Jeffrey A. Singer
Few people noticed—the press didn’t cover it much—but Coloradans in pain and the clinicians who treat them got relief this legislative session when Colorado Governor Jared Polis signed SB 144 into law last May. The bill revised an earlier statute that had placed restrictions on how clinicians treat chronic pain. The new law, which removed those restrictions, went into effect in August.
Like the majority of states, Colorado placed limits on the dosage and amount of opioids clinicians can prescribe to patients in pain, effectively enshrining in law the flawed 2016 Centers for Disease Control and Prevention recommendations for treating pain. Responding to criticism from physicians, pharmacologists, and addiction specialists who argued, among other things, that the CDC’s morphine milligram equivalent conversion tables were junk science, the CDC revised its guideline in 2022. Unfortunately, the revised pain‐prescribing guideline has hardly any more basis in the evidence than the original. And though the agency stressed that it is not intended as a mandate, policymakers will likely interpret it that way.
In SB 144, Colorado lawmakers returned the clinical decision‐making process to clinicians. Lawmakers also recognized the fallacy of using morphine milligram equivalent conversion tables to govern how clinicians treat individual patients. The following are among the bill’s provisions:
A HEALTH-CARE PROVIDER ACTING IN GOOD FAITH AND BASED ON THE NEEDS OF THE PATIENT WITH A DIAGNOSED CONDITION CAUSING CHRONIC PAIN IS NOT SUBJECT TO DISCIPLINE FROM THE REGULATOR SOLELY FOR PRESCRIBING A DOSAGE THAT EQUATES TO AN UPWARD DEVIATION FROM MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATIONS OR FROM THRESHOLDS SPECIFIED IN STATE OR FEDERAL OPIOID PRESCRIBING GUIDELINES OR POLICIES. A HEALTH-CARE PROVIDER TREATING A PATIENT WITH CHRONIC PAIN…SHALL NOT BE REQUIRED TO TAPER A PATIENT’S MEDICATION DOSAGE SOLELY TO MEET A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD IF THE PATIENT IS STABLE AND COMPLIANT WITH THE TREATMENT PLAN AND IS NOT EXPERIENCING SERIOUS HARM FROM THE LEVEL OF MEDICATION CURRENTLY BEING PRESCRIBED OR PREVIOUSLY PRESCRIBED. A DECISION TO TAPER OR MAINTAIN MEDICATION MUST INCLUDE AN INDIVIDUALIZED ASSESSMENT OF THE PATIENT’S CURRENT MEDICAL CONDITION AND TREATMENT PLAN, THE RISKS AND BENEFITS OF MAINTAINING OR TAPERING THE PATIENT’S MEDICATION, AND A DISCUSSION WITH THE PATIENT. A PHARMACY, CARRIER, OR PHARMACY BENEFIT MANAGER SHALL NOT HAVE A POLICY IN PLACE THAT REQUIRES THE PHARMACIST TO REFUSE TO FILL A PRESCRIPTION FOR AN OPIATE ISSUED BY A HEALTH-CARE PROVIDER WITH THE AUTHORITY TO PRESCRIBE OPIATES SOLELY BECAUSE THE PRESCRIPTION IS FOR AN OPIATE OR BECAUSE THE PRESCRIPTION ORDER EXCEEDS A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD. A HEALTH-CARE PRACTICE OR CLINIC IN WHICH A HEALTH-CARE PROVIDER IS AUTHORIZED TO PRESCRIBE…SHALL NOT HAVE A POLICY IN PLACE THAT REQUIRES THE HEALTH-CARE PROVIDER TO REFUSE TO PRESCRIBE, ADMINISTER, OR DISPENSE A PRESCRIPTION FOR AN OPIATE SOLELY BECAUSE THE PRESCRIPTION EXCEEDS A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD.
While I appreciate and agree with the spirit behind the last two provisions, I don’t think lawmakers should mandate what policies private clinics, pharmacies, or pharmacy benefit managers choose to institute. However, Colorado’s lawmakers and governor deserve credit for unshackling clinicians who are trying to help their patients who are in pain and for tacitly repudiating morphine milligram equivalent junk science.
SB 144 should improve patients’ access to pain management. It isn’t the only step Colorado has taken this session to increase access to care. Earlier this year, Governor Polis signed into law HB 1071, making Colorado the sixth state to expand access to mental health care by removing barriers to psychologists prescribing.
Colorado’s lawmakers and governor deserve praise for these reforms.
