TAPERING OPIOIDS FOR CHRONIC PAIN… WHAT DOES THE CDC SAY?

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When in the course of human events it becomes necessary for patients to dissolve the chemical bonds which have connected them with opioids, one can look to the Centers for Disease Control for guidance.

Tapering opioids (and benzodiazepines) was addressed multiple times in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. Here are some instructive excerpts, reproduced in an effort to preserve consistency with the guideline’s overriding message…

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Link: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence.

Experts noted that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.

Clinicians should remain alert to signs of anxiety, depression, and opioid use disorder that might be unmasked by an opioid taper and arrange for management of these co-morbidities.

For patients agreeing to taper to lower opioid dosages as well as for those remaining on high opioid dosages, clinicians should establish goals with the patient for continued opioid therapy, maximize pain treatment with nonpharmacologic and nonopioid pharmacologic treatments as appropriate, and consider consulting a pain specialist as needed to assist with pain management.

Although the clinical evidence review did not find high-quality studies comparing the effectiveness of different tapering protocols for use when opioid dosage is reduced or opioids are discontinued, tapers reducing weekly dosage by 10%–50% of the original dosage have been recommended by other clinical guidelines, and a rapid taper over 2–3 weeks has been recommended in the case of a severe adverse event such as overdose.

Experts noted that tapers slower than 10% per week (e.g., 10% per month) also might be appropriate and better tolerated than more rapid tapers, particularly when patients have been taking opioids for longer durations (e.g., for years).

Opioid withdrawal during pregnancy has been associated with spontaneous abortion and premature labor.

When opioids are reduced or discontinued, a taper slow enough to minimize symptoms and signs of opioid withdrawal (e.g., drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection) should be used.

A decrease of 10% of the original dose per week is a reasonable starting point; experts agreed that tapering plans may be individualized based on patient goals and concerns.

Experts noted that at times, tapers might have to be paused and restarted again when the patient is ready and might have to be slowed once patients reach low dosages.

Tapers may be considered successful as long as the patient is making progress. Once the smallest available dose is reached, the interval between doses can be extended. Opioids may be stopped when taken less frequently than once a day.

More rapid tapers might be needed for patient safety under certain circumstances (e.g., for patients who have experienced overdose on their current dosage). Ultrarapid detoxification under anesthesia is associated with substantial risks, including death, and should not be used.

Clinicians should access appropriate expertise if considering tapering opioids during pregnancy because of possible risk to the pregnant patient and to the fetus if the patient goes into withdrawal.

Patients who are not taking opioids (including patients who are diverting all opioids they obtain) do not require tapers.

Clinicians should discuss with patients undergoing tapering the increased risk for overdose on abrupt return to a previously prescribed higher dose.

Primary care clinicians should collaborate with mental health providers and with other specialists as needed to optimize nonopioid pain management, as well as psychosocial support for anxiety related to the taper.

If a patient exhibits signs of opioid use disorder, clinicians should offer or arrange for treatment of opioid use disorder and consider offering naloxone for overdose prevention.

For pregnant women already receiving opioids, clinicians should access appropriate expertise if considering tapering opioids because of possible risk to the pregnant patient and to the fetus if the patient goes into withdrawal.

If tests for prescribed opioids are repeatedly negative, confirming that the patient is not taking the prescribed opioid, clinicians can discontinue the prescription without a taper.

Because of greater risks of benzodiazepine withdrawal relative to opioid withdrawal, and because tapering opioids can be associated with anxiety, when patients receiving both benzodiazepines and opioids require tapering to reduce risk for fatal respiratory depression, it might be safer and more practical to taper opioids first.

Clinicians should taper benzodiazepines gradually if discontinued because abrupt withdrawal can be associated with rebound anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death.

A commonly used tapering schedule that has been used safely and with moderate success is a reduction of the benzodiazepine dose by 25% every 1–2 weeks.

If benzodiazepines prescribed for anxiety are tapered or discontinued, or if patients receiving opioids require treatment for anxiety, evidence-based psychotherapies (e.g., CBT) and/or specific anti-depressants or other nonbenzodiazepine medications approved for anxiety should be offered. Experts emphasized that clinicians should communicate with mental health professionals managing the patient to discuss the patient’s needs, prioritize patient goals, weigh risks of concurrent benzodiazepine and opioid exposure, and coordinate care.

For patients with problematic opioid use that does not meet criteria for opioid use disorder, experts noted that clinicians can offer to taper and discontinue opioids. For patients who choose to but are unable to taper, clinicians may reassess for opioid use disorder and offer opioid agonist therapy if criteria are met.

 

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https://www.cdc.gov/drugoverdose/pdf/Clinical_Pocket_Guide_Tapering-a.pdf

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CDC Guideline for Prescribing Opioids for Chronic Pain www.cdc.gov/drugoverdose/prescribing/guideline.html

 

Washington State Opioid Taper Plan Calculator www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

 

Tapering Long-Term Opioid Therapy in Chronic Noncancer Pain www.mayoclinicproceedings.org/article/S0025-6196(15)00303-1/fulltext

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Prescribing Controlled Substances in Kentucky – A presentation for The Kentucky Osteopathic Medical Association annual meeting, June 8, 2018

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On June 8, 2018 it was my honor to present to the Kentucky Osteopathic Medical Association (KOMA) an update regarding requirements to prescribe controlled substances, particularly opioids, for chronic pain patients in Kentucky. It is nearly impossible to cover every important aspect of this subject in one hour, however I gave it an earnest effort. And as I promised the gracious KOMA attendees, what follows is the principal content of my presentation. To my osteopath colleagues, I thank you for all that you do, and I deeply appreciate the invitation to present at your annual meeting.

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Dropbox link for related documents of interest:

https://www.dropbox.com/sh/onebv2dyj0f3qpa/AACo4LxBLYmGLcSvy7MKxdEBa?dl=0

 

 

Related links of interest:

Kentucky Board of Medical Licensure (KBML website)
https://kbml.ky.gov/Pages/index.aspx

 

 

Considerations for Patient Education (KBML)
https://kbml.ky.gov/hb1/Pages/Considerations-For-Patient-Education.aspx

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

 

 

THE CHRONIC PAIN PATIENT’S GUIDE TO KENTUCKY’S REGULATIONS<

https://jamespmurphymd.com/2015/02/13/pathway-to-partnership/

PLAN TO THINK… HOW TO PRESCRIBE CONTROLLED SUBSTANCES IN KENTUCKY FOR THE FIRST THREE MONTHS

https://jamespmurphymd.com/2015/06/

 

 

 

ARE WE IN AGREEMENT? …One Pain Specialist’s Take on the Controlled Substances Prescriber-Patient Agreement 

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

 

 

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A Letter in Support of a Support Group

groucho

Dear colleague,

I know a “club” in Jeffersonville that would welcome Groucho with open arms. It’s a new chronic pain support group meeting on Wednesday, April 11, 2018 at St. Paul’s Episcopal Church.

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This is needed. The CDC Guideline for Prescribing Opioids for Chronic Pain has been declared the best practice. And the guideline’s very first recommendation is:

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

The CDC Guideline further recommends: …there are free or low-cost patient support, self-help, and educational community-based programs that can provide stress reduction and other mental health benefits.

In fact, support groups, like the new one in Jeffersonville, are one of the most overlooked ways of treating pain, which is unfortunate considering the multitude of benefits a person can receive from such groups. Chronic pain can be a lonely experience. Even patients with strong personal social networks often feel isolated and unsupported. Evidence has shown that a pain support group can augment pain relief measures while encouraging improved function.

Thus, I am spreading the word about the new chronic pain support group in Jeffersonville:

ST. PAUL’S EPISCOPAL CHURCH, EDUCATION WING
321 E. Market St, Jeffersonville, IN 47130
@ the corner of Walnut & Market Streets

The next meeting will be: WEDNESDAY, APRIL 11, FROM 4:00 to 5:30 PM

I attended a meeting and found the group to be welcoming and casual. The moderator, Marylee, is a great facilitator of supportive group interaction. The group is relatively new and would like to grow. It’s is a grass roots effort with structure, but still flexible. The location is convenient. There is no charge to attend. All are welcome. Informative flyers are attached to this email.

So, if you have a patient or just know someone who might benefit from some “nonpharmacologic” and “nonopioid” therapy for their chronic pain, well now you have a CDC recommended option that will never need an insurance prior-authorization. It just needs you and me to pass it on.

God’s dream is that you and I and all of us will realize that we are family,that we are made for togetherness, for goodness, and for compassion. – Desmond Tutu

All the best,

James Patrick Murphy, MD

Medical Director and CEO, Murphy Pain Center

720 Rolling Creek Drive, Suite 101
New Albany, Indiana 47210
Main Office: (502) 736-3636
Appointments: (502) 736-2902
Toll Free Fax: (877) 497-8259
Website: http://www.murphypaincenter.com/louisville
SEAK Directory listing: https://goo.gl/gdEkNr

REFERENCES:
The Development and Impact of a Chronic Pain Support Group. J of Pain and Symptom Mgmt., 1999, Vol 7, Issue 5 http://www.jpsmjournal.com/article/S0885-3924(99)00012-3/fulltext?showall=true%3D

Mayo Clinic Website: https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/support-groups/art-20044655

CDC Guideline for Prescribing Opioids for Chronic Pain https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

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Flyers, courtesy of Marylee James, a.k.a. https://maryleejames.com

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Prescribing Controlled Substances in the Midst of a Crisis – A presentation for Ohio County Hospital

What if you knew her and found her dead on the ground?
How can you run when you know?
 Ohio by Crosby, Stills, Nash & Young

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On March 9, 2018 in Hartford, Kentucky it was my pleasure to offer for the medical staff of Ohio County Hospital, on behalf of Norton Healthcare, a 1.5 hour presentation on prescribing controlled substances in Kentucky – guidelines and regulations.

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This post contains pictures of the handout, which covers most of the important points.

My PowerPoint presentation, along with other useful information, can, for a limited time, be downloaded from my Dropbox at this link: https://goo.gl/6bk8ZY

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This is an elephant*

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There is an Indian fable about a group of blind wise men asked to describe an elephant. Each felt only the part of the pachyderm closest to him and thus came up with vastly different truths as to what an elephant is.

Our country has an elephant in our room and it’s called the OPIOID CRISIS. And many of our wise men and women are trying very hard to slay this colossus. Sadly, like the blind men in the fable, they often take aim at only what’s in front of them, missing the heart of the matter and making the beast more angry.

For many, the opioid crisis is primarily perceived as a prescribing problem. Thus, their weapon of choice is PAIN REGULATIONS.

One example of this is House Bill 333, passed this summer by Kentucky’s legislature and later turned into regulations by the Kentucky Board of Medical Licensure on November 15, 2017. These new regulations are have been advertised as (a) merely imposing a three-day limit on prescribing controlled substances for acute pain, because (b) the CDC Guideline demands it. In fact, the clearly voluntary CDC Guideline falls way short of demanding anything…Screen Shot 2017-12-08 at 10.25.53 AM

…And the new Kentucky regulations dictate more than has been advertised.

Even before House Bill 333 came along, embedded in the many pages of Kentucky pain regulations was this dictum:
“The physician shall discontinue controlled substance treatment or refer the patient to addiction management if: There has been no improvement in function and response to the medical complaint and related symptoms, if improvement is medically expected.”

And, as pointed out earlier, Kentucky physicians have been led to believe that the only new regulation is a three-day limit on prescribing schedule two controlled substances to treat acute pain. But there’s more. Much more.

For starters, Kentucky has added a new definition of “high risk” regimens: “dosages greater than or equal to fifty (50) MME/day or opioids with benzodiazepines, without evidence of benefit.” (MME = morphine milligram equivalent)

Now, going forward if a patient meets these criteria…

Or: “Controlled substance therapy has produced significant adverse effects, including instances such as an overdose or events leading to hospitalization or disability”

Or: “The patient exhibits inappropriate drug-seeking behavior or diversion”

Then the physician shall “taper controlled substances.”

But wait, you can’t just taper someone anyway you want to anymore. Now you must taper the medications “in a manner slow enough to minimize symptoms and signs of opioid withdrawal.”

And, hold on, we aren’t done with these new tapering regulations yet. While you are slowly and carefully tapering you must also, “Collaborate with other specialists as needed to optimize nonopioid pain management and psychosocial support for anxiety related to the taper.”

So, let’s review what you have learned about this new regulatory elephant gun:

(1) We are now prohibited (with some exceptions) from giving more than three days of schedule two meds for acute pain.

(2) We’d better find a way to adequately document that there is benefit to our “high risk” regimens.

(3) If virtually anything goes awry, we now must taper very carefully (and with the help of specialists to relieve the patient’s anxiety) to minimize withdrawal symptoms.

(4) And I have failed to mention that, inexplicably, there is now the requirement that a physician “shall stop prescribing or dispensing any controlled substance taken less frequently than once a day.” So if you are somehow able to get your patient to take less pain medication, and it becomes needed less frequently than everyday, your wonderful patient gets rewarded by you having to stop prescribing pain meds altogether? Seriously, what part of the elephant were they feeling when they wrote that regulation?

In conclusion, my purpose in writing this article is not to be overly critical of the well-meaning people who write our regulations. I simply want my colleagues in Kentucky to know that there is much more to the opioid crisis elephant than simply the prescribing component and much more to Kentucky’s new pain regulations than just a limit on acute pain meds. Please don’t get trampled.

Disclaimer: This is not medical or legal advice. This is my personal opinion. Please read the regulations yourself and get a lawyer if you want legal advice.

References:
Indian fable:https://wildequus.org/2014/05/07/sufi-story-blind-men-elephant
OpioidCrisis:https://www.cdc.gov/drugoverdose/epidemic/index.html
CDCGuideline:https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
KBML Pain Regs:https://kbml.ky.gov/board/Pages/krs-amendment.aspx

*This is Water. Commencement Speech to Kenyon College class of 2005 written by David Foster Wallace:  https://www.youtube.com/watch?v=8CrOL-ydFMI

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CORE VALUES

ATTENTION – all clinicians who engage in the noble, but angst-engendering, practice of prescribing opioids for chronic pain…. For those prescribers who wonder how or if they can ever get their patients to use less opioid, this blog post is for you.

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Do you want your patients on fewer opioids?

Announcing!

Murphy Pain Center’s

Chronic Opioid Reduction Empowerment Program

C. O. R. E.

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“Established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence. However, these patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk.” – CDC Prescribing Guideline

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* KENTUCKY’s PAIN REGULATIONS require PHYSICIANS to refer the patient to addiction management if: (1) There has been no improvement in function; (2) Therapy has produced significant adverse effects; or (3) The patient exhibits inappropriate drug-seeking behavior or diversion.

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**INDIANA’s ATTORNEY GENERAL directs PRESCRIBERS to “Develop a personal relationship with a PAIN PHYSICIAN. The pain specialist can act as your THERAPEUTIC SHIELD.”

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As a PAIN and ADDICTION specialist I can assess your most challenging patients and develop plans to reduce or eliminate the need for opioids. My C. O. R. E. program can act as your “therapeutic shield.”

Dr Murphy Pain and Addiction

C.O.R.E. is a collaborative approach to caring for the pain patient on chronic opioid therapy. The goal is to reduce dependence on opioid pain medication. The program begins with an evaluation by Dr. James Patrick Murphy – Pain and Addiction Specialist. Then, a plan to minimize opioids is developed that both the patient and referring physician find acceptable. At the conclusion of the C.O.R.E. program the patient returns to the referring physician with Dr. Murphy providing support and guidance as needed. This ongoing relationship with Dr. Murphy has been described by Indiana’s Attorney General as the prescribing physician’s THERAPEUTIC SHIELD, but you will come to think of it as your peace of mind.

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BEFORE WRITING ANOTHER Rx FOR OPIOIDS YOU OWE IT TO YOURSELF TO CALL

(502) 736-3636

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James Patrick Murphy MD

720 Rolling Creek Drive, Suite 101

New Albany, IN 47150 

References:

* 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances

** First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain

 

New: Indiana’s Pain laws, limiting opioid prescribing to seven days (added to post on 6.29.17) http://iga.in.gov/static-documents/b/9/5/2/b9523207/SB0226.05.ENRH.pdf

Pain Management Opioid Taper Decision Tool A VA Clinician’s Guide:
https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

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Links of interest:

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When Breath Becomes Air…Becomes Me

WBBA

I knew I would love this book.

When I learned that a young doctor had written about his journey to the end of his life, I thought I would probably find his words meaningful. Individuals who are keenly aware of their mortality and are willing to talk about it, usually can find something important to say.

What I didn’t expect was how much this important book, When Breath Becomes Airwould become me.

Dr. Paul Kalanithi died on March 9, 2015, only weeks after completing his Neurosurgery residency at Stanford. Tragically, he had been diagnosed with lung cancer 22 months earlier as he was entering his final year of residency. But rather than curl up in a corner, he cried, grieved, embraced his wife Lucy, and lived every remaining moment on his own terms.

Even if I’m dying, until I actually die, I am still living.

Through multiple rounds of chemotherapy, physical therapy, endless tests, and unrelenting pain, Paul (I call him “Paul” because I feel like I really know him) cared for patients, loved his family, had a baby, and wrote a book.

When Breath Becomes Air has five distinct parts: Foreword, Prologue, Part I, Part II and Epilogue. Each part could stand alone as fantastic literature, but when taken together the whole becomes transcendent.

The foreword was written by Dr. Abraham Verghese, Paul’s Stanford colleague who, like the reader, really didn’t know Paul very well until after his death.  Dr. Verghese eloquently sets the stage for the reader’s journey and perfectly ends his foreword with: Let me not stand between you and Paul.

Paul’s writing begins with the prologue, where we witness this young man’s life being completely broadsided by his cancer diagnosis. But it’s not just Paul’s story that draws you in, it’s how he tells his story, the images his words create.

Now I lay there, wide awake. A young nurse, one I hadn’t met, poked her head in.  
“The doctor will be in soon.”
And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

The reader cannot help but feel sorry for Paul’s plight. But we are just beginning to know him. After the prologue, Part I is Paul’s account of growing up in the remote town of Kingman, Nevada. His father was a cardiologist, his mother a tireless advocate for Paul and the other young would-be scholars in that desert town.

And while I was highly interested in Paul’s story, it’s his account of medical school -especially his cadaver lab- that made me feel like I had found a kinsman. I can’t imagine any doctor reading Part I and not coming away with the same feeling of connectedness.

And it just gets better and better, as we are there with Paul through the ups and downs of medical school and residency. Being a doctor, with all the responsibility and pressure, can be lonely. Paul’s writing not only made me feel connected to him, but to all doctors as well. All doctors go through many of the same crises, deal with the same emotions, and struggle with the same problems that Paul describes in Part I.

Then, after Part I left me feeling like Paul and I were family, along comes Part II and a kick to the gut. In language that is pure poetry, Paul recounts the series of events encompassing his head-on struggle with cancer and tries to put them into context. Near the end of Part II his language is noticeably more thick with meaning and metaphor. He was clearly more ill and suffering when he authored his final pages. Parts I and II are Paul’s voice, and when Part II ends we fear the worst and feel the loss.

The epilogue comes next, authored by Paul’s wife Lucy, also a nascent physician. Her job is to tell us the details of how Paul died and how she and their daughter, Cady -to whom the book is dedicated- are getting along. We need to know, because after all, by this time the reader feels like one of their family, needing closure, needing consoling, needing comfort.

I knew I would love this book, but I didn’t know that I would feel so close to Paul, Lucy, and Cady. It might be because Paul died just over a year ago. The emotions are still at the surface. Lucy and Cady still live in the San Francisco area. They are real people (I know because Lucy “favorited” one of my Twitter posts about the book). This is not fiction.

It also might be due to the shared experiences that Paul and I (and every other doctor) have in common.

But I’m certain that a major reason I love this book is that it is so well written. Dr. Verghese’s foreword aptly declared: The prose was unforgettable. Out of his pen he was spinning gold.

I agree. There are many passages in Paul’s book that could stand on their own and glisten with poignancy. Did I mention that I love this book? I could offer numerous examples of how wonderfully When Breath Becomes Air is written, but being a physician I think I’ll end my review with Paul’s take on the physician’s duty:

The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

When Breath Becomes Air should be required reading for any premed or medical student, resident, attending physician, retired doctor, patient, future patient, or mortal human being. It’s that good.

Thank you Paul and Lucy. Because of When Breath Becomes Air, this beautiful literary gift, we can all come a bit closer to making sense of our own existence.

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From the website: PaulKalanithi.com:

Paul Kalanithi, M.D., was a neurosurgeon and writer. Paul grew up in Kingman, Arizona, before attending Stanford University, from which he graduated in 2000 with a B.A. and M.A. in English Literature and a B.A. in Human Biology. He earned an M.Phil in History and Philosophy of Science and Medicine from the University of Cambridge before attending medical school. In 2007, Paul graduated cum laude from the Yale School of Medicine, winning the Lewis H. Nahum Prize for outstanding research and membership in the Alpha Omega Alpha medical honor society. He returned to Stanford for residency training in Neurological Surgery and a postdoctoral fellowship in neuroscience, during which he authored over twenty scientific publications and received the American Academy of Neurological Surgery’s highest award for research.

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Video: A Strange Relativity: Altered Time for Surgeon-Turned-Patient

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