I wouldn’t give 2 cents for the CDC opioid guidelines?

The world has until 11:59 pm EST today (January 13, 2016) to comment on the proposed United States Centers for Disease Control Guideline and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain. I got my two cents in just under the wire…

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Here are the twelve draft “Recommendations” from the CDC website along with my suggestions in italics.

 CDC RECOMMENDATIONS

Section (1) Determining When to Initiate or Continue Opioids for Chronic Pain

 

  1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

The phrase “pain and function” should be “pain or function.” Sometimes pain relief is reason enough to prescribe opioids. And “risks to the patient” should be “harm to the patient.” (The word “benefit” is very often coupled with “risk” when it more correctly should be coupled with “harm.”)

 

  1. Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

The last phrase should be “…only if there is meaningful improvement in pain or function that outweighs harm to the patient.” The word “clinically” is ambiguous and unnecessary.

 

  1. Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

The word “known” is unnecessary and ambiguous (i.e. Known by whom?)

 

Section (2) Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

 

  1. When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

The phrase “providers should prescribe” should be “providers should strongly consider prescribing…” (When starting opioid therapy there can be clinical scenarios where prescribing a ER/LA opioid would be the best course of action.)

 

  1. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/day.

The use of the arbitrary thresholds (50 mgms and 90 mgms) is acceptable here because the flexible helping verb “should” is used instead of the inflexible verb “shall.” This allows the provider some flexibility for clinical judgment.

 

  1. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.

This is reasonable as written.

 

  1. Providers should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.

Change the first two sentences to: “Soon after starting or escalating opioid therapy, providers should evaluate patients in order to gauge any benefits or harms associated with the treatment plan. This initial reevaluation is usually within the first four weeks. Providers generally should evaluate benefits and harms of continued opioid therapy every 3 months – and more frequently or less frequently depending upon the clinical course.”

 

Section (3) Assessing Risk and Addressing Harms of Opioid Use

 

  1. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or higher opioid dosage (≥50 MME) are present.

The second sentence should read: “Providers should incorporate into the management plan strategies to mitigate risk. One such risk mitigation strategy worth of consideration is offering naloxone when…”

 

  1. Providers should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

Change to: “Providers should review the patient’s history of controlled substance prescriptions by way of prescription drug monitoring program (PDMP) data, such as those offered by most states. This data can allow insight into aberrant and risky behaviors, such as when a patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months or longer – depending upon clinical and regulatory circumstances.”

 

  1. When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

Change to: “When prescribing opioids for chronic pain, providers should consider appropriate biologic tissue drug testing before starting opioid therapy. Additional drug testing should occur randomly and when clinically indicated.”

 

  1. Providers should avoid prescribing opioid pain medication for patients receiving benzodiazepines whenever possible.

Change to: “Providers should exercise caution when prescribing opioid pain medication for patients receiving benzodiazepines.”

 

  1. Providers should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

Change to: “Providers should offer or arrange evidence-based treatment (such as medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.”

 

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Overall, I am impressed with the amount of detail and collaborative effort that went into creating this impressive document. There are no easy answers and no universally accepted dictums – all the more reason to allow flexibility for clinical judgment. I hope we can continue to seek truth with open minds and open hearts. That’s my real recommendation, my two cents worth. 
The CDC draft is available at:
http://www.cdc.gov/drugoverdose/prescribing/guideline.html

My comments were posted to the CDC website and can be viewed at:
http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-4296

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The Least Meaningful Time of the Year

‘Twas the week before Christmas, and all through the clinic,
My patients were fuming, and I was a cynic.

My hopes had been dashed by “Affordable Care.”
I’d thought the ridiculous rules might be fair.

But patients were desperately seeking their meds,
‘Cause benefits had been curtailed by the feds.

The managed care mischief and benefits cap,
That sounded so good, was merely a trap.

Then out in the foyer arose such a clatter,
Someone’s co-pay was the crux of the matter.

Away to the window I flew like a flash,
Shut down the computer and asked him for cash.

He wasn’t abreast of his new plan in place,
That cut off his nose just in spite of his face.

When what to my wondering eyes did appear,
But a government man, somewhat tiny and weird.

He asked for an audit so detailed and quick,
That I prayed to the Lord, “This must be a trick.”

More than just illegal, this wasn’t a game.
And he whistled and shouted transgressions by name…

“You downcode! You miscode! You don’t even fix ‘em!
You’re sloppy! You’re stupid! More crooked than Nixon!”

“I’ll file my report! From on top you will fall!
Now cash you’ll pay! Cash you’ll pay! Cash you’ll pay! All!”

As dry heaves, that before a wild emesis fly,
When faced this obstacle, I thought I would die.

So onto his ribcage, my fingers they flew,
Which gave him no joy. He ain’t ticklish too.

And then in a twinkling, he wanted the proof,
And documentation for each little goof.

So I drew in my head what I thought would astound,
But this audit’s ridiculous claims did abound.

He addressed all inferred, and he read what was put,
In our policy manual, which was thick as a foot.

Our bundles of charges he said was a ruse,
And he scoffed at our data on Meaningful Use.

Then his knee! How it bucked! …It’s simple, so very.
It started to hemorrhage and looked rather scary.

It no-mattered at all was he friend or a foe,
For the loss of his blood made his suffering show.

So his stump of a leg I held tight, no conceding.
And my hands they encircled his thigh to stop bleeding.

He’d had a bad cut, from his leg to his belly.
But his bandage was only petroleum jelly.

I asked why he’d done oh so little to soothe.
“ ‘Cause that’s all,” he replied, “that my plan would approve.”

An i.v. for some fluids and lowering his head,
Soon gave him to know he had nothing to dread.

He asked why I’d saved him, though he’d been a jerk?
Physicians just do this. It’s just how we work.

Then thinking about his life saved, I suppose,
Giving a nod, from the stretcher he rose.

He then took his report, his scathing epistle,
And into the trash, threw it down like a missile.

And I heard him exclaim, as he drove out of sight,
“Don’t you ever give up. We need you in the fight.”

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Acute Pain Management for the Patient on Chronic Opioid Therapy

Screen Shot 2015-12-01 at 10.24.50 AMPatients benefitting from the therapeutic effects of chronic opioid therapy generally fall into two categories: (1) chronic pain treatment and (2) addiction “medication assisted treatment.” Both groups will at times need additional pain care measures to address acute issues, such as: trauma, surgery, and hospitalizations. Care providers, in trying to find the right balance between too much and too little, can find these situations challenging.

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Today (December 1, 2015)  I am traveling to Leitchfield, Kentucky to conduct a seminar at Twin Lakes Regional Medical Center on acute pain management for the patient on chronic opioid therapy. Below are the slides that I prepared, followed by the references. My hope is that, whether you are a healthcare provider or recipient, as you peruse this information and explore the references and links a better understanding will emerge and your comfort level will improve. 

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Guidelines for Perioperative Management of Buprenorphine

http://www.theapms.com/sitePagesContent/stephens-docs/SuboxoneInfoStephens.pdf

 

ASAM Definition of Addiction

https://www.naabt.org/documents/APS_consensus_document.pdf

 

Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816

 

Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction

http://www.thci.org/Opioid/June11docs/Session8_ALFORD%20MAT%20pain%20management%206-9-11%20FINAL.pdf

 

Clinical Opiate Withdrawal Scale

https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf

 

Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846172/

 

Methadone Dose Conversion Guidelines Adapted from AAHPM Palliative Care Primer, 2010 edition with permission from Timothy Quill M.D.

http://www.compassionandsupport.org/pdfs/professionals/pain/Methadone_Dose_Conversion_Guidelines.051810_.pdf

 

Buprenorphine Hydrochloride Injection

http://www.hospira.com/en/images/EN-2088_tcm81-5649.pdf

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http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf

 

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A stellar time at Bellarmine

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On Thursday, September 24, 2015, I had the pleasure of serving as a guest “professor” for about sixty or so students at Bellarmine University, Louisville, KY. I promised them I would post some of the major points discussed along with some links for reference.

Here we go…

(1) We have a big problem in this country with drug abuse. To illustrate, a recent 2014 government survey found that about 1 in 10 Americans (12 years or older) have used an illicit drug in the past thirty days! About two-thirds of the abuse drugs are pharmaceuticals.

Ref: http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

(2) Drug overdose deaths continue to increase and are now the leading cause of deaths from injury in the United States, even outpacing deaths due to motor vehicle accidents.

Ref: http://www.medscape.com/viewarticle/846636

(3) While drug overdose deaths have been on the rise for the past two decades, the number of drug overdose deaths from heroin use has skyrocketed recently – up by 39% over the past 3 years.

Ref: http://www.cnn.com/2015/01/14/health/heroin-deaths-increase

(4) Obviously, prescription drugs help many people. Take for example the most abused class of drugs – opioids (i.e., morphine-like drugs). Opioids are powerful painkillers that many suffering people need to have any quality of life. Pain is a big problem in this country too. Here are some pain facts, courtesy of our government:

-Pain affects more Americans than diabetes, heart disease and cancer combined.

-Pain is cited as the most common reason Americans access the health care system.

-One in every four Americans, have suffered from pain that lasts longer than 24 hours and millions more suffer from acute pain.

-Chronic pain is the most common cause of long-term disability.

Ref: http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57

Note: There is evidence to suggest treating previously drug-naïve chronic pain patients with opioids is associated with a very low risk of addiction. The presence of ongoing pain appears to lower rather than increase the risk of opiate addiction.

Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133

(5) The majority of individuals abusing opioids (usually young people) are getting “high” taking grandma’s Oxycontin, stealing it or buying it from their friends or relatives and do not get them from their physician.

Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133

(6) Words matter. Here are some important words to understand:

Tolerance– the body adapts to the drug, requiring more of it to achieve a certain effect

Physical dependence– the body adapts to the drug, eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). This can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction.

Ref: http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/there-difference-between-physical-dependence

Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal.

ADDICTION: a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

The FOUR C’s of ADDICTION

CONTROL, LOSS OF

COMPULSIVE USE

CONTINUED USE DESPITE HARM

CRAVING

Ref: http://www.asam.org/for-the-public/definition-of-addiction

(7) Risk factors of developing addiction:

Genetics: Addiction tends to run in families. Heredity is a major risk factor for addiction. In fact, scientists estimate that 40 to 60 percent of a person’s risk for addiction is based on genetics.

Age: The younger the user is, the more likely he or she is to become addicted.

Environment: Where one lives, works, and plays can be factors.

Mental health: Underlying mental health issues can increase the risk of addiction.

Drug of choice: The object of the addiction can play a role.

Speed to reach the brain: Drugs that are smoked or injected into the body tend to be more addictive than those that you swallow.

Ref: http://www.healthline.com/health/addiction/risk-factors#Overview1

These are just some of the major points that were covered. The class was engaged, attentive, and focused. I am certain I was speaking to future leaders and policymakers as well. I truly believe that the world in which I will soon live belongs to them. I feel this group now better understands the complexity of balancing preventive and therapeutic drug control with the necessity to allow effective pain care for the suffering.

I humbly thank the students for their earnest attention and their professor, Dr. Marylee Jamesfor the invitation.

I look forward to their thoughts and actions.

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And thanks for the Bellarmine swag!

Go KNIGHTS!

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Leadership, steadfast and plucky

He showed us daily, with his words and actions, what it really means to be a servant-leader.
– Bert Guinn, MBA, CAE, Executive Director, Greater Louisville Medical Society

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Today was truly the end of an era for Louisville’s medical community. After thirty-five years of incredible service to the Greater Louisville Medical Society, Lelan Woodmansee is retiring. At stately Whitehall Mansion, hundreds gathered to say good-bye and thank you.
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Having now passed the baton (literally) to his protégé, Bert Guinn, Lelan and his soul mate Marlena will finally have time to travel, visit family, and enjoy a little down time. He will be missed, but his presence will be felt for generations to come. As Dr. Gordon Tobin so eloquently put it, “Our members are the bricks but Lelan was the mortar.”

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During my time with the GLMS, Lelan was more than my Chief Executive. He was my mentor, counselor and friend. He deserves an epic poem, however it is late and an epic limerick will just have to do.

 

 

There was a young man named Woodmansee,
Felt writing might tickle his fancy.
He thought it was great,
At Ohio State,
But later he got really antsy.

 
So travelled he down to Kentucky.
For this we are all very lucky.
He gave it his best,
At GLMS,
With leadership, steadfast and plucky.

 
His value is more that you can see.
He helped us be all that we can be.
Three decades have gone,
Now we say, “So long,”
To our dear friend Lelan Woodmansee.

 

 

 

You are invited to read all about this amazing person in the August issue of Louisville Medicine.
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http://www.joomag.com/magazine/mag/0693170001438189547?feature=archive

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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. 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

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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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