by Kate Nicholson; Executive Director and Founder, National Pain Advocacy Center
Featured in the Fall 2023 Colorado Medicine Colorado Medicine.
With opioid pain medication, 59-year-old Kenneth Maestas, a Latino man with quadriplegia, lived a full life. He raised his son as a single father, managed a Walmart store, worked as the legislative policy director for the Colorado Cross Disability Coalition, and contributed to his rural Colorado community.
In August 2019, Kenny wasn’t feeling well and went to the doctor. His regular physician had left the practice, so he saw a new provider. The new provider abruptly stopped Kenny’s opioid medication: Kenny went from taking 30 milligrams of oxycodone three times a day to zero. Kenny fared poorly with the opioid taper. When his breathing became extremely labored, his son called 911. At the hospital, Kenny flatlined. He woke on a ventilator, grateful to be alive, but deeply troubled by the trauma that the results of the medically inappropriate forced taper put his child through.
S.B. 23-144, signed into law by Gov. Polis on May 4, 2023, is designed to protect people like Kenny who have chronic pain and use opioids for pain management.
With the passage of S.B. 23-144, Colorado became one of the first states legally to reverse harm to patients with chronic pain from well-intended policies aimed at reducing addiction and overdose that were too often implemented as one-size-fits-all mandates. Most notably, dosage guidance in the Centers for Disease Control and Prevention’s 2016 prescribing guidelines was widely misapplied in ways that risk patient safety, as the agency has repeatedly acknowledged.
As a result, nearly half of all primary care clinics in the U.S. will refuse to treat a person with chronic pain who takes opioids. A dozen studies show that forced opioid tapering is on the rise and that it actually increases risks of suicide and overdose, in addition to destabilizing people’s health and lives
But you can’t protect patients’ access to care unless you also protect their health care providers. With S.B. 23-144, Colorado became one of the first states to safeguard providers from the threat of unwarranted regulatory oversight.
- Defines chronic pain and explicitly notes that the source of the pain (i.e., whether it stems from cancer or multiple sclerosis) cannot be the basis for interfering with medically necessary treatment including prescribing of scheduled medications.
- Removes the threat of discipline from providers. Prescribers cannot be subjected to oversight for prescribing opioids for chronic pain as long as their records are accurate and the prescribing is for a legitimate medical purpose in the usual course of professional practice. Nor can they be disciplined solely for prescribing at a dosage that exceeds preset morphine milligram equivalents (MME) found in guidelines.
- Promotes clinician discretion and individualized care in decisions about tapering. Health care providers cannot be forced to taper a patient simply to meet a preset MME if the patient is stable and compliant and not experiencing serious harm from their medication.
- Prohibits discrimination at pharmacies and clinics. Pharmacies, carriers and pharmacy benefit managers cannot have policies refusing to fill opioid prescriptions altogether, or prescriptions that deviate from a preset MME. Policies at clinics and health care practices requiring physicians to refuse to prescribe opioids solely on the basis of MMEs are similarly forbidden.
It’s important to remember that the specter of opioids amid an addiction and overdose crisis blamed on prescribing them for pain has had far-reaching implications for patients even when opioids are not prescribed. When Quána Madison, a Black woman with chronic pain following preventive surgeries for cancer, went to a Colorado emergency room for help, for example, she asked the treating nurse to use a smaller gauge needle to draw her blood due to her hypersensitivity to pain. Rather than care for her, the nurse assumed she was exaggerating to seek drugs, and reported Quána to the police.
S.B. 23-144 is intended to restore balance and ensure that all patients with chronic pain receive appropriate care without discrimination. For the law to have an impact, it must be implemented. Providers must feel free to exercise their clinical discretion, treat patients as individuals, and – where appropriate – prescribe opioids for chronic pain.
- Colorado Medical Society website, https://www.cms.org/articles/colorado-leads-in-protecting-pain-patients-and-their-providers
- Dowell et al., No Shortcuts to Safer Prescribing, N Engl J Med 2019; 380:2285-2287, and the 2022 CDC updated guideline, https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w (although the CDC removed arbitrary dosage thresholds from the topline recommendations in its 2022 updated guideline, patients continue to suffer discrimination and harm.
- Colorado Medical Society website, https://cms.org/advocacy/tapering-studies
- Minnesota is the only other state that provides some safeguards to prescribers. https://mnphysicalmedicine.com/2022/08/08/law-change-helps-patients-fighting-chronic-pain-in-minnesota/