‘Twas the Fight in Our Clinic

orange jumpsuit

It was right before clinic and all through morn,
Not a patient was hurting, nor feeling forlorn.
The stocking of meds on the shelves was with care,
In hopes that ridiculous pain would be rare.
The front desk was nestled all snug in their seats,
Collecting the copays while smiling so sweet.
And I in my lab coat, scrub top, and a glove,
Had just settled in for the job that I love.

When out in the hall there arose such a clatter,
I sprang from my chair to see what was the matter.
Away to the window I flew like a flash,
Tore open the shutters and covered the cash.
A man on a quest, who did not like a “no,”
Gave bluster and chaos to our status quo.
When what to my watering eyes did appear?
But my signature forged on a pad that was near.
The villain prescriber had written so quick,
I knew in a moment it must be some trick.
I asked him his name and just why he had come,
But all he could say was he had to be on…

On Morphine, on Codeine, on Oxy, on Contin,
On Soma, on Xanax, and lots of Neurontin!
Don’t stop for the chart. Don’t stop in the hall.

Now right away! Right away! Write for it all !!!

As dry heaves that before a wild emesis fly,
When I met this intruder I thought I could die.
So onto the restroom I coerced him to…
Pee into a cup that might give me a clue.
But then, in his tinkling, I heard through his bleating,
The faucet, the flushing and knew he was cheating.
As I pulled back my hand and was turning around,
Through the window the specimen came with a bound.

I was stressed by his sight, and I thought for a while,
That his clothes were an orangey prisoner style.
A stencil of words were in print on his back,
When I asked him about it he called me a quack.

His lies, how repugnant; how simple his tally -
Prescription pain pills to sell in the back alley !!!

He had a clear package tied up with a bow,
And the powder inside was as white as the snow.
A piece of lead pipe he held tight in his hand,
And he swung it at me as he started to stand.
He had a gaunt face and not much of a belly,
And I shook when he laughed ‘cause his breath was so smelly.
He was stealing prescriptions, I thought to myself,
And I cringed when I saw him reach into the shelf.

A wink of his eye and a poke to my head,
Soon gave me to know I had something to dread.
He said he had come to us straight from his “work,”
And turned ’round to face me and called me a jerk.
He gave me the finger, then fingered my nose,
‘Til both of my nurses, they stomped on his toes.
He sprang to his car when we asked about jail,
And away he did run with the cops on his tail.
But he heard me exclaim, ‘ere he drove out of sight,

No prescriptions for you, because we do it right!

022812 police-chase

 

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While drug diversion is certainly no laughing matter, I couldn’t resist poking a little fun at some of the bumblers who have chosen this “career” path.

Here’s hoping that you have a joyous and pain-free holiday season!

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Treating pain patients like addicts?

Treating pain can be simple or complex.

simple_complex

The simple approach focuses on cause and effect.

Knee_Jerk_large

Remove the cause of pain and the effect is…relief.

This often works when the cause is clear, i.e. acute pain. Just ask the lion with the thorn in his paw.

lion

But chronic pain is often more complex.

Nature tries to smooth out rough spots; this is called “adaptation.” So when the brain is exposed to prolonged painful stimuli, or to foreign chemicals, such as opioid pain pills, the brain adapts.

Two examples of these neuroadaptations are:

(a) tolerance – the need for increasing doses to maintain the same effect; and
(b) physical dependence – the need to keep taking a drug to ward off withdrawal symptoms

The presence of drug tolerance and physical dependence does not mean the individual is addicted to the drug.

pain not addiction

Addiction is a life-threatening disease of the brain’s reward circuitry, typified by a persistent destructive preoccupation with satisfying an unhealthy craving for a substance or behavior.

Brain

Addicts will often develop tolerance to drugs of abuse and develop physical dependence. And they experience withdrawal symptoms when these drugs are leaving their bodies. But tolerance and physical dependence (and withdrawal symptoms) are normal expected physiologic adaptations that can also occur in non-addicted people who take their medications as prescribed.

Furthermore, in the American Psychiatric Association’s authoritative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, tolerance and withdrawal symptoms are no longer counted as criteria for diagnosis of substance use disorders when occurring in the context of appropriate medical treatment with prescribed medications.

Screen Shot 2014-11-21 at 11.06.01 AM

In pain sufferers exposed to opioids for an extended period of time, drug tolerance and physical dependence can extend to brain structures that control stress, anxiety, pain, memory, emotions, judgment, critical thinking, and even the ability to experience joy. These patients may not be addicts, but if and when they are in withdrawal they sure feel like addicts. They may need the opioid for more than just pain relief; they may need the opioid just to feel “normal.”

depressed patient

If not addiction, then what is this complex neuroadaptation to long-term exposure to opioids? In a 2012 commentary article from JAMA Internal Medicine, Doctors Ballantyne, Sullivan, and Kolodny referred to it as “complex persistent opioid dependence” (JAMA Internal Medicine September 24, 2012, Vol 172, No. 17):

Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists.

I concur.

mpc

For years in my practice, my colleagues and I have treated chronic pain patients, many of whom are stable and functioning well on opioids. Interestingly, many will describe their pain as severe (i.e. “ten out of ten”) but in the same breath say they are doing “OK.” We have had a measure of success at tapering some patients to lower opioid doses, but a significant number simply will not function well at lower doses.

How can this be?

I believe the answer is in their neuroadaptation. To my understanding, long-term pain coupled with long-term opioid use appears to alter the way one’s brain experiences pain. It is almost as if the pain level is “locked in” and will not fluctuate significantly regardless of interventions (e.g. physical therapy, biofeedback, injections, adjunctive medications, or even more opioids). In this sense it is similar to how a patient with phantom limb pain can have real pain where the limb once was. In both situations the pain experience is determined by complex interactions between multiple nerve pathways – far from simple cause and effect.

Therefore, when treating complex persistent opioid dependent patients (“CPOD”) the most beneficial course might be to shift focus from the conventional drumbeats of: (a) trying a steady progression of new treatments; and/or (b) tapering off the opioids “at all costs.”

I would never suggest these pain patients abandon efforts to achieve more relief and improved function. But I am suggesting, as do Doctors Ballantyne, Sullivan, and Kolodny, that the better therapeutic approach may be to view their care through the lens of Addiction Medicine in addition to that of Pain Medicine.

asam book pic

CPOD patients might be well served by care plans influenced by principles outlined in The ASAM Criteria from the American Society of Addiction Medicine.

asam crit screen

In this paradigm a patient is assessed in six categories or “domains.” Care plans are determined by severity in each domain. With CPOD patients the six domains would look like this (i.e.,“ABC & RRR”):

  1. Acute issues
  2. Biomedical issues
  3. Cognitive and behavioral issues
  4. Readiness to comply with the program
  5. Relapse potential to aberrant behaviors
  6. Recovery environment for ongoing safe use of opioids

Consideration of these six domains assists the clinician in formulating a treatment plan with the most appropriate structure, monitoring, counseling, and use of opioid medications.

For example, a patient with chronic pain who presents for continued use of opioids and is assessed to be stable in five domains but has not adequately addressed his or her diabetes. The diabetes is a biomedical issue that left untreated could jeopardize safe use of opioids. In order to move forward with the plan of care, optimizing this “biomedical” domain becomes a priority.

Treating pain can be simple or complex. When the cause of pain is known and removing the cause is expected to result in pain relief, the decision whether or not to include opioids in the plan of care is straightforward. However, when long-term suffering and opioid use lead to significant neuroadaptations and the development of complex persistent opioid dependency, the best course of action may be to offer these non-addicted pain patients a plan of care modeled after that which has been shown to be effective in treating addiction.

Those afflicted with the disease of addiction suffer biological, psychological, and social harm. Respect, dignity, and science are the pillars of treatment. Success requires ongoing partnership between the patient, caregiver, and support group.

This plan of care can also work well for complex persistent opioid dependent pain patients. They may not be addicts…But you can treat them that way.

Simple.

 

joyful

 

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Purified Prose

I think of poetry as prose that has been purified.

And with brevity the soul of it’s wit, Twitter can be thought of as a “language distillery.”

Now please allow me to offer you a taste of my higher proof poetweets…

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purified prose
produces poetry

*November 10, 2014

 

every scratch
a fallen petal
on father’s watch
is precious mettle

*November 8, 2014

 

give pain meds the blame
for drug abuse shame
and outlaw their use
to combat abuse

but when drugs are craved
lives will not be saved
and no addiction
is only fiction

so passing the laws
that ignore the cause
may rid us of pills
but won’t solve our ills

*October 31, 2014

 

fascination
from
finding
fall’s
finest
foliage
foreshadows
finally
feeling
fate’s
farthest
fall

*October 26, 2014

 

if
why
when shared
shows us where

then
where
will now
show us how

*October 10, 2014

 

I hid but my failure discovered me.
I ran but my failure recovered me.
I forgot by my failure reminded me.
I blinked but my failure it blinded me.

I talked and my failure it studied me.
I bathed and my failure it muddied me.
I fought and my failure it pounded me.
I fell and my failure it grounded me.

I hoped that my failure would end for me.
I found that my failure was friend to me.
I learned that my failure was me to me.
I then let my failure be free from me.

*October 2, 2014

 

To fight poor health discreetly
You gave yourself completely
You might have loved your medical career
But will you love this tomorrow?

Is care a hope to treasure
Or something you must measure?
Can you believe the tragic change in sight?
Will you still love this tomorrow?

Faced with healthcare that’s broken
You say that you are only “one”
But you won’t feel like jokin’
When your right to a choice is gone

You’d like to show that you love
To give what we’re in need of
So tell yourself to face that task again
And you’ll still love this tomorrow

September 16, 2014
Hint: Try singing it to the tune of Carole King’s Will You Still Love Me Tomorrow?

 

though my ideas
are in my post
it’s your ideas
that matter most

*August 27, 2014

 

my body age
not so illogical
is easy to
discern

but true mind age
not chronological
is really my
concern

*August 23, 2014

 

first day of spring
say thank you please
to those who ease
our suffering

*August 5, 2014

 

artist
is not what you
do
it’s who you
are

*May 9, 2014

 

And finally…

since brevity is the soul of twitter
longevity as a goal is bitter

*November 13, 2014

 

 

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Words that matter…to me

journal

September 24 was a mentally fertile day…on at least three occasions in my life.

From time to time I have managed to keep a journal.
Here are three of my 9/24 entries.

September, 24 1978 (College sophomore, 18 years old)

I cannot afford to lose a day;
my life is only as short as it is.

9 24 78

September 24, 1983 (Third year medical student, 23 years old)

Life and alarm clocks
go hand in hand
unnaturally.

9 24 83

September 24, 1995 (Anesthesiologist, 35 years old)

Unless it makes any difference why the sun comes up everyday,
don’t waste time arguing about it.

9 24 95

If you’d like to see more of this kind of thing, they pop up from time to time on my Twitter feed.

Or check out the listing in this post’s comments section.

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I need some advice…

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Tomorrow (Tuesday – September 16, 2014) I will have the honor of speaking to a gathering of mostly retired physicians at the Kentucky Medical Association’s annual meeting in Louisville, KY.

Given this opportunity, what would you say to them?

What would you encourage them to do?

How would you instill hope that our nation’s healthcare delivery system will survive?

I only have a few hours to hone my message. I need your help.

Please leave your remarks in this blog’s comments section…

Or send me a message on Twitter @jamespmurphymd

Or email me at: basicpaincare@gmail.com

Thanks!

Dr M

Dawn of the planet of the value based

sunrise clark

It is the dawn of a new era.

Many cogs are now required to turn the wheels of our nation’s juggernaut health care industry. Physicians, historically the driving force in medicine, are not generally the “cog” type. This juxtaposition can have unhealthy consequences for all of us.

In his August Wall Street Journal article “Why Doctors Are Sick of Their Profession,” Dr. Sandeep Jauhar documented the pathology in our nation’s medical history. And while I agree with the good doctor’s diagnosis, I am not as comfortable with his treatment plan, which includes:

  1. “giving rewards for patient satisfaction”
  2. “replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves”
  3. “pay for performance, which offers incentives for good health outcomes.”

At first glance, Dr. Jauhar’s suggestions would appear to be reasonable measures. But employing such metrics may not sit well with our current physician workforce for a number of valid reasons.

In days past, the medical profession attracted highly intelligent practical dreamers in search of a career that allowed and rewarded unfettered blending of art and science; answering a “calling” that revered the heartfelt patient-physician relationship. If you were a “Renaissance man” or woman, crossing medicine’s threshold felt like coming home. Now in this modern medical renaissance, home is not necessarily where the heart is. Home is now inhabited by impostors masquerading as quality and value.

In days past, creativity and problem solving were vital to success in health care. Now strict adherence to guidelines, meeting quotas, and saving money for third party payers are paramount. Now the “rough spots” in the delivery line -physicians who view patients as individuals as opposed to populations – are being made smooth or else discarded.

Given a metric that determines their “bonus,” worker bees will instinctively aim for that mark. So if earning money to send their kids to college depends on getting a “five star” customer satisfaction rating, then expect health care professionals to make flashing a salesman’s smile the priority. Running a clinic on time will become more important than taking time to comfort that patient who’s problem unexpectedly deserves more attention than the automated schedule allowed…can’t risk upsetting twenty people for the sake of one, you know.

The story goes that Albert Einstein once wrote on his blackboard: Not everything that counts can be counted, and not everything that can be counted counts.

Regardless of the origin, this statement rings with truth. More than an observation, it is a challenge.

hand

I held a hand the other day. There was no procedure code for it. It did not satisfy any quality metric. Truth be told, it was probably more beneficial and more appreciated than the epidural injection that preceded it.

We are living in the dawn of the planet of the value based. Students now embarking upon their medical school journey will emerge light years away from where they began. When they graduate and step into the blinding sunlight of the real world, will they even recognize it?

Or, as in the climactic scene from Planet of the Apes – when Charlton Heston’s character realized man’s demise was his own doing – will they cry out…

You finally really did it!

You maniacs!

You blew it up!

 planet-of-the-apes-1968-movies-14704094-1920-811-which-was-the-best-planet-of-the-apes-a-look-across-time

 

I hope not.

I will do what I can.

But, then again, I am a rough spot.

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White is the new look for fall

sep me cover

On July 28, 2013, the University of Louisville welcomed the Class of 2017 medical students. As an annual contribution to each new generation of emerging physicians, the Greater Louisville Medical Society purchases the students’ first white coat. As President, it was my honor to congratulate the students on behalf of the Greater Louisville Medical Society. Here are my remarks from the podium.

share in an adventure gandolf

“I’m looking for someone to share in an adventure.”

Fans of the author J.R.R. Tolkein, will recognize this as the challenge Gandalf the wizard made to the hobbit, Bilbo Baggins. This is, among other things, an adventure.

I am honored to be here on behalf your medical society – The Greater Louisville Medical Society – to congratulate you on this milestone. At close to 4000 members, we are one of the largest in country. Our mission is to: promote medicine as art and science, advocate for the wellness of our community, and protect the patient – physician relationship.

Today is a big day for you and for us. Today is a milestone along the road that will lead to a your joining our ranks. Today you are not only putting on your white coats, but you are also becoming members of the Greater Louisville Medical Society. To help you stay connected you will have access to our mobile app, where you can get alerts, educational materials, and access information about your new GLMS colleagues. As sponsors of the White Coat Ceremony, your medical society colleagues are honored to provide: your first white coat, provide, your medical society pin, membership in the Greater Louisville Medical Society, professional photographic portrait of you in your new white coat. We are your colleagues, here to support you, and we welcome you.

The Greater Louisville Medical Society has strong ties to the University of Louisville. Most of our members either graduated from the University or did post-graduate training there. I am proud to call myself a graduate of the University of Louisville Medical School Class of 1985.

Back when I was in your shoes, we did not have a white coat ceremony. Back then they wouldn’t let us wear a white coat until third year, much less actually touch a living patient. I wish we could have had a ceremony like this. That is why I invited my own family to come today. This is a special day for you and for your family and friends who have supported you. To these special people in your life, I also offer my congratulations and my gratitude.

Gratitude, yes, because you have chosen a path that is not easy and does not compensate you materially for the years spent, the sacrifices, the risks – financial, physical, emotional. But it is indeed an adventure.

As I look out upon you I see a discovery. I see a cure. I see lives saved from disaster. I see longer, better, meaningful lives. I see a suicide prevented. I see a critically ill baby saved. I see an aneurysm removed. I see a heart murmur discovered. I see a cancer detected because you followed up on the red blood cells you saw in the urinalysis report.

I also see heartache, depression, fractured lives, and failures. It is all part of the path you have chosen to follow. You may not know all the reasons why you are sitting here today. I don’t think I knew. But every day, from this day forward you will be finding answers.

The white coat itself is significant. I remember the day I finally got mine. We walked around the medical complex and even went to eat lunch in one of the hospital cafeterias. In my 3rd year of medical school Dean Ganzel was my attending on rotation through Otolaryngology. On the last day she, so graciously, took her four medical students to lunch. We ate lunch at the Kentucky Center for the Arts in our white coats. The coat meant something. It said something to the world.

9403531070_63bc08e2e1_o

I have worn many white coats since them – short, long, in between – but whenever I put on the coat it still has meaning. It speaks. So I wondered what the message would be if instead of me, my white coat could says a few words. Well, my white coat and I discussed it and now, on behalf of my white coat, I offer this:

a white coat
I symbolize
the goals you hope
to realize

a white coat
my color’s pure
to show your values
will endure

a white coat
I will glisten
if you can try
to mostly listen

a white coat
in my presence
comfort, care and
convalescence

a white coat
wear this fashion
only if
you share my passion

a white coat
for my profession
put patients first
make no concession

a white coat
answer alarm
with answers that
first do no harm

a white coat
hear the calling
wear me when
you lift the falling

a white coat
my fabric must
be nothing but
a weave of trust

a white coat
ability
tailored with
humility

a white coat
a solemn oath
a way of life
or maybe both

a white coat
I’m going to
forever be
a part of you

Dean Ganzel, colleagues, friends and families, Mom, I thank you for this day. And to the class of 2017, I congratulate you and welcome you. For those who hear this calling there is no greater professional honor than to wear that white coat and hear the words, “That’s my doctor.”

Looking out at you, it is clear that I have found someone to share in an adventure.

Gandalf_the_White_returns

… and the white look is very becoming, I must say.

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This year’s White Coat Ceremony was held on July 27, 2014 and is the subject of current GLMS President, Dr. Bruce Scott’s September eVoice.

bruce evoice

 

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