Pain patients hope new Arizona opioid prescribing law will improve their lives

Christina van Waasbergen
Arizona Republic
Advocates of the new law's exception say Arizona's 2018 opioid law has made many health care providers hesitant to prescribe opioid pain medication for fear they will get in trouble.

Some patients say they haven’t been able to get the medication they need as a result of Arizona’s 2018 opioid law. A new law creates an exception for certain patients with chronic pain.

Senate Bill 1162, signed April 13 by Gov. Doug Ducey, creates an exception to Arizona’s opioid daily dose limit for patients with “chronic intractable pain,” which it defines as pain that “is excruciating, constant, incurable and of such severity that it dominates virtually every conscious moment” and “produces mental and physical debilitation.”

Advocates of the law say Arizona's 2018 opioid law has made many health care providers hesitant to prescribe opioid pain medication for fear they will get in trouble. As a result, advocates say, some chronic pain patients haven't been able to get the medication they need.

Ideally, advocates of the new law say, Arizona doctors will be more comfortable prescribing opioids to certain patients suffering from severe, chronic pain. However, it's unclear whether that will happen once the law takes effect.

'They were able to live, work and enjoy life. But now they are in excruciating pain.'

The Arizona Opioid Epidemic Act, signed by Ducey on Jan. 26, 2018, was created to combat the opioid abuse epidemic.

It prohibits health professionals who aren’t physicians board-certified in pain from writing new outpatient prescriptions of opioid medications at a daily dose higher than 90 morphine milligram equivalents. MME is a measure that represents the equivalent amount of morphine to the opioid dose.

SB 1162’s sponsor, Sen. Nancy Barto, R-Phoenix, told The Arizona Republic in an email she decided to sponsor the bill after hearing from constituents who previously were able to function on high doses of opioids but are no longer able to access their medication under the 2018 law.

“They were able to live, work and enjoy life,” Barto said. “But now they are in excruciating pain and disabled.”

Under the 2018 law, health professionals who aren’t physicians board-certified in pain but want to prescribe more than 90 MME are required to consult with either a physician board-certified in pain or the Arizona Department of Health Services' opioid assistance and referral call service, who must agree that a higher dose is necessary.

The law already included some exceptions to the consultation requirement, such as for cancer patients and patients with preexisting prescriptions above 90 MME.

Will Humble, executive director of the Arizona Public Health Association, who signed on in support of SB 1162, said the consultation requirement is unnecessarily cumbersome.

In an April 26, 2018, statement, Dr. Cara Christ, then-director of the Arizona Department of Health Services, said that the new prescribing regulations were not intended to punish current chronic pain patients already receiving opioid medication. 

"There is no legislation requiring providers to reduce opioid doses or stop prescriptions; medical management is left to the discretion of the provider," she said at the time.

But Gold Canyon resident Barby Ingle, a chronic pain patient and president of the International Pain Foundation, who testified in support of SB 1162, told The Republic an unintended consequence of the 2018 law has been that some pain patients haven’t been able to get the medication they need.

Some doctors have become afraid to prescribe opioids for fear they will get in legal trouble, which is is why the new law is necessary, she said.

'I think among some prescribing physicians there was an overreaction'

Dr. Ross Goldberg, immediate past president of the Arizona Medical Association, told The Republic that because of some instances where physicians have gotten in trouble for prescribing opioids, many physicians are no longer prescribing opioids and are instead sending their patients to pain management specialists.

"There is concern, if you're not a chronic pain doctor and you're writing for a fair amount of opioids, that you can find your license or your practice in trouble," Goldberg said.

This has resulted in a backlog of patients trying to see pain specialists, he said.

Humble similarly said he has heard anecdotally that some health care providers have stopped prescribing opioids because of the 2018 law.

“What the law says and what actually happens in practice can be two different things,” Humble said. “And I think among some prescribing physicians there was an overreaction.”

Both Humble and Goldberg say they don't know if the new law will make health care providers more likely to prescribe opioids to chronic pain patients.

Ingle said she hopes the new law will make health professionals feel more comfortable prescribing opioids to chronic pain patients. However, she said this is only a first step and that more legislation is needed.

“I know that there is bad actors out there and I believe that the bad actors should be stopped,” Ingle said. “But the patients that need access to care shouldn't be penalized for the people who are doing it illegally.”

The 2018 law reflects opioid prescribing guidelines released in 2016 by the Centers for Disease Control and Prevention. The guidelines instruct health care providers treating chronic pain patients to start by prescribing the lowest effective dose of opioids and to avoid increasing or carefully justify a decision to increase an opioid dosage to 90 MME per day or more.

In 2019, the CDC warned that its opioid guidelines were being incorrectly applied.

“Policies that mandate hard limits conflict with the guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient,” the statement said.

A draft of the CDC's updated 2022 opioid prescribing guidelines does not include the 90 MME per day limit.

'We are not criminals; we are patients'

Rep. Walt Blackman, R-Snowflake, one of five representatives who voted against SB 1162, said when voting against it that he was concerned it could lead to more issues with opioid abuse.

But Humble said the law has sufficient guardrails in place to prevent opioid abuse.

An amendment added by Rep. Joanne Osborne, R-Goodyear, the Arizona House Health and Human Services Committee chair, says the chronic intractable pain exception only applies when there’s an established health professional-patient relationship, which it defines as when a patient has physically presented to the health professional with a complaint and the health professional has taken the patient’s history and done a physical examination.

The amendment requires that the patient has tried doses of less than 90 MME that have been ineffective at addressing their pain.

That, combined with SB 1162’s specific definition of chronic intractable pain, is sufficient to keep the law from leading to opioid abuse, Humble said.

Phoenix resident Penelope Zahn, who has Arnold-Chiari malformation, a condition where brain tissue extends into the spinal canal, testified March 21 before the state's House Health and Human Services Committee in support of SB 1162. She told the committee she was forced to go off of her pain medication as a result of the CDC guidelines and the Arizona opioid law.

Zahn testified that her primary care doctor recently told her she needed to accept that no physician would prescribe her the medication she’d been taking.

“It is to the point that the only options I’m given is illicit drugs, suicide or just curl up in a ball and die,” Zahn said.

Prior to this, Zahn said her pain had been controlled through medication for 16 and a half years, and she’d been six months away from getting a master’s degree in criminal justice.

“We are not criminals; we are patients,” Zahn said. “We no longer have a say in our medical care.”

Zahn told The Republic her neurologist has told her he has to send her to a pain management specialist to get the prescription she needs, but she said pain management specialists don’t understand her condition.

"(My neurologist) says, ‘I’ve failed you. I’ve failed you. I’ve failed you because I’m unable to write your medication that you need,’” Zahn said. “Now, with the passage of (SB 1162) … he will be able to do that."