Holly Rehder grew up surrounded by drug addiction. Her stepfather was a dealer; she had a sister who married a dealer and became an addict by the age of 16. Now Rehder is fighting a new drug war — as a parent, business owner and state politician.
At 17, Rehder's own daughter became addicted to opioids after receiving a legal prescription from a doctor. Later Rehder's grandson was born with opioids in his system.
"We've had 13 years of ups and downs. ... This is not what you would think, a middle-class suburban teen going to church, with both parents working. ... That's not who you think about when you think about addiction," Rehder said. "All it took was that first prescription. After that, she started buying at work. ... There's a plethora of these pills on the street."
A Republican member of the Missouri House of Representatives, Rehder has been the leader of a multiyear — and so far failed — effort to convince Missouri's government to put in place a prescription drug-monitoring program (PDMP), a system used nationwide to flag patients attempting to go to more than one doctor for opioids, known among addiction experts as "doctor shopping.'
Missouri is the only state in the country that does not have a PDMP.
As an entrepreneur — Rehder and her husband own a cable TV and internet contracting company that operates in seven states — she has seen the opioid crisis make running a business harder. "It's difficult finding people who pass drug screens and show up every day," Rehder said.
Yet other than Mallinckrodt, a drug manufacturer, and retailers such as drugstores and grocers with pharmacy businesses — where there is a clear and rational self-interest in being proactive on the addiction issue — no individual companies in Missouri have been supporters of the PDMP campaign. "This has not gotten buy-in from companies around here," Rehder said.
Behind the scenes, big business is paying attention to the opioid addiction epidemic.
Tracy King, vice president of government affairs at The Missouri Chamber of Commerce and Industry, which supports Rehder's legislation on behalf of area companies, said the addiction crisis is driving up the costs for businesses since companies are the predominant payers of private insurance. One recent analysis estimated that the cost to private health insurance plans stemming from opioid addiction rose by more than 3,200 percent in the years 2007 to 2014.
Quality of life for employees and quality of workforce are also big business concerns. "When we go out and talk to members here, which we do all the time, we hear them say, 'We have the jobs; we just can't find the qualified, skilled workers,'" King said. "Part of that is having trained workers come in to run machines, but then many of them can't pass drug screens. ... Part of that is prescription drug abuse," King said.
According to CNBC's 2016 Top States for Business ranking, Missouri does not have much margin for error in these key business attractiveness categories: It finished 49th among U.S. states in both the Quality of Life and Workforce categories.
Nearly two-and-a-half million Americans are addicted to opioids, with 1.9 million addicted to prescription painkillers specifically, according to the most recent National Survey on Drug Use and Health.
Research published by Christopher Jones, PharmD, director of the Division of Science Policy in the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS), looks at the opioid crisis across the 50 states using a classic business concept: supply and demand (see infographic below). The data measures a state's incidence of addiction per each 1,000 residents (the demand) against a state's supply of trained physicians and programs to treat addiction.
Jones' data backs up a complaint he has heard from many state politicians who reference his research. "A common refrain from stakeholders in states like Ohio and Kentucky is, 'We've got jobs but can't fill them.'"
In the vast majority of states, there is more need for addiction treatment than capacity to provide it. "We [HHS] have received communication from members on the Hill to get more funding to the states and work with the states and the National Governors Association among other key external stakeholders interested in closing the gap between treatment need and capacity," Jones said.
Rhode Island has a large number of middle-class, blue-collar residents in professions requiring work with heavy machinery. That work environment can lead to injuries that can be associated with chronic pain, surgeries, prescriptions post-surgery, and once back on the job with machinery, complete a vicious feedback loop, making drug issues more dangerous.
Elinore McCance Katz, chief medical office for Rhode Island's Department of Behavioral Healthcare, Development Disabilities and Hospitals, said the message from Rhode Island Governor Gina Raimondo has been clear: a state's business environment isn't limited to resources like roads and construction. Health care access — the health of a state's population and how it addresses illness in its citizens — impact business decisions. (Before moving to Rhode Island late last year, she was the first-ever Chief Medical Officer for the Substance Abuse and Mental Health Services Administration, part of HHS).
"If you don't get enough of the drug, you go into withdrawal. It's physically painful and anxiety-provoking, and it's also painful for the people in your life, including co-workers," McCance Katz said. "We know employers look at how a state attends to a variety of issues, one being health care and how we treat the most vulnerable. States that do a good job of it will attract more business than states which don't."
Rhode Island finished last in CNBC's 2016 Top States for Business ranking, but its Quality of Life (No. 23) and Workforce (No. 24) are middle of the pack.
By one of the only comprehensive measures available, a majority of U.S. states deserve a failing grade when its comes to fighting drug addiction.
The National Safety Council (NSC), a nonprofit organization that focuses on the prevention of injury and fatalities, recently graded all 50 states on how they are handling the opioid crisis. The NSC outlined six key measures that it believes should be taken by all states to prevent and treat addiction — including implementation of a PDMP.
Twenty-eight states were graded by the NSC as "failing"; 47 states were graded as "needing improvement."
"Employers hold the cards," said Jane Terry, government affairs director at the NSC. "They can say, 'We will only move the plant here if you take this public health epidemic seriously.' Bringing these issues up can help move the needle. There are a lot of opportunities for states to do more," she said.
Only five states met 5 out of the 6 indicators: Vermont, New Mexico, Kentucky, Maine and Tennessee. Vermont and New Mexico are among the states with the highest incidence of heroin deaths. Prescription painkiller addiction can start with a legal prescription, proceed to buying painkillers illegally on the street and end with heroin, which is in many cases a cheaper option. "They've been so hard-hit, they are doing a lot to deal with it," Terry said. An estimated 600,000 Americans are addicted to heroin, according to the most recent national survey.
Vermont is also one of the only states to have enough treatment capacity to handle the percentage of its population suffering from addiction. "Vermont's model is working and getting treatment to people," Jones at the Department of Health and Human Services said.
McCance Katz said Rhode Island is now developing an addiction-treatment model based on Vermont's success.
Three states — Missouri, Michigan and Nebraska — received the lowest grade possible from the NSC.
A spokeswoman for the Nebraska Department of Health and Human Services said the National Safety Council report did not capture any of the initiatives that Nebraska has under way to combat this problem, including prescription drug monitoring, access to the anti-overdose drug Naloxone, and several addiction prevention and treatment-related grants.
Michigan did not respond to a request for comment on NSC's evaluation.
A spokesman for Missouri Gov. Nixon said the state disagrees with many aspects of NSC's evaluation and noted that the governor called for a prescription drug-monitoring program in his most recent State of the State address. He aslo signed legislation expanding access to anti-overdose drug Naloxone.
Rehder herself noted that Gov. Nixon spoke in favor of the PDMP during his annual address but said he has not followed through with executive action or responded to Rehder's direct inquiries to his office. Rehder's frustration with Missouri's failure to enact a PDMP has made her more determined as a legislator. "This is my No.1 priority," she said. "It is too great to ignore."
Standing in her way is Missouri's Republican Sen. Rob Schaaf. Rehder cited Schaaf, who is an M.D., as being the primary reason Missouri remains the only state to not have a PDMP. "I'm not the only legislator opposed," Schaaf told CNBC.
Schaaf's argument, in a nutshell, is that a PDMP is an example of government overreach that infringes on personal liberty and also has the unintended consequence of opening up individual medical records to potential hacking. "This is a government database on which every citizen's private medical data will be placed and thousands of people will have access with a username and password," Schaaf said. He also said it won't have the desired outcome.
"The rate of opioid deaths is going up in spite of PDMPs in 49 states," he said. "Catching the 1 percent of patients who are 'doctor shoppers' through a surveillance database isn't going to materially impact the productivity of the state."
Schaaf said he has always been willing to compromise — by putting the PDMP to a public vote. "They wouldn't allow it to go to a vote of the people," he said. "If you can convince the people they should have it, then you'll get it. Missouri people don't want it."
Rehder said it never went ahead to a public vote because Schaaf would only allow that if he got to choose the ballot language.
Schaaf said physicians do prescribe "far too much narcotics." He has proposed an alternative through which the state's Bureau of Narcotics would have access to opioid prescription information and be able to flag potential abuse instead of allowing 30,000 individuals to have access to this information. Rehder said these 30,000 individuals are physicians and pharmacists bound by HIPAA confidentiality rules and they are only allowed to look at their patients' records, not everyone in the system.
The Missouri Chamber of Commerce and Industry plans to again support the PDMP in the 2017 legislative agenda and to make it a priority early in the session before filibustering in the Senate — a tactic Schaaf and his peers have used to kill it.
King said while he knows of no company that has left Missouri due to its status as the only state in the U.S. without a PDMP, the Chamber is worried about the state's future business attractiveness: "Will the lack of a PDMP deter a company from moving to Missouri when going through a long list of pros and cons when they are doing site selection? Yes, it could be a factor," King said.
"The Missouri Chamber is an entity that is composed of member companies and member companies that want this, like Mallinckrodt. It is no wonder they support it," Schaaf said. "In my view, business thrives best where liberty thrives. The interests of business do not trump the interest of the people."
"We are not doing anything for businesses," Rehder said. "It's just one of the many residuals of this epidemic. ... It's criminal in my opinion to have a proven tool to help, not fix but greatly help this crises, yet turn a blind eye."