Treating Pain With Truth – now an online “textbook”

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You’ve seen the blog post… now read the book!

Having received such positive feedback on my blog post Treating Pain With Truth -a collection of essays about treating chronic pain from my website Confluential Truth– I have now compiled the pieces in one convenient place – my dropbox.

So for now, anyone wishing to view or download the entire “virtual textbook” can do so by going to this link:

https://www.dropbox.com/s/an3cfvtnlbl6vj2/TREATING%20PAIN%20WITH%C2%A0TRUTH%204.17.15.pdf?dl=0

I am happy with how it turned out and appreciate all the support and advice I have received from my “editorial board.”

Treating Pain With Truth is still, and perhaps always will be, a work in progress.  Please leave comments, share ideas and offer suggestions on edits and future topics. After all, treating pain with truth is never a destination…always a journey. Together, maybe we can avoid the rocks…

beach rocksJames Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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Treating Pain With Truth

Then you will know the truth, and the truth will set you free.
~ John 8:32 (NIV)

…Pain free?

Confluential Truth blog posts address various issues, and many share a healthcare theme. Often the focus is on chronic pain. The following collection of Confluential Truth offers my views on how chronic pain may be effectively and safely treated, especially when the treatment involves controlled substances. Each essay is like a chapter in a mini-textbook about treating chronic pain. They are offered here hoping to provide insight into improving quality of life for pain sufferers and pain care providers.

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PROLOGUE:  The Algiatrist – To set the tone, a poem about treating pain and being “useful.”

INTRO ALGIATRIST http://jamespmurphymd.com/2013/11/22/the-algiatrist

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CHAPTER ONE:  The Dream of Pain Care – A transcript of my address to the physicians and staff of Norton Healthcare – the what, why & how. If you only have time to read one essay, this is the one.

1 wolfe http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture

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CHAPTER TWO:  Pathway to Partnership, Part 1 (KY) – Here is how we do it in Kentucky when we do it right.2 ky path  http://jamespmurphymd.com/2015/02/13/pathway-to-partnership

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CHAPTER THREE:  Pathway to Partnership, Part 2 (IN) – Here is how we do it in Indiana when we do it right.

3 ind pathhttp://jamespmurphymd.com/2015/03/29/pathway-to-partnership-part-ii-in

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CHAPTER FOUR:  Are We In Agreement? – Expectations, edification and enlightenment result from properly implemented patient-physician “agreements.”

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http://jamespmurphymd.com/2014/02/19/are-we-in-agreement

 

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CHAPTER FIVE:  Treating Pain Patients Like Addicts – There is ample overlap between optimal treatment for addiction and optimal treatment for chronic pain. Utilizing this knowledge can enhance the effectiveness and mitigate the risks inherent to treating chronic pain with controlled substances.5 tx like addicts http://jamespmurphymd.com/2014/11/21/treating-pain-patients-like-addicts

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CHAPTER SIX:  Basic Pain Care Certification – It’s a sad fact the number of deaths associated with drug overdose is roughly equivalent to the number of motor vehicle fatalities. Imagine how many might die on our roads if, instead of a driver’s license, all you needed to drive a car was a prescription from a doctor. Now, imagine how many less might die of drug overdose if you had earn a “license” to use controlled substances…

4.5 pain care certhttp://jamespmurphymd.com/2014/08/06/basic-pain-care-certification

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CHAPTER SEVEN:  Strength in Numbers – Successful chronic pain treatment involves: (a) medical care; (b) counseling; and (c) a support system. Find all three and you have probably found…

6 str in num http://jamespmurphymd.com/2014/07/02/strength-in-numbers

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CHAPTER EIGHT:  It’s Only Words – Over the years I have given many presentations concerning medication management for chronic pain. Often I have said that if there is only one concept I want the group to take away it’s that “addiction” and “physical dependence” are not the same thing.

8 words http://jamespmurphymd.com/2014/04/03/its-only-words

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CHAPTER NINE:  Talking Trash – We spend much time worrying about the acquisition of pain medications but too often don’t know what to do with them when we are done.

7 talk trash     http://jamespmurphymd.com/2014/07/21/talking-trash

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CHAPTER TEN:  Is There Method To This March Madness? – Too often our focus is on a specific drug, when in reality the culprit is the disease.

9 march madnesshttp://jamespmurphymd.com/2014/03/18/is-there-method-to-this-march-madness

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EPILOGUE:  Proclaim Pain Care Providers Day! – Don’t just provide great pain care… Proclaim it!

10 PCPD http://jamespmurphymd.com/2015/01/22/proclaim-pain-care-providers-day

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James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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Pathway to Partnership, Part II (IN)

THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATONS

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No man is an island,
Entire of itself,
Every man is a piece of the continent,
A part of the main.

– John Donne

The poet, John Donne, knew it. Every Hoosier pain patient and Hoosier pain care provider should take it to heart. No patient or provider is an island. And pain care is best when there is a partnership between the patient and provider.

The Pathway to Partnership

If you are treated for pain in the Hoosier State the pathway to partnership with your physician passes through Indiana’s pain regulations.

Indiana’s entire southern border is Kentucky. And when it comes to patient responsibilities, Kentucky’s pain regulations have much in common with Indiana’s. Therefore, Hoosier patients can begin preparation for their Indiana chronic pain care evaluation by reading my article: Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations.

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Available at: http://jamespmurphymd.com/2015/02/13/pathway-to-partnership

Particular to Indiana is the Hoosier state’s emphasis on medication dosing limits that trigger mandatory compliance with the regulations. Calculating these dosing limits can be quite confusing and, frankly, patients are not responsible for knowing them. Prescribers are. But to be a good “partner” with your prescriber, you should at least become familiar with these dosing limits. Later in this article I will summarize.

But first, in order to hold up your end of the partnership, here are ten items you can prepare:

  1. Your past medical history
  2. Your pertinent medical records
  3. An accurate medication list
  4. Any substance abuse history
  5. Your social and family history
  6. Any other medical issues
  7. Educate yourself for proper informed consent
  8. Your current level of function
  9. Your treatment goals
  10. Complete questionnaires & mental health screens

These ten items are discussed in detail in Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations.

Prepare as described above you will be well on your way to becoming a great partner in your care. As your partnership continues, expect to have contact with your physician on a regular basis and even randomly to:

      1. Review your progress with your treatment plan;
      2. Review the goals of your plan; and
      3. Review expectations (i.e. attending therapy, counseling, tests, etc.)

Insider Information
As a partner, you are entitled to some “insider” information. Here it is…

A new section of Indiana’s regulations contain a lengthy explanation of what prescribers must consider when ordering drug screens. By doing so, this section offers insight into appropriate patient behavior. The following list, summarized from the regulations, offers an insider’s look at what Indiana expects of a pain patient:

In determining whether a drug monitoring test…is medically necessary, the physician shall consider” if the patient has:

      • Taken the meds as prescribed?
      • Taken more meds than allowed?
      • Given or sold meds to anyone?
      • Benefitted from the meds?
      • Taken any other drugs – legal or illegal?
      • Been honest and up front about past drug use?
      • Tried to get early refills?
      • Lost meds? Had them stolen?
      • Had an abnormal INSPECT state prescription report?
      • Failed a drug screen?
      • Been intoxicated?
      • Been acting aggressive, depressed, anxious, etc.?
      • Been diagnosed with a psychiatric condition?
      • Demanded certain specific meds?
      • Had a major illness? Pregnancy? Hospitalization?
      • Been resistant to any changes in the care plan?
      • Refused or failed to follow through with exams/tests?
      • Just not done well overall?

Bottom line: Be honest, up front and “transparent.” No one likes surprises. A good partnership is all about trust and communication. Understand what your treatment agreement says and live up to it.

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Dosing Limits

Now, about those dosing limits… As I said, it can be confusing, but you should try to understand the concepts and discuss them with your prescriber.

Not all pain prescriptions are subject to the Indiana regulations. Therefore, it is important to understand the dosing limits that trigger mandatory compliance. These limits are dependent upon: (1) the dose, (2) the quantity and (3) the duration.

The Morphine Equivalent Dose (“MED”) is basically how strong your medication would be if it were to be substituted for morphine. This is very important to INDIANA regulatory agencies. I highly recommend you learn how to calculate your MED.

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Calculating the MED

Step ONE: Calculate the MED for one pill

Determine the dose of morphine that would be equal to one of your pills using a standard conversion table (For example: a FIVE mgm hydrocodone pill is the same as a FIVE mgm morphine pill; but a FIVE mgm oxycodone pill would be the same as a 7.5 mgm morphine pill). Indiana officials recommend this website for help with making this determination: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm

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Step TWO: Calculate your DAILY MED

Once you have converted your pill to its “morphine equivalent,” simply add up the maximum number of pills your prescription allows you to take in a day and multiply this number by the morphine equivalent (MED) you determined in step one.

(Number of pills per day) x MED/one pill = Daily MED

For example: Since a FIVE mgm hydrocodone pill is equal to a FIVE mgm morphine pill, the daily MED of someone taking THREE of these hydrocodone pills per day would be:

5 mgm x 3 pills per day = 15 mgm MED

Here are some common ORALLY prescribed opioids that compare to a MED of 15:

Hydrocodone (oral) 15 mgm/day = 15 mgm of morphine (oral)
Oxycodone(oral) 10 mgm/day = 15 mgm of morphine (oral)
Oxymorphone (oral) 5 mgm/day = 15 mgm of morphine (oral)
Codeine (oral) mgm/day = 15 mgm of morphine (oral)
Hydromorphone (oral) 3.75 mgm/day = 15 mgm of morphine (oral)
Tramaldol (oral) 150 = 15 mgm of morphine (oral)

Note: MED greater than SIXTY

If you are on a treatment regimen with a morphine equivalent dose of more than SIXTY (60) MED, the physician may require you to have an evaluation by a specialist. According to the regulations, your physician must explain to you that there is an increased risk of adverse outcomes, including death, when your daily MED is greater than SIXTY.

So now that you understand the MED, you are ready to look at the DOSING LIMITS that trigger compliance with the regulations.

DOSE, QUANTITY & DURATION

When any of the following conditions are met, your physician (and you) must comply with the Indiana pain regulations.

      1. DOSE & DURATION >15 MED for >3 months

DAILY MED greater than FIFTEEN for DURATION of more than three consecutive months

Or…

      1. QUANTITY & DURATION >60 pills for >3 months

More than SIXTY opioid pills per month for DURATION of more than THREE consecutive months

Or…

      1. PATCHES > 3 months

Any opioid skin patches (e.g., fentanyl or buprenorphine), regardless of the dose or quantity, for DURATION of more than THREE consecutive months

Or…

      1. Hydrocodone-Only Extended Release

Any hydrocodone-only extended release medication that is NOT in an “abuse deterrent” form, regardless of the DOSE, QUANTITY or DURATION

Or…

      1. TRAMADOL (My advice) >150 mgm for >3 months

Actual language in the regulations state: “If the patient’s tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months.” This tramadol dose limit seems to be overly generous when compared to other MED dosing limits.

A SIXTY (60) MGM MED of tramadol is in the range of 300 to 600 mgm of tramadol. Considering that the maximum therapeutic dose for tramadol is only 400 mgm per day, one could potentially exceed the safe upper limit of tramadol and still not exceed Indiana’s dosing limit. This seems to be inconsistent with the regulation’s other opioid dosing limits.

My advice: Since 150 mgm of tramadol is equivalent to a FIFTEEN (15) MED, I believe it is more consistent with the other Indiana opioid dosage limits to consider TRAMADOL greater than 150 mgm/day for more than THREE consecutive months as the dosage limit congruent with other opioid dosage limits.

Reference: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm

Wait!!! There are EXEMPTIONS !!!

Regardless of the dose, quantity or duration, the Indiana pain regulations do not apply to these patients:

(1) With a terminal condition
(2) Residing in a licensed health facility
(3) Enrolled in a licensed hospice program
(4) Enrolled in a licensed palliative care program

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In summary, patients and physicians should travel the pathway to partnership together. Patients can do their part by (1) preparing for the clinical visits, (2) understanding and adhering to their treatment agreements, and (3) educating themselves about risks, side-effects, and legal aspects of their care.

It is a real challenge to treat chronic pain in this day and age. Your physician needs your help. Will you leave it all up to your physician? Or will you be a good partner, heeding the words of the poet Donne

And therefore never send to know
For whom the bell tolls;
It tolls for thee.

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James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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References and links pertaining to this article are provided in the comments.

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This unofficial summary is my personal opinion. A full, official version of the final rule should be consulted for compliance purposes at: http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html

The Indian State Medical Association also has a summary available at: http://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf

no harm

And if you really want to explore the Indiana pain regulations in detail, there is no better source than the online guide: First Do No Harm, The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain.

http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf

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Hey Hoosier! Who’s your partner?

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Pathway to Partnership, Part I (KY)

THE CHRONIC PAIN PATIENT’S GUIDE
TO KENTUCKY’S REGULATIONS
pathway rainbow

Even though I’m on the lowest dose possible to keep my chronic pain under control I still worry this too will be taken away. At each appointment I get scared I will be told my doctor can no longer prescribe what little medication I do get. I appreciate the pain relief I do get, it means more to me than people can imagine.
~Samuel
October 1, 2014 at 7:47 PM

People with pain must recognize that they have a role to play in making sure these medications remain available, as needed, to all.
~Steven D. Passik, PhD

Abstract: This is a summary of how chronic pain patients can effectively prepare for a productive and meaningful visit with their Kentucky physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that patients and physicians will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.

karen neck

Pain is the most common reason patients see physicians. We all feel pain, but everyone experiences pain in a unique way. There are many ways to treat pain, but treatment is best when tailored to the needs of the individual. Sometimes adequate pain treatment requires drugs (i.e. “controlled substances”) that expose users to risks of addictions, abuse and misuse. In these cases, patients and physicians must work together to minimize these risks.

It has been estimated that in the U.S. there is only one pain specialist for every 26,000 patients with chronic pain. Thus the majority of chronic pain treatment remains in the hands of primary care physicians.

Treating chronic pain can be straightforward when the primary focus is providing relief. But inescapable concerns about potential drug abuse and regulatory scrutiny can make treating chronic pain very complex and stressful for patients and physicians.

Most states have specific prescribing regulations that sometimes are inadequately communicated and poorly understood. This contributes to physician anxiety and adds to the physicians’ clinical, legal, and administrative burdens.

The patient-physician relationship must be a true partnership based on respect, trust, honesty, and clear communication. The following is a summary of what patients can do to help their physician partners.

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The Chronic Pain Patient’s Guide to Kentucky’s Regulations

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General Recommendations:

  1. Prepare answers to some basic medical history questions.
  2. Obtain copies of pertinent documents and medical records.
  3. Make a list of your healthcare providers along with their contact information.
  4. You may wish to store the data on a flash drive, CD/DVD or upload to a secure website for retrieval by your physician. Be advised, until you give these documents to your physician you are responsible for keeping them private.
  5. Bring a friend or family member with you for support, assistance with questions, and to help verify information.

For the initial visit prepare the following:

  1. Medical history
  2. Medical records
  3. Medications
  4. Substance use
  5. Social and family history
  6. Other medical issues
  7. Education and consent
  8. Ability to function
  9. Goals
  10. Questionnaires / mental health screen
    1. Medical history. 

It begins with your “Chief Complaint.” This is where you tell your physician what hurts.

Chief complaint: My pain is _______________________
For example: “My pain is in my low back.”

Next, fill in some DETAILS about your pain:
(i) Cause. Based on what you know about your condition, what do you think is causing your pain?
Examples: a bad disk / pinched nerve / arthritis, etc. Be as specific as you can.
(ii) Location. Where does it start? Where does it go?
(iii) Quality. Sharp? Aching? Electrical? Sensitive to touch?
(iv) Symptoms. Numbness? Tingling? Weakness? Muscle wasting? Skin color changes? Swelling?
(v) Timing. Started when? Is it constant? Variable? Worse at certain times of the day? Lasts how long?
(vi) Aggravating factors. What makes it worse? Bending? Standing? Twisting? Being anxious? Working?
Housework? Sleep?
(vii) Relieving factors. What makes it better? Resting? Heat? Ice? Massage? Medication? Injections? Being
distracted? Sleep?
(viii) Pain scale. Rate your pain on a scale from: ZERO (no pain) to TEN (worst pain imaginable).

  1. Medical records.

Your physician may not need every record, but information about care related to your pain is useful and includes:

  • Surgery reports related to your pain (back surgeries, etc.);
  • Laboratory tests (blood tests, urine drug screens, etc.);
  • Studies (x-rays, MRI, CT, EMG, etc.);
  • Pain care treatments (epidurals, physical therapy, acupuncture, chiropractic, etc.);
  • Consultations with specialists (surgeons, pain, chiropractic, mental health).

Make a list of your diagnostic tests, especially the most recent ones; include dates and contact information. Gather the reports. If you wait for your physician to get the reports faxed, your pain care could be delayed significantly. You may want to copy them onto a flash drive, CD/DVD, or to a secure website.

  1. Medications.

(a) An accurate and current medication list is extremely important. Include the date, dosage, quantity, and directions. Bring the medicine bottles with you and/or labels, written prescriptions, etc.

Provide answers to these questions:

  • Do you find your current medications to be effective?
  • Are you taking them the way they have been prescribed for you?
  • How long have you been on your current medications?
  • When was the last time you had a medication change?
  • Are they causing you any unacceptable side effects such as: sedation, fatigue, nausea, constipation, etc.?

(b) Your medication “journey.” It is extremely important for your physician to know (and document) how you got to this point. What medications did you use in the past? Did you try some over-the-counter medications? Non-controlled substance prescriptions? Gather records (medical, pharmacy, etc.) to show how your dosages have changed over time.

(c) If you have a prescribing “agreement” with another physician, bring a copy.

  1. Substance use.

It is vital to be forthcoming about any substance abuse or any substance abuse treatment involving you or any close relative (especially a mother, father, son or daughter). And report any drug-related arrests?

Do you drink alcohol? Do you smoke?

Remember to drink plenty of fluids before your visit in case you are asked to provide a specimen for a random urine drug screen.

  1. Social and family history.

Where do you live and with whom?
Is your home life a challenge?
What is your occupation? Are you disabled?
Where do you get money to live on?
How much formal education have you had?

  1. Other medical issues.

Are you dealing with any other medical issues such as: diabetes, heart disease, cancer, etc.? When was your last general medical evaluation?

Note: To receive long-term controlled substances for pain in Kentucky, it is mandatory that you have a yearly preventive health evaluation.

  1. Education and consent.

Show that you have educated yourself about controlled substances and prepare to document your “informed consent.”

(a) The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website.

I have prepared an educational summary for both Kentucky and Indiana which is available here: http://goo.gl/IJ4I1l

Or download the Murphy Pain Center New Patient Package. Study the patient education sheet. Print it out. Sign it. And bring it with you.

Watch this outstanding video by Dr. Mike Evans that explains many of the pros and cons of the use of controlled substances for chronic pain care.

(b) Once you have been informed, you are ready to give your “informed consent.” You may download this document and bring it to your physician:

I have written an article about informed consent and treatment agreements, Are We In Agreement, available on my website: Confluential Truth.

  1. Ability to function.

Describe your current ability to participate in life’s activities. This will give your physician a baseline from which to judge your progress. You may visit the website for ICSI (Institute for Clinical Systems Improvement) and download and complete the form in Appendix C: Physical Functional Ability Questionnaire (FAQ-5).

  1. Goals.

Come up with some specific and realistic goals that might be attainable. Think of how you can show when you have achieved them. Within reason, think about what you would like to do that you cannot do now. Be prepared to demonstrate this to the physician; i.e. walk without a cane, bend to pick up something, rise from a chair unassisted.

Set goals that are SMART: specific, measurable, attainable, realistic, and track-able.

  1. Questionnaires / Mental Health Screen

Complete these “screening” questionnaires and bring them to your visit.

You may go to the Kentucky Board of Medical Licensure website, download these self-report questionnaires, fill them out, and bring them to your office visit.

  • Opioid Risk Tool
  • Patient Health Questionnaire (PHQ-9), mental health screen

You may also go to the website for ICSI (Institute for Clinical Systems Improvement) and download and complete these two forms:

Appendix A (Brief Pain Inventory); and
Appendix B (Patient Health Questionnaire PHQ-9)

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If this all seems a bit overwhelming, you can begin to simplify matters by visiting the Murphy Pain Center website and downloading the “New Patient Package.” In it you will find policies, consent forms, agreements, educational materials, and a “New Patient Evaluation” form. These are the kinds of materials you will likely be filling out at your physician’s office visit. Having this information on hand can make your visit more productive.

In conclusion: Due to growing concerns about drug abuse, coupled with layer upon layer of regulations, physicians are becoming increasingly anxious about prescribing controlled substances for patients suffering in chronic pain.

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This has been a summary of how a chronic pain patient can effectively prepare for a productive and meaningful visit with his or her physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that both parties will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.

When patients are adequately prepared, physicians can feel more comfortable, and patients can more likely receive safe, effective, and proper pain care.

It is a partnership.

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Note: For the purposes of this summary “controlled substances” refers to CSA scheduled drugs 2 – 4 (Schedule 5 drugs are exempt from Kentucky’s regulations).

Note: Kentucky’s regulations do not apply if the patient is being treated:

(a) in hospice or “end-of-life” treatment;
(c) for cancer pain or pain associated with the treatment of cancer;
(b) in a licensed hospital as inpatient, outpatient, or observation status
(d) as a registered resident of a long-term-care facility
(e) during a disaster or mass casualty situation
(f) as a single dose for a diagnostic test or procedure

So now that you know the pathway…

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James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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References and links pertaining to this article are provided in the comments.

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Let them see CAKE

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A Pain/Addiction specialist’s review of the movie CAKE

January 24, 2015

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I saw the movie CAKE tonight. I felt it was my duty. I am, after all, a pain specialist.

I’d read that it was gritty, honest, and accurate, and that Jennifer Aniston was very convincing. I found all that to be true.

It’s the show’s first weekend in Louisville theatres, and the crowd at this 5:30 pm showing was decidedly mature, reverently attentive, and noticeably equipped with more walkers and canes than I’m accustomed to seeing at the cinemas. I almost felt like I was in a pain support group. Perhaps in a way, I was.

I went in expecting to not like the movie. And if it had been a movie just about chronic pain, then I might not have been won over. However, CAKE is not so much a story about chronic pain as it is a story about dealing with loss.

Claire, played by Ms. Aniston, initially comes across as an angry, bitchy, sarcastic, and self-centered woman, who clearly has legitimate pain and the scars to prove it. But as the story unfolds and it is gradually revealed to us the degree to which Claire’s life has been altered by tragedy, a sad empathy takes root.

It’s not that Claire doesn’t have people in her life who care about her. On the contrary, is seems that everyone in her life is trying to help her. In fact, I wouldn’t say there is a real villain in the story. Claire is struggling to climb a mountain. And we, like the people in Claire’s life, feel powerless to help. So we just watch, hoping she can hang on and have some sort of epiphany.

Where the movie begins, Claire is several months removed from the tragic event that caused her life-changing pain and loss. She is clearly living the chronic pain existence: from her pleasant but over-booked doctor, to the impersonal waiting rooms where she winces as her number is called instead of her name, to the group therapy from which she is “fired,” to her continuous pre-occupation with obtaining pain pills – often times via demeaning and risky methods.

As a pain physician, I felt myself wanting to treat her – wanting to provide for her a regimen that was not insulting, dehumanizing, or uncaring. And I hope all health care providers who see this movie are moved in such a way that they see their patients as people who, more than pain, are grieving over what they have lost: autonomy, freedom, happiness, self.

And despite the script’s inclusion of so many themes common in the lives of patients with chronic pain, I hope that those people in the audience who were there with their canes and walkers understand that this movie is only about one person’s journey – not theirs. We all suffer loss. We all have pain. We all have a journey. And the journey is specific to the individual. There are no villains, but there are mountains to climb.

I thought CAKE was a very good movie for general audiences -and a great movie for pain patients and pain care providers. My advice: just make sure you allow yourself some time to process it afterwards. Then you might find it really was a pain support group after all.

James Patrick Murphy, MD

 

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Proclaim Pain Care Providers Day!

pcpd at courthouse

Another headline today. Another physician indicted. I read the phrase “faces life imprisonment” and it pierces my suddenly fragile psyche like a spinal needle. My resolve threatens to hemorrhage, figuratively but painfully, leaving me wondering why I do this. Why do I treat chronic pain?

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I’ve seen headlines like this too often. But I know the doctor in the headline this time. We work in the same hospital. And though I do not know details, I know him to be a solo practitioner willing to embrace suffering people, many of whom are among the most marginalized, downtrodden, and castoff. I hope and pray that truth and justice will prevail. But my confidence is fragile.

Yesterday, my fifteen-year-old son and I were driving in the car, and he asked about this doctor because it was “all over the news.” My son knows what I do for a living. He’s heard me lament about how frightening the heavy hand of regulatory oversight by non-medical types can be for us medical types. I can only imagine how news of another pain specialist facing life in prison must make him feel – how it must make my wife feel, my other children, my parents, my friends, my employees, my patients…all those who depend on me, care about me, love me.

But I don’t dare go into the deep dark honest place in my heart to ask how it makes me feel. I can’t. I have work to do.

I have “Mama P” in my exam room right now. Despite the indescribably painful metastatic cancer that has invaded her spine, she manages a warm smile, offers me her outstretched trembling arms, and we embrace. She is here and she needs me. And as my moist tears well up, I realize that, today, I need her. And I know, again, why I do this.

And I know what we must do to make sure that she and every other suffering soul has hope. We must let pain care providers feel our powerful and uplifting embrace – the embrace of the fragile people they serve – because, in reality, we are all fragile suffering souls. We all need each other.

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Let’s do this.

Let’s start right now.

Let’s make PAIN CARE PROVIDERS DAY happen.

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Pain Care Providers Day is March 20, 2015, the first day of spring. It will be a day to recognize our caregivers from all walks of life who do what they can to ease the pain of others.

Ways to make this day special might include dropping off a nice thank you note for your therapist, baking some cookies for the clinic staff, sending flowers to the person who schedules your appointments, blogging, or writing a letter to the editor in support of better access to effective pain care for all. Unleash your creativity and spread the message.

A powerful way to raise awareness is by asking your friendly neighborhood municipal leader to officially proclaim March 20, 2015 as Pain Care Providers Day.

A proclamation is a formal public declaration often written by government officials to commend individuals or to raise awareness of upcoming events, celebrations, and issues of significance.

the med school ap

Pain Care Providers Day is a prime opportunity for us to secure proclamations honoring our caregivers from all walks of life who labor, often under duress, to alleviate suffering in our communities.

Here’s how it can be done…

  1. Identify the best person/office to approach for the proclamation, such as: city leaders, state representatives and/or members of congress.
  2. Contact the offices to request a proclamation.
  3. View official websites for instructions on how to submit a formal request; a form may be available for online submission.
  4. Use the draft proclamation language below as a guide for submission with the understanding that the final language may change to conform to standard protocols.
  5. If possible, meet with the official for the signing of the proclamation. Take a photograph and obtain permission to use the photograph to further increase awareness of Pain Care Providers Day.

PAIN CARE PROVIDERS DAY
We can’t just want it to happen.
We have to make it happen.

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DRAFT

PAIN CARE PROVIDERS DAY PROCLAMATION

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WHEREAS, PAIN is a universal feeling, which for millions becomes chronic, impacting every facet of life; and affects more Americans than diabetes, heart disease and cancer combined; and is cited as the most common reason Americans access the health care system; and
(Ref: 1, 2; see comments section)

WHEREAS, there exist regulatory, legal, institutional, financial, educational, and geographical barriers that impede access to pain care; barriers that contribute to increased suffering along with feelings of despair, futility and shame on the part of people with pain; and
(Ref: 3, 4, 5)

WHEREAS, in the face of this national pain epidemic there is less than one board-certified pain specialist for every twenty thousand pain sufferers; and these pain specialists are subject to tremendous stressors, leading to a high rate of professional burnout, interpersonal difficulties, suicidal tendencies, and even life-threatening physical harm; and
(Ref: 6, 7, 8, 9, 10)

WHEREAS, because of the shortage of pain specialists, the vast majority of our nation’s pain care must remain the duty of a vast array of dedicated but increasingly anxious medical professionals, kindhearted laypersons, and overburdened loved ones who bravely and compassionately persevere in treating pain as best they can;
(Ref: 7)

NOW, THEREFORE, I, [name, title], do hereby proclaim March 20, 2015, the first day of spring, as PAIN CARE PROVIDERS DAY throughout [city or state name] and encourage our citizens to recognize all who professionally, clinically or emotionally offer more than their expertise -that is, they offer their hearts- and therefore are deserving of our gratitude, encouragement, and support so that they might carry on, empowered to provide care and comfort to those suffering.

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Please use social media to the fullest extent and tweet with the hashtag #WhyPCPD

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If you want to connect personally with me about Pain Care Providers Day, I can be reached at: paincareprovidersday@gmail.com

Thank you. I’m feeling stronger already.

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Please check out the Pain Care Providers Day Facebook page.

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https://www.facebook.com/PainCareProvidersDay

 

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US Pain Foundation has a sample proclamation available for easy download at:

http://goo.gl/qPsfCL

 

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The Quintessential Pain Care Provider

My dear friend, Debbie Tichenor RN, passed quietly and unexpectedly from this world on New Year’s Day 2015.

For more than twelve years, Debbie and I worked side-by-side, sometimes head-to-head, and always heart-to-heart. She was the quintessential pain care provider, possessing a unique abundance of clinical know-how, moral fiber, and you-can’t-outwork-me ethic. I trusted her with my business, my career, my family, and my life. She helped so many, loved so many, and will be missed by so many.

Today it would be my honor to participate in Debbie’s eulogy. And though I dearly wanted to serve in this role, I feared the challenge might overwhelm me, because Debbie was no longer here for me. You see Debbie was one of my vital touchstones. We shared core values, and I could always count on her for honest, intelligent, and constructive feedback. This time, however, I feared I was on my own. And my words, at best, would fall well short of the tribute due this humble angel of mercy.

Nevertheless, knowing that I owed it to my dear friend, sometime after midnight I began writing, not certain where it would lead. Hours passed, and as I fell into and out of exhaustion, the words on my computer screen gradually began to resemble verse. By 5:45 am I had composed a poem – Debbie’s poem. And when I read it aloud, alone in my room, I felt her presence, knew we had written it together, and knew I was not alone.

My sincere wish is that this poem for Debbie provides comfort to those who miss her, inspiration to those who never knew her, and encouragement to those who aspire to be like her. She was, is, and always will be the quintessential pain care provider.

 

A Poem for Debbie

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When she was born it’s right to say,
A blessing came to earth that day.

To ease our pain and bring us love,
Directly from the Lord above.

 A daughter, mother, wife, and friend,
With caring that would see no end. 

A nurse who’d go the extra mile,
Who always met you with a smile. 

If she was anywhere you were,
Then you were family to her. 

And could expect, as from God’s grace,
The blessing of her warm embrace. 

With such profound humility,
Her skill defied futility. 

And when she faced what most would fear,
With love and hope she’d persevere. 

But tending to the quiet needs,
Might count as her most noble deeds. 

And though this blessing we now miss,
God comforts us in knowing this… 

If love defines a life’s treasure,
She lived a life beyond measure.

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~Written with your help, my dear friend,

January 6, 2015

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