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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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…

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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.

Screen Shot 2015-05-09 at 11.14.52 PM

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.

Screen Shot 2015-05-09 at 11.44.29 PM

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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certificate on mantle copy

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The Five Essentials for Pain Practice Success

cloudmpc

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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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.”

agree

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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westminster podium

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.

cs agree pic

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

microphone 5

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?

handshake_between_doctor_and_patient_with_the_sky_background_1341168865

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