederick filed legislation again in early January. He said he feels "quite good" about the chances of it passing.
"A number of senators are interested in it, and I have faith the legislative process will work as it is intended to work," Frederick said.
Eric Berger is a freelance writer in St. Louis.