SB 23-144: Addressing Prescription Drugs for Chronic Pain Patients
Physicians all take an oath to do no harm. Most get into this work to help people. Pain is the largest driver of disability worldwide. It impairs the ability of people to engage in work, play, and community. Sometimes the root cause of the pain can be addressed or eliminated but for many it cannot. At that point, treating the pain becomes the remedy with the goal of improving patient function. Degrees of improvement will vary but enabling people to function well enough to engage in daily life is always a good goal.
While there are many ways of treating pain, some people require opioids. Risks related to taking people who have used opioids for pain – in many cases for decades -off of this therapy, are now well documented. Both abrupt discontinuation and forced tapering are harmful.
SB 23-144 is one of the first bills in the country to give providers protection regarding prescribing opioids for chronic pain. SB 123-144 was crafted by a coalition of chronic pain patients, including people with disabilities and older adults, and medical professionals. It has been widely acknowledged that policies implemented in response to the opioid epidemic went too far and caused harm to pain patients. The CDC has rescinded and replaced the 2016 guidance on which so much opioid related policy was created. The state Department of Health Care Policy and Financing has even created a position to give providers resources and consultation so they can safely prescribe opioids for patients in need.
Opioids can be useful for chronic pain even for non-cancer pain. There are patients with a variety of pain conditions that do well on long-term opioids. There are also patients who have pain who are not helped by opioids. Like everything else in medicine, an individual assessment is necessary along with regular evaluation to assess the efficacy of the treatment. We urge providers to consider functional improvement, not only the complete absence of pain. Functional improvement may mean that a pain patient is able to get up and engage with their family 3 hours a day on most days instead of staying in bed all day every day. Alternatively, it may mean that the patient is able to hold down a full-time job. The point is to ascertain if the patient is doing better with the medication than without it. As is true for all medications, side effects should be considered. As you well know, any medication can have side effects. The fact that a medication is not an opioid should not be the sole determinant of success. The narratives that opioids are never a good idea, that opioids cause people to be in more pain due to disrupted pain sensors, or that taking opioids as prescribed to manage physical pain is highly likely to lead to abuse and addiction have proven false and dangerous. In fact, forced tapering, refusal to prescribe when necessary, and having one size fits all pain management programs are much more damaging to patients and lead to declines in functioning, poor health outcomes, overdose, unauthorized use (because people just need the pain to stop), mental health problems and even suicide.
The issue of how much to prescribe is also important and the law protects providers by saying that you cannot be told how much you can prescribe or held to specific limits by your employers. You get to use your clinical judgment. MME limits came from the false narratives described above and are not evidence-based. One person may need 120 or more MME and function well while another person with a similar diagnosis may do well at 60 or less MME and yet another does best on a non-opioid alternative. As you know, people’s bodies are different and chronic pain is complicated.
What pain patients desperately need is doctors to treat us. When a patient calls and says they need a certain dose of opioids, we understand the environment has made you suspicious. We hope this signal from the legislature will give you the comfort to be able to listen to what they are trying to communicate. This does not mean you have to do exactly what they ask; you are the prescriber. But please engage in a discussion with the patient about why they are making such a request? Did this amount work for them in the past? If so, when they had it what was different about their function? When patients have something that allows them to live a full life, and then have it taken away causing loss of function, they desperately try to get back what worked so they can reclaim their lives. They start calling people, perhaps sounding demanding, insistent. Please look at it from their perspective. Engage in discussion. Negotiate. Maybe there is a compromise. Most patients do not want an argument. They want a provider with whom they can have a relationship. It is hard to be rational when one is in intractable pain. Perhaps one short term solution is to address the severe pain so more productive conversation can follow. When one is out of severe pain and can think clearly, one can have a more rational discussion about a long-term strategy. Engaging in this dialogue does not mean you MUST prescribe any specific medication or dose. That is always up to you as the physician. The goal here is to ascertain if returning them to a previous dose, or any other proposed solution, will provide benefits that likely outweigh the risks. There is no one right answer because pain is complicated. This kind of assessment can only be done with real conversation and through building a relationship with the patient. Sometimes there is trial and error involved.
Our hope in passing SB 23-144 was to make sure that providers could use their significant skills to make individualized assessments of each patient to treat chronic pain. When the recommendation is opioids, short or long term, at whatever MME level is appropriate, you now can prescribe this. You are now protected from others telling you “No” due to a one size fits all policy. Patients desperately need you. You entered this field to alleviate suffering and cure illness. Some illnesses or injuries cannot be cured, and then the job is to mitigate or manage symptoms. For some people this requires prescribing medication that alleviates pain. For all people it requires a conversation and engagement with the patient.
By Julie Reiskin, LCSW, Co-Executive Director, Colorado Cross-Disability Coalition