Plan to THINK… How to prescribe controlled substances in Kentucky for the first three months

64-100-10459-2Kentucky’s controlled substances regulations make clear distinctions between: (1) initial prescribing, (2) prescribing by the three-month mark, and (3) prescribing beyond three months. To make matters even more confusing, the regulations are two-tiered, with specific language pertaining only to schedule II drugs, with schedule V drugs being exempt from the regulations.

Because of some seemingly redundant and contradictory language, understanding Kentucky’s regulations can be challenging. Prescriber uncertainty can interfere with proper patient care. In an effort to simplify this process I have summarized Kentucky’s regulations governing the initial prescribing of controlled substances in a convenient “check list” format. Future articles will look at the three-month mark and beyond.

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The bold components of the checklist are required only when prescribing schedule II controlled substances. However, to be safe I recommend checking off all of the requirements when prescribing any schedule II-IV drug.

Note: I am a physician; not a lawyer. This summary is not legal advice. Each facility and physician should consult its own legal counsel for advice and guidance.

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P lan to T H I N K

What to do initially when prescribing during the first three months of treatment.

P lan

___ Deliberate decision that it is medically appropriate to prescribe or dispense the controlled substance in the amount specified

___ Written plan stating the objectives of the treatment

____Written plan stating any further diagnostic examinations                 

 

T each

___ Safe use

___ A controlled substance for an acute complaint is for time-limited use

___ Discontinue medication when the condition has resolved

___ Proper disposal of any unused medications

___ KBML website resources

Note: Educational materials relating to these subjects may be found on the board’s web site, www.kbml.ky.gov or
 http://kbml.ky.gov/hb1/Pages/Considerations-For-Patient-Education.aspx

 

H istory and physical

___ Appropriate medical history relevant to the medical complaint, including a history of present illness

___ Physical examination of the patient relevant to the medical complaint and related symptoms

I nformed consent

__ Discuss the benefits and risks of prescribing or dispensing a controlled substance to the patient, including:

(a) nontreatment, (b) other treatment, (c) the risk of tolerance and (d) the risk of drug dependence

__ Obtain written consent for the treatment.

o  long-acting opioids

___ No long-acting or controlled-release opioids for acute pain that is not directly related to and “close in time” to a specific surgical procedure

K ASPER

___ Obtain and review KASPER report for that patient for the preceding 12 months

___ Appropriately utilize KASPER information in evaluation and treatment

Additional documentation required for patient prescribed a schedule II controlled substance, as “appropriate”:

___Diagnostics (labs, studies, etc.)

___Evaluations and consultations;

___Treatments and outcomes

___Medications (date, type, dosage, and quantity)

___Instructions

___Agreements

     

When prescribing “additional” Schedule II, at “reasonable” and individualized intervals review:

___ Plan of care

___ Provide any new information about the treatment

___ Modify or terminate the treatment as appropriate

EXEMPTIONS to Kentucky’s regulations:

The exemptions are very confusing. While the first set of exemptions (see below) are supposed to apply to all controlled substance, there are additional exemptions that pertain only to schedule II controlled substances.

I believe the most important points here are:

  1. Cancer patients are exempted.
  2. In-patients are exempted for Schedule III-IV
  3. In-patients receiving schedule II drugs must have a KASPER, but all the treating physicians can share the report.
  4. Post-op schedule II drugs are exempted for 2 weeks.
  5. Schedule V drugs are always exempted. 

Here are the exemptions in detail:

Kentucky’s regulations shall not apply to a physician prescribing or dispensing a controlled substance:

(a) To a patient as part of the patient’s hospice or end-of-life treatment;

(b) To a patient admitted to a licensed hospital as an inpatient, outpatient, or observation patient, during and as part of a normal and expected part of the patient’s course of care at that hospital;

(c) To a patient for the treatment of pain associated with cancer or with the treatment of cancer;

(d) To a patient who is a registered resident of a long-term-care facility as defined in KRS 216.510;

(e) During the effective period of any period of disaster or mass casualties which has a direct impact upon the physician’s practice;

(f) In a single dose prescribed or dispensed to relieve the anxiety, pain, or discomfort experienced by that patient submitting to a diagnostic test or procedure; or

(g) That has been classified as a Schedule V controlled substance.

But wait! There are more exemptions that pertain only when prescribing Schedule II controlled substances…

For each patient for whom a physician prescribes or dispenses a Schedule II these regulations shall not apply to:

  • A physician prescribing or administering that controlled substance immediately prior to, during, or within the fourteen (14) days following an operative or invasive procedure or a delivery if the prescribing or administering is medically related to the operative or invasive procedure or delivery and the medication usage does not extend beyond the fourteen (14) days; or
  • For administration in a hospital or long-term-care facility if the hospital or long-term-care facility with an institutional account, or a physician in those hospitals or facilities if no institutional account exists, queries KASPER for all available data on the patient or resident for the twelve (12) month period immediately preceding the query, within twelve (12) hours of the patient’s or resident’s admission, and places a copy of the query in the patient’s or resident’s medical records for use during the duration of the patient’s stay at the facility;
  • As part of the patient’s hospice or end-of-life treatment;
  • For the treatment of pain associated with cancer or with the treatment of cancer;
  • In a single dose to relieve the anxiety, pain, or discomfort experienced by a patient submitting to a diagnostic test or procedure;
  • Within seven (7) days of an initial prescribing or dispensing under subsection (1) of this section if the prescribing or dispensing:
    1. (1) Is done as a substitute for the initial prescribing or dispensing;
    2. Cancels any refills for the initial prescription; and
    3. Requires the patient to dispose of any remaining unconsumed medication;
  • Within ninety (90) days of an initial prescribing or dispensing under subsection (1) of this section if the prescribing or dispensing is done by another physician in the same practice or in an existing coverage arrangement, if done for the same patient for the same medical condition; or
  • To a research subject enrolled in a research protocol approved by an institutional review board that has an active federalwide assurance number from the United States Department for Health and Human Services, Office for Human Research Protections if the research involves single, double, or triple blind drug administration or is additionally covered by a certificate of confidentiality from the National Institutes of Health.

There are additional “Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint” that must be met before a physician commences to prescribe or dispense any controlled substance to a patient sixteen (16) years or older for pain or other symptoms associated with the same primary medical complaint for a total period of longer than three (3) months.

To address this information and much more, there will be another Confluential Truth article coming soon. You may also refer to the regulations as posted on the KBML website (http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx) and in the “comments” section accompanying this article.

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The Fawn

fawn copy

September 15, 1985

She strikes me as a little too calm. I like her immediately. It is my third month of internship, a brand new United States Navy doctor. My newness does not seem to matter to patients, mostly military dependents – wives, kids – and retirees. I am the doctor, their doctor. People do not understand the whole hierarchy of residency. Words like “intern,” “resident,” “chief,” and “attending” do not betray the sublime wholeness of “doctor.”

She is wearing a plain, soft, cotton, flower pattern dress. Nice figure. There is a pink ribbon in her curly auburn hair. A little shy, she makes eye contact rarely, mostly maintaining her gaze downward and to the right or left, except when I speak. Then her eyes fix on mine. Like a fawn, her countenance is intensely vacant, vulnerable.

I am assigned to the Internal Medicine outpatient clinic for only one afternoon a week. I always welcome it as a much needed break from the perpetual grind of chasing down lab slips, writing progress notes, dictating discharge summaries, drawing labs, doing exams, and basically functioning as the chief resident’s smart phone.   The outpatient clinic is never too busy, never too dramatic, and is a safe place where I can play doctor and probably not hurt anyone.

My patient is a thirty-two year old white female – dependent wife of an active duty Petty Officer with two young children at home. But today she has come by herself to follow up on her breast biopsy. Already aware that she probably has some form of cancer and will likely need surgery; the specifics are not clear to her. But I will find out. After all, I am her doctor.

“Well, what’s the path say?” demands my attending supervising physician from his centralized station in the hallway.

“Inflammatory breast cancer,” I report, not fully understanding what it means.

“Not good,” he groans with a half-grimace. “She needs chemo. Get her hooked up with Oncology right away.” And away he goes, leaving me holding what has suddenly become a heavy bag.

Back in the room I waste no time. “The biopsy showed cancer. You will need to see an Oncologist right away.”

There’s a quick breath in and out. A fawn breath. “Okay,” she monotones, looking down. I think she is taking this well. Then her eyes without blinking fix on me. “Am I going to be all right?”

“You are going to need chemotherapy”…pause…swallow. I am aware that I am not answering her question.

I give her the forms she needs to get her appointment and she leaves. She will not be coming back to Internal Medicine. She is an Oncology patient now. I wonder how she will do. I don’t expect to see her again.

March 31, 1986

I am next to be assigned an admission to the hospital. It’s only 10:30 p.m. My “hit” will not likely be my last. The night is still young, the ER is packed, and the admitting resident is not known for being a “wall” – he freely admits patients from the emergency room rather than treating them and sending them home.

The pager goes off. Even though I know it is inevitable, my heart sinks a little. I am given the room number, last name, and chief complaint. “Breast cancer, terminal.” I would rather have an asthmatic, diabetic, pneumonia, something I can fix. I tread the long linoleum corridors to the nurse’s station just outside her room. There is commotion going on. I enter the room and into a tempest.

It is the fawn. In severe distress now. Groaning. Panting. Painful noises from deep beneath her vocal cords. Sounds that would be screams were they not buried in rapid frothy gasps. Her eyes are wide and crazed, unfocused, her skin pale and edematous.  Her hands grasping at bed sheets.

How do I manage this catastrophe? She is my admission, my patient. But I am so peripheral to this unfolding tragedy. Present are three doctors, two nurses, a respiratory therapist, and me. We need an I.V. No success. Not by anyone. I try five times. No success.

“Anesthesia is here!” announces a nurse. And the masked man proceeds to prep, drape, then stab her undulating chest until finally dark blood fills the syringe. The central line is placed. Fluids and morphine are given. And we enter the eye of the storm.

A second year resident pleads, “She needs to be intubated. Anesthesia should do it now while he is here.” And with that cue the doctor known only as “anesthesia” moves like a cat to the head of the bed, brandishing his flashing laryngoscope and plastic endotracheal tube.

“NO! You can’t,” barks the chief resident. “She’s a D.N.R. – DO NOT RESUSCITATE!” And with that realization, the participants collectively exhale, begin to collect belongings, and throw away the piles of disposable wrappers, used I.V. catheters, tape, tubing, and other compulsory medical paraphernalia.

Realizing I have done nothing but jab this poor creature numerous times while failing to get her I.V. started, I decide I might as well begin the paperwork. I do not have the luxury of too much reflection. There will be more patients, more admissions, and more paperwork as the night wears on. I go to get my clip board, “Scut Monkey Handbook,” and some fresh air.

When I return to the ward a half hour or so later, I immediately notice things are way too quiet. I enter the room and find what I expect to find.

She is still. Cold. Gone.

How can the first patient to die in your care not leave a lasting impression?

How little can I alter the inevitable?

I am a doctor, but a doctor is not all that I am.

I am also the fawn.

We are all fawns.

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James Patrick Murphy, MD (1987)
Lieutenant
Medical Corps
United States Navy Reserves

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The Fawn, by James Patrick Murphy, MD, was first published in the July 2010 issue of Louisville Medicine (pg 20-21). The piece was awarded first prize in The Richard Spear, MD Memorial Essay Contest, 2010, Practicing and Life Member Category.
https://www.glms.org/Content/User/Documents/Louisville%20Medicine/LM%202010/GLMSMagJuly2010.pdf

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emerge again

the
child
is curious
in a joyful way
and can understand
the roundness of the world
and that anything divided by zero is infinity

at some point the child’s gaze turns earthward, then
grades, awards, and accolades come in quanta
there will be more schooling, and
a student emerges

the student learns, expresses, yearns, dreams
and catches a glimpse of a destination
and there will be no turning back
medical school happens, and
an explorer emerges

then running, leaping, feeling the rush of new air,
the exhilaration of wonder, the anticipation
of plunging into the water rapidly rising
a baptism requiring boundaries
and a deference to practicality
residency is completed, and
a physician emerges

into a system seeking to program, package, and automate
in the name of value and quality, yet
it is what the system does
and there is no blame

the creative mind wilts under the weight of endless regulations
the compassionate soul suffocates in the coils of informatics
the joyful heart fatigues fighting resistance to caring
and the physician is tagged, branded, and blended
into the health care provider herd, and
a demoralized physician emerges

but there endures a calling for
practical dreamers who can
remain child, student
explorer, and
physician

be
this
physician
and emerge again

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kel in surf*

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The Seven Ages of a Physician*

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The healthcare world’s a stage,
And all physicians merely players.
They have their dreams and their realities,
And one doc in this time plays many parts,
With acts seeing seven ages.

At first, the med student,
Stressing and puking in the nurse’s way.

Then the whining intern,
With an anxious and sleepless morning face,
Creeping like a snail unwillingly to rounds.

And then the resident,
Trying, in earnest, treatments so valid,
made to appear so highbrow.

Then a doc bolder,
Full of strange oaths and focused on patients,
Jealous in honor, sudden and quick in quarrel,
Seeking a stellar reputation, even if anonymous.

And then private practice,
Independently not following a party line,
With secure and diverse payer mix,
Full of work comp and private insurers,
And so they pay their part.

The sixth age shifts into the disillusioned physician,
Regulations arise in overreach;
The youthful zeal, beat down, controlled, employed;
In this shrunk role, banished there by no choice,
Yearning again for independence,
Sulks and bristles on the rounds.

Last scene of all,
That ends this strange eventful history,
Is demoralization and mere oblivion,
Sans practice, sans patients, sans joy, sans everything.

*This melancholic monologue was adapted from William Shakespeare’s play As You Like It, Act II, Scene VII.

If this default future is not as you like it,
don’t just audition for a role,
write your own play!

we are great

http://jamespmurphymd.com/2014/01/06/is-this-future-unstoppable

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A Moment to Chair-ish

May 8, 2015 marked the end of my tenure as Chair of the Greater Louisville Medical Society Board of Governors. Here is the text of my farewell address…

engraved

I must start by thanking the Greater Louisville Medical Society staff, our board members, my private practice staff, my patients, and mostly my family.

Two years ago I stood on the stage of the Performing Arts Center at Kentucky Country Day School and in my first remarks as President said these words:

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The Greater Louisville Medical Society is our organization. It is our tribe. It is our road to a place where medicine is both science and art. It is where our community enjoys wellness and the sacred bond between our patients and us is secure. Imagine that future. Let’s go there together. Let’s get connected. Let’s unite. Let’s have that journey start today.

Now, after that year as President and this past year as Board Chair, the journey has brought me here, where a short time from now I will bring down the gavel for the last time, signaling the end to what has been the most rewarding period of my professional life. It’s been quite a ride. But it is time to transition.

However, I leave knowing that (a) the GLMS did not crash and burn under my watch; and (b) I am leaving the GLMS in great shape and in great hands.

hourglass

Gifts are often bestowed at a time like this. Last year you gave me an hourglass. I like hourglasses because they remind me of how each moment is precious. How, once spent, we can never relive the precious present. This is what Rudyard Kipling meant when he wrote:

If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,   
Yours is the Earth and everything that’s in it,
And, which is more, you’ll be a man, my son!

In his final “From the President” article, our outgoing President, Dr. Bruce Scott, documented how well the Greater Louisville Medical Society has filled this past year’s unforgiving minutes.

Since this time last year, our medical society has weathered political mayhem, economic upheaval, and competitive challenges, and we have emerged strong. In addition to our ongoing good works in the community, our advocacy, and our support of physicians:

-we substantially impacted policymaking in Frankfort and in Washington;

-we made the investment necessary to revamp our computer, Internet, and information technology capabilities so we may fulfill our mission as a modern and influential medical society for years to come; and

-we built a bridge to future successes by cultivating the transfer of executive leadership from Lelan Woodmansee’s thirty-five amazing years -steady at the helm- to Bert Guinn’s innovative and energetic vision for the next chapter in GLMS history.

To commemorate my past year in leading our Board of Governors, Lelan asked me if I would like the usual and customary gift of a trophy chair or perhaps something else. Of course I wanted the chair! Just like that hourglass, this chair has meaning. Every time I look at it I am reminded of so many aspects pertaining to the physician life.

edited chair

First, it’s an award. And physicians are always striving to achieve that next level, graduate, move up, re-certify, and achieve recognition. So this chair will be a source of pride. It stands for something. And so do physicians.

Second, it’s sharp looking. My dad always said that half of being a ball player is looking like one. This chair has an air – a graceful, confident air. And so do physicians.

Third, it doesn’t have a cushion. It’s not the most comfortable way to go. And neither is a physician’s life.

Fourth, it’s made of wood. It is firm, steady, but can bend a bit. Absorb some stress. But over time this chair will wear and eventually succumb to the stress of its purpose. And so will physicians, eventually.

Fifth, it is a work of art. It is a chair, like other chairs, but it is one-of-a-kind. And so are physicians.

Sixth, it’s functional. Serves a purpose. As do physicians

Seventh, it provides comfort. A place to rest. Heal. And so do physicians.

Eighth, it connects me to my colleagues and mentors who have gone before me and who will come after. All physicians should be connected.

I humbly accept this gift and will cherish it. Thank you.

But I also know this chair is neither innovative nor creative. It is incapable of disruptive thinking. This chair cannot act and cannot feel. When I sit in it, this chair will not become me. It will only be trappings.

We know we must be more than just the trappings of our profession. Appearances matter. Words matter. But actions matter much more.

I am proud of where we have been and where we are going. And I am proud of each of you for being here – for being more than just a spectator or critic.

Theodore Roosevelt said it well:

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again -because there is no effort without error and shortcoming- but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.

Roosevelt described a person in the arena. But a great person cannot achieve as can a great people.

Abraham Lincoln knew this. In his address dedicating the Gettysburg Battlefield National Cemetery, Lincoln proclaimed:

The world will little note, nor long remember what we say here, but it can never forget what they did here.

When we are united in a cause, bound together by values we share -trust, integrity, truth, excellence, selflessness, giving – then we raise all of us.

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As I survey the battlefield in which our profession is currently engaged -with foes ranging from rival healthcare provider disciplines, to profit hungry corporations, to misguided and self-serving political groups- I know that if divided we will be conquered.

And I’m reminded of what Shakespeare’s Henry V said to inspire his soldiers before the climactic St. Crispin’s Day battle:

From this day to the ending of the world,
But we in it shall be remembered-
We few, we happy few, we band of brothers;
For he today that sheds his blood with me
Shall be my brother.

Over the past year, in this room, I have had the honor of leading, if only for a few hours, a collection of men and women, the likes of which I may never see equaled. We happy few. If in this unforgiving minute I have reached the pinnacle of my career, I will have been truly blessed. And if ever I lay claim to higher success, I know I will have risen there only because of the firm foundation that you and the Greater Louisville Medical Society have provided me.

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The Greater Louisville Medical Society. Our organization. Our tribe. Our road to a place where medicine is both science and art. Where our community enjoys wellness. And where the sacred bond between the physician and the patient is secure. I have imagined that future. I want us to go there together. Let us stay connected. Let us stay united. Let us continue that journey, together.

Thank you.

gavel

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James Patrick Murphy, MD, MMM is 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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The Five Essentials for Pain Practice Success

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Success is counted sweetest by those who ne’er succeed.
~Emily Dickinson

You treat chronic pain? Thank goodness someone does.
~My physician colleagues … on numerous occasions

I have treated chronic pain in a variety of practice settings, large and small, for almost thirty years. It has not always been easy. But I have found that success in this specialty is possible when the practice foundation consists of five basic elements:

Compliance
Consensus
Culture
Cause
Care

Chronic pain is not an exotic clinical niche. It is a chronic illness and should be approached step-wise as one would approach other chronic illnesses:

(1) Gather information;
(2) Make a diagnosis;
(3) Implement a plan of care;
(4) Assess the results; and
(5) Make adjustments.

A physician is generally comfortable with this paradigm when it applies to caring for an individual pain patient. However, regardless of one’s clinical confidence, when the practice’s primary mission is to treat chronic pain, overriding concerns about economic viability, community safety, and regulatory scrutiny become major stressors for a physician. More than just a paradigm is needed.

By embracing The Five Essentials for Pain Practice Success a healthcare organization of any size or complexity can meet this need and provide quality pain care that is valued by the patient and professionally satisfying to the provider.

The Five Essentials for Pain Practice Success

  1. COMPLIANCE

Be a follower. In addition to an ever-increasing database of clinical guidelines, there are numerous regulations and statutes governing how healthcare providers may treat pain, particularly when treatment involves controlled substances. Some of the rules are federal statutes that apply universally. Other rules are only specific to individual states or communities. Rules governing pain care delivery may not necessarily reflect the best clinical practice, but are usually based upon sound principles. Search for the reason behind the rule. But if all else fails, go ahead and “teach to the test.” Compliance is mandatory. Even if you think “outside the box” do not act outside the box. Know the rules and follow the rules.

  1. CONSENSUS

A successful pain practice must agree on how they will operate. Do some providers allow early refills, while others will not? Are some quick to discharge a patient who has an abnormal drug screen, while others give second chances? How often do we drug screen? Do we prescribe drugs on the first visit? Through honest communication the group must reach a consensus on “our way” of doing things.

  1. CULTURE

Every organization has its own culture. A successful pain practice understands its culture, knows its weaknesses and knows its strengths. For example, if the group’s dominant culture is intuitive, then it needs safeguards (i.e. objective and detail-oriented policies and procedures) to focus on specifics. Success requires that individuals not only understand their roles, but also are willing to perform in a manner that supports the group’s dominant culture.

  1. CAUSE

Successful pain practices know their cause, their mission, the reason the practice exists. Even the most mundane task can be passionately undertaken when team members understand how their actions contribute to the cause. In addition, successful practice managers make sure team members feel appreciated for their efforts.

  1. CARE

Caring is the foundation for success. In all decisions, successful pain practices first ask: “Is it in the patient’s best interest?” Beyond that, every human encountered by the organization -patients, family members, hospital administrators, government regulators, insurance brokers, pharmaceutical representatives, colleagues, etc.- is worthy of dignity, respect, and care. The “golden rule” always comes before the rule of gold. Remember that no one cares how much you know until they know how much you care.

Each of the five essentials for pain practice success is vital. Ignore one and the organization is on thin ice. Embrace them all and the practice, regardless of its size, can be on economical, clinical and ethical solid ground.

Then no one will have to “thank goodness” for what you do.
Instead, you can be thanked for the goodness that you do.

That is sweet success.

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we are great

https://vimeo.com/channels/glms/68703810

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. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

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Treating Pain With Truth – now an online “textbook”

collage

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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