Media update…

Relatively recently, I’ve participated in three presentations that I’d like to share: (1) Louisville Bar Association, (2) Louisville Forward Radio, and (3) the KY Harm Reduction Coalition

First is a discussion about the medical potential, as well as the risks, of marijuana.

Here’s four good references I used for the medical marijuana forum…

(1) American Medical Association:

(2) American Society of Addiction Medicine:

(3) American Psychiatric Association:

(4) Greater Louisville Medical Society (my article begins on page 16):

And second, I’d like to share a two-part discussion on “the opioid crisis” from Louisville Forward Radio

Dr. Pat Murphy, pain and addiction specialist in a discussion with Mike Flynn and Gene Shively regarding the U.S. addiction epidemic and a healing path forward.

Part 1 • March 10, 2022

Part 2 • June 7, 2022

And finally, here is a video posted on the Kentucky Harm Reduction Coalition’s Facebook page with me discussing, what else? – Harm Reduction.

We interviewed board member and addiction specialist Dr. James Murphy on all things addiction, harm reduction, and the opioid epidemic. Give it a watch and spread the word – together we can break the stigma!

Medication Assisted Treatment – a Presentation for the Kentucky Department of Public Advocacy • 50th Annual Public Defender Education Conference • The Galt House Hotel • Louisville, KY, June 13, 2022

On June 13, 2022, I had the pleasure of presenting on the topic of MAT, i.e., Medication Assisted Treatment, or more recently known as MOUD, Medication for Opioid Use Disorder. Here is a selected portion of my slides, with some recommended references at the end. I sincerely appreciate being asked to give this presentation to such a wonderful and vital group of people serving our community and our justice system. It was an honor to be there with them for their Annual Public Defender Education Conference.


• AMA  –  The nation’s drug-related overdose epidemic

 • OPIOID TASK FORCE 2020 PROGRESS REPORT (AMA), Physicians’ progress toward ending the nation’s drug overdose and death epidemic

• Methadone and buprenorphine reduce risk of death after opioid overdose – News Release, June 19, 2018

• 2020 Overdose Fatality Report Kentucky Office of Drug Control Policy

• 2021 Overdose Fatality Report Kentucky Office of Drug Control Policy


• Public Policy Statement on Substance Use, Misuse, and Use Disorders During and Following Pregnancy, with an Emphasis on Opioids – ASAM

• Treatment in Correctional Settings Toolkit – ASAM

• SAMHSA TIP 63: Medications for Opioid Use Disorder – Full Document.

• Parsons, Jim: Minimizing Harm: Public Health and Justice System Responses to Drug Use and the Opioid Crisis by Jim Parsons. Vera Evidence Brief. December 2017

• Against Our Instincts: Decriminalization of Buprenorphine – John C. Messinger, Anand Chukka and J. Wesley Boyd.The Journal of the American Board of Family Medicine March 2022,  35 (2) 394-397; DOI:

• The Science of Opioid Addiction and Treatment – NOVA PBS

During COVID-19, Telephone calls are telemedicine – an open letter to Indiana’s Governor Holcomb*




Once a prescriber has conducted an in-person medical evaluation or has conducted an evaluation using an audio-visual, real-time, two-way interactive communication system for the initial prescription; further health consultation may be done via audio-only or audio-visual telecommunication, as long as all other applicable state and federal laws are followed.  (LINK:



Dear Governor Holcomb,

I am a New Albany, Indiana physician with an urgent plea. During the COVID-19 emergency, Indiana must allow prescribers to treat pain patients on opioids via audio-only telemedicine. Currently the requirement is for audio-visual telemedicine.

On March 6, 2020, Indiana declared a state of emergency due to COVID-19. As a result, extraordinary measures have been taken to allow patients to shelter in their homes. However, many chronic pain patients, among the most vulnerable to the SARS-CoV-2 Coronavirus, are still required to have in-person face-to-face visits with prescribers in order to receive a prescription for a controlled substance. This is because, although Indiana now allows audio-visual telemedicine for follow-ups, the state does not allow audio-only telephone calls to serve as telemedicine for controlled substance follow-up visits.

This has to change immediately.

We know that many people, especially the elderly, do not have access to audio-visual telecommunication. However, everyone has a telephone. Therefore, Indiana practitioners must be allowed to conduct audio-only telephone follow ups when prescribing controlled substances for their patients, especially patients who have previously had an in person examination. As it stands now, to prescribe an opioid via telemedicine, the Indiana Professional Licensing Agency still includes a requirement that: “The telecommunication is conducted using an audio-visual, real-time, two-way interactive communication system.”

Indiana has fallen dangerously behind the curve on this issue.

For example, look to the DEA’s COVID-19 Prescribing Guidance, which has been updated “to allow DEA-registered practitioners to prescribe controlled substances without having to interact in-person with their patients.” Specifically, the DEA now allows prescribers who have “previously examined the patient in person” to “conduct any needed follow-up evaluation by any method: in person, telemedicine, telephone, email, etc.”

And the American Medical Association’s “COVID-19 policy recommendations for OUD, pain, harm reduction” could not be more clear: “For patients with chronic pain, waive testing requirements and in-person counseling requirements for refills; allow for telephonic counseling to fulfill state prescribing and treatment requirements.”

In these extraordinary times, we must do everything in our power to ensure that all patients can access care remotely when at all possible. And for our patients with chronic pain on opioid therapy, the extreme stress from withdrawal or fear of withdrawal must be prevented or else we shall see increased and unnecessary morbidity and mortality amongst our citizenry. When patients are forced to leave their safe homes for face-to-face visits with providers, they imperil their lives, the lives of healthcare workers, and the lives of their community.

Audio-visual telemedicine, despite the perceived advantages as compared to a simple telephone call, is not feasible for many vulnerable Hoosiers. Indiana must join with the DEA, the AMA, and numerous other private and government organizations and immediately allow providers to remotely treat patients, for whom controlled substances are necessary, via any appropriate method, including audio-only telecommunication.

Thank you for your service to Indiana and thank you for taking the time to read this e-message. As soon as I hit “send” I will be on the telephone with my patient, Judy, who is 73, crippled with unimaginable arthritis, sheltering in her home, and anxiously waiting for her doctor to call. I have provided you my personal cell phone number in case you or someone on your staff would like to call me. I must apologize in advance, however, if the line is busy. As you well know, these are extraordinary times.


James Patrick Murphy, MD

Medical Director, Murphy Pain Center, New Albany, IN
Assistant Clinical Professor, University of Louisville School of Medicine
Past-president, Greater Louisville Medical Society
Member, American Medical Association Pain Care Task Force

April 2, 2020


Governor Eric J. Holcomb’s phone number is: 317-232-4567
And the Governor can be emailed via this link:


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Where a prescription for a controlled substance is issued by means of the Internet, the CSA (as amended by the Ryan Haight Act) requires that such prescription involve at least one in-person medical evaluation, with limited exceptions. After conducting one in-person medical evaluation, a practitioner may thereafter prescribe controlled substances by means of the Internet or via telephone.

  • DEA068 – March 31, 2020

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A verbal response to my question (see above) was transmitted during the Q&A portion of the Indiana State Department of Health Provider Webcast on April 3, 2020 and was encouraging:

Yes, we are doing this. We are putting together all the waivers that are done into a package and as soon as all the right people approve that will be done. So we heard you. I brought your question last week to the powers that be and they agree. So we’re working on that. 

  • Lindsay Weaver, MD, FACEP, Chief Medical Officer, Indiana State Department of Health

Thank you, Dr. Weaver.

•     •     •     •     •

APRIL 9, 2020 UPDATE: 

Today another Indiana State Department of Health Provider Webcast took place. At the conclusion, I asked this question of Dr. Weaver:

april 9 indiana webcast

DoctorJamesMurphy: Just to be clear, the information on the slide you posted today regarding controlled substances prescribing does not allow for audio-only telephone calls. The DEA specifically allows for audio-only telephone calls. Kentucky allows this. We are behind the curve on this. We need this in Indiana. Can you comment on the progress made in getting this done?

And here was the answer that Dr. Weaver recited on air:

So this again is a question about audio-only telephone calls. So I spoke specifically with our group about this and they did feel like it allowed for audio-only telephone calls. So I don’t know where the miscommunication is. I think there probably is another point to that waiver or that order that wasn’t included in that slide. If you just want to go ahead and send you name, then we can follow up with you or your email address. [Addendum: I immediately sent my email address]

Here is what I believe to be the miscommunication:

Dr. Weaver’s slide says this:

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This slide indicates that Executive Order 2020-13 allows for “using a real-time, two-way interactive communication system.” This would appear to include audio-only telephone calls. But wait…

Dr. Weaver’s slide is not consistent with what Executive Order 2020-13 actually says, see below:

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And there is more to the story… Executive Order 20-13 also says this:

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In other words, Executive Order 20-13 seems to lift the prohibition against audio-only telemedicine by amending Indiana’s definition of telemedicine to include audio-only phone calls. Here is actual language from Indiana Code 25-1-9.5-6 that Executive Order 20-13 amends:

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Therefore, it would seem that telemedicine in Indiana might now include “audio-only communication.”

So, as of 4:30 pm on April 9, 2020 here is where I believe this stands:

The slide presented today from Dr. Weaver, acting as an agent of the Indiana Department of Health, would appear to give a green light to audio-only telephone calls for issuing a controlled substance. But Dr. Weaver’s slide references Executive Order 20-13 that clearly does not say that audio-only telephone calls are sufficient.  Where did Dr. Weaver get the verbiage for her slide?

And the COVID-19 updates to the the Indiana PLA website only references the previous Executive Order 20-12, which, like Executive Order 20-13, does not give the “OK” for audio-only telephone calls.

On top of that, the Indiana prescribing regulations, which no one is mentioning, still mandate a face-to-face visit (i.e. no mention of a telemedicine option) at least every four months.

From my non-lawyer, not offering legal advice, physician taking care of patients day in and day out point of view, it seems that somewhere in this cacophony of regulations, orders and pronouncements there is probably enough leeway to allow Indiana prescribers to go ahead and act in the best interest of their patients.

Dr. Lindsay Weaver is a board-certified Emergency Medicine physician engaged in battling the defining medical crisis of our time. She is doing an admirable job. And, with regards what the regs and the laws say we can and cannot do when prescribing controlled substances, she and I can totally agree on this…

What we’ve got here is failure to communicate.



Physician, define thyself

In the United States, prescribers may be federally indicted and prosecuted based upon interpretation of these ten words:

legitimate medical purpose in the usual course of professional practice

The entire phrase found in the DEA Practitioner’s Manual reads:

To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.

Importantly, the DEA Practitioner’s Manual goes on to say:

Federal courts have long recognized that it is not possible to expand on the phrase “legitimate medical purpose in the usual course of professional practice” in a way that will provide definitive guidelines to address all the varied situations physicians may encounter.

Based on my research, terms like “legitimate medical purpose” and “usual course of professional practice” are not found in medical textbooks, nor are they taught in medical schools. It does not seem to be necessary. It is intuitive to physicians what we do and why we do it.

Nevertheless, courts need more definitive guidance, otherwise they might default to: “You just know it when you see it.

I am simply not comfortable with such a vital phrase remaining so inscrutable. And as a physician, I feel the dearth of clarity surrounding those ten words places all physicians, including myself, at risk. Consequently, this physician set out on a journey to “define thyself.”

The following (with links to references) represents a work in progress that, with help from numerous colleagues, wordsmiths, legal experts, patients, friends, lay people and trusted advisors, comprises my current best effort at expanding upon:

Legitimate medical purpose in the usual course of professional practice

In essence, for a duly licensed M.D or D.O. physician practicing medicine in the United States, this phrase from the DEA Practitioner’s Manual corresponds to a generally accepted process that, in the context of a patient-physician relationship, can correctly be expanded to mean: a science-based, moral art of caring wherein a physician serves a patient’s medical needs, primarily, by accessing and evaluating information that is utilized by the physician in deriving a clinical assessment, leading to the physician formulating a plan of care. With intent to mitigate harm to the patient, intent to provide benefit to the patient, intent to respect the patient’s right to autonomy, and intent to be mindful of how consequences might affect others, the physician in this course of practice exercises judgment that is considerate of scientific evidence, judgment that is reasoned by the physician to be in accord with standards in the field of medicine, and judgment that is born out of the physician’s knowledge, observations and intuition.

James Patrick Murphy, MD

First draft: 1/17/2020; most recent revision: 2/22/2020




FIVE-STEP Initial Approach to Caring for the Displaced Pain Patient on Chronic Opioid Therapy

(1) History and Physical Exam
(2) Objective Data
(3) Documents
(4) Pain Treatment
(5) Decision: Maintain, Alter, Taper or Discontinue

The following is derived from an article that appeared in Louisville Medicine (September 2018). This is not an exact reprint. Some Internet links, references, graphics and phrasing have been updated for accuracy and relevancy • James Patrick Murphy MD, April 9, 2019

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Providing therapeutic continuity for patients who have abruptly lost access to their prescriber (e.g. pain clinic closure) can be a challenge, especially if the patient has been treated with opioids and other controlled substances.

A patient in pain, facing the possibility of worsening pain combined with medication withdrawal, can feel very stressed. In this potentially difficult scenario, the caregiver must convey an air of calmness and empathy. Providers may seize this clinical inflection point as an opportunity to redirect the course of treatment, or provide a therapeutic bridge to specialty care by way of referral or consultation.

While not meant as a substitute for more comprehensive guidelines, the following is a concise five-step initial approach to caring for the displaced pain patient on chronic opioid therapy.

Always exercise compliance with statutory requirements.


STEP ONE • History and Physical Exam


STEP TWO • Objective Data


STEP THREE • Documents (may be combined into one)


STEP FOUR • Pain Treatment

      1. Educational points Kentucky Board of Medical Licensure
      2. CDC Opioid Factsheet for Patients (Reference 9)
      3. VA National Pain Management Program


STEP FIVE • Decision: Maintain, Alter, Taper or Discontinue. A decision regarding maintaining, altering, tapering, or discontinuing controlled substances must be made. Some stable patients might be well served by maintaining their current regimen, however you are under no obligation to prescribe or continue with a treatment plan you don’t agree with.

  • If the patient does not need a prescription and still has some medication, advise on how to gradually taper (i.e. decrease 10 to 50 percent per week). To prescribe a taper with controlled substances: Calculate the current Morphine Equivalent Daily Dose (Ref 10: Calculating Total Daily Dose of Opioids For Safer Dosage, CDC)
      1. Initially prescribe zero to three days of a reduced MEDD (e.g. decrease 10 to 50 percent)
      2. Use immediate release medications
      3. Arrange follow up early and often
      4. Additional days of medications may be prescribed at follow up if risk/benefit assessment is deemed acceptable by the prescriber
      5. The CDC advises against a rapid taper (e.g. three weeks or less) for people taking ≥90 MEDD
      6. Regardless of taper speed, withdrawal may still happen

From ASAM: The Guideline Committee recommends, based on consensus opinion, the inclusion of clonidine as a recommended practice to support opioid withdrawal. Clonidine is not US FDA-approved for the treatment of opioid withdrawal, but it has been extensively used off-label for this purpose. Clonidine may be used orally or transdermally at doses of 0.1–0.3 mg every 6–8 hours, with a maximum dose of 1.2 mg daily to assist in the management of opioid withdrawal symptoms. Its hypotensive effects often limit the amount that can be used. Clonidine can be combined with other non-narcotic medications targeting specific opioid withdrawal symptoms such as benzodiazepines for anxiety, loperamide for diarrhea, acetaminophen or NSAIDs for pain, and ondansetron or other agents for nausea.

        • If tapering benzodiazepines, do so gradually.
        • Risk mitigation topics e.g. CDC Guideline Factsheet
          • Discuss with patients undergoing tapering that, because their tolerance to medications may return to normal, they are at increased risk for overdose on abrupt return to previously prescribed higher doses.
          • Consider offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MEDD/day), or concurrent benzodiazepine use, are present (Ref 12: Opioid Reversal With Naloxone, NIDA)



  1. Clinical Opiate Withdrawal Scale
  1. Knowing When to Say When: Transitioning Patients from Opioid Therapy University of Massachusetts Medical School (Massachusetts Consortium) Jeff Baxter, M.D. April 2, 2014
  1. PEG Scale (Pain, Enjoyment, General Activity)
  2. Opioid Risk Tool (ORT)
  3. Patient Health Questionnaire (PHQ 4)
  4. National Institute on Drug Abuse (NIDA) Sample Informed Consent Form
  5. National Institute on Drug Abuse (NIDA) Sample Patient Agreement Forms
  6. CDC: Treating Chronic Pain Without Opioids
  7. CDC: Opioid Factsheet for Patients
  8. Calculating Total Daily Dose of Opioids For Safer Dosage (CDC)
  9. American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, Part 3: Treating Opioid Withdrawal, Summary of Recommendations (7), page 29.
  1. Opioid Reversal With Naloxone (NIDA)


  1. CDC Checklist for Prescribing Opioids for Chronic Pain
  2. Universal Precautions Revisited: Managing the Inherited Pain Patient by Douglas L. Gourlay, MD, MSc, FRCPC, FASAM,* and Howard A. Heit, MD, FACP, FASAM. Published in Pain Medicine Volume 10 • Number S2 • 2009
  3. SAMHSA Behavioral Health Treatment Services Locator
  4. Federation of State Medical Boards, Pain Management Policies, Board-by-Board Overview
  5. Knowing When to Say When: Transitioning Patients from Opioid Therapy University of Massachusetts Medical School (Massachusetts Consortium) Jeff Baxter, M.D. April 2, 2014
  6. The Pain Clinic Closure Survival Guide for Patients and Clinicians
  7. Patient Education Resources:
    1. Kentucky Board of Medical Licensure, Education for Patients
    2. VA: Patient Education
    3. VA: Taking Opioids Responsibly
  8. Murphy, James Patrick. 5-Step Initial Approach to Caring for the Displaced Pain Patient on Chronic Opioid Therapy. Louisville Medicine, September 2018


Calculating MME, from the CDC:

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Disclaimer: This is for informational purposes only, does not constitute medical advice or a patient/provider relationship. It is not meant to establish a standard of care. I have made every effort to cite references where applicable, however the opinions expressed are my own and have not been endorsed by any organization. Links to references or other materials are taken at your own risk. The content provided here is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately.

James Patrick Murphy, MD, MMM, FASAM is a board-certified Pain Medicine and Addiction Medicine specialist who represents the American Society of Addiction Medicine on the American Medical Association’s newly formed Pain Task Force.

methodist 10.25.19

The wisdom of Dr. Russell K. Portenoy

Opioid maintenance therapy should be considered only after all other reasonable attempts at analgesia have failed and when persistent pain is a significant impediment to improved function.

Functional improvement should be emphasized as the most important goal of therapy, and the patient should be encouraged at every step to capitalize on progress in analgesia by gains in physical activity or social interaction. However, it should be recognized that partial analgesia with relatively little functional gain is the more likely outcome.

A substance-abuse history should be viewed as a relative contraindication to opioid maintenance therapy. No other factor is likely to predict treatment failure or the development of management problems.

A single committed physician must take primary responsibility for the management of therapy. In all reported cases of successful opioid maintenance therapy, the close and concerned involvement of such an individual was available; indeed, the strength of this relationship is one potential explanation for the success of treatment.

Since many patients begun on chronic opioids obtain partial or inadequate analgesia, the physician must be willing to stop ineffective therapy or escalation of doses when clinical judgment indicates diminishing returns. These interventions, occurring at a time the patient may be first experiencing some degree of analgesia, are difficult. They are simplified by a therapeutic alliance based on the physician’s sensitive understanding of the patient’s position and the patient’s perception that decisions are taken solely in his or her best interest.

  • Russell K. Portenoy, MD


From the chapter “Opioids in Nonmalignant Pain,” by Russell K. Portenoy, MD, Psychiatrist, Pain Specialist and Professor, in the textbook CURRENT THERAPY OF PAIN, published in 1989. (Reproduced with emphasis added.)

Reference: Current Therapy of Pain

Publisher: Mosby Inc (January 1, 1989)

ISBN-10: 1550090089

ISBN-13: 978-1550090086





Pain Clinic Closure Survival Guide for Patients & Clinicians


Part One is for patients and Part Two is for the clinicians who care for them. Both sections have relevant information and a complete reading of the entire article is recommended. Due to the fluid nature of this subject, this post will be updated regularly as new information becomes available (Last update: August 10, 2018).

Part One – For Patients (A) Tapering Medications and (B) Continuity of Care

The abrupt closure of a pain clinic is stressful for patients. Concerns include worsening pain, medication withdrawal, and finding a new pain care provider. This article catalogues resources and information that may be useful to patients, particularly in the Greater Louisville (KY) area, suddenly faced with lost access to their pain care provider.

This following information is for chronic pain patients and does not address the needs of a person struggling with addiction or a substance use disorder. If you think you may need substance use treatment services, call the KY Help Call Center toll-free hotline — 1-833-8KY-HELP (1-833-859-4357).

If you’re struggling to deal with your pain and are feeling hopeless or distraught, please call the National Suicide Prevention Lifeline at 1-800-273-8255.

The Metro United Way Crisis Hotline is accessed by dialing 211.

If your pain clinic suddenly closes, you need answers to some vital questions, which, depending upon the circumstances could be difficult. Rely on trusted sources for information (such as your Primary Care Provider). You’ll want to know answers to questions such as:

Why was my pain clinic closed?
When will it reopen?
Do I want to go back there?
Do I need to find a new pain clinic?
Can I get a copy of my medical records?
Will my current prescriptions be accepted by my pharmacy?
What can I expect if I have to taper or discontinue medications? Risks?
Should I seek to alter my current pain care regimen? Change course?
Will my primary care physician treat me during this process?

When we think of pain medications, we usually think about opioids. But medications other than opioids are often used in pain management and can also lead to withdrawal symptoms, if tapered rapidly or discontinued (e.g. benzodiazepines, gabapentin, anti-depressants). If circumstances force you to taper, do it as gradually as possible and seek guidance from  your physician. You might also ask your pharmacist for help with calculating a gradual taper using the medications you already have.

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An article in Psychology Today has a warning to patients about opioid and benzodiazepine withdrawal:

UntitledOpiates – Many people are surprised to learn that in most cases, withdrawal from many opiates is not deadly.

Benzodiazepines – Benzos were introduced as a replacement to barbiturates that were causing common overdose cases, many of which resulted in death. Nevertheless, withdrawal from extended use of benzodiazepines can kill. Whether Xanax (alprazolam), Ativan (lorazepam), Valium (diazepam) or other variations, long term use of Benzodiazepines requires medical supervision to be completed successfully with minimal side-effects and risk to the patient.


Pregnant women, children, the elderly, and patients with heart disease, seizure disorders, and depression are at particular risk if forced into withdrawal. Specifically, opioid withdrawal during pregnancy has been associated with spontaneous abortion and premature labor. If you are worried about withdrawal or if it becomes unmanageable, get proper medical advice (i.e. see your physician or go to the ER).

To gain a general understanding of the temporal aspect of withdrawal I offer this timeline I found on the Workit Health website:


(A) Tapering Medications

Patients with chronic pain who take opioids and other controlled substances will in most cases develop physical dependence on medications. This is a normal physiologic response and is not addiction. However, withdrawal from medications can certainly make a person feel as though they are addicted. It is important to make the distinction.

pain not addiction

The group Physicians for Responsible Opioid Prescribing have posted an informative video regarding physical dependence.

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If you cannot get medications (refills or replacement meds), you may find yourself with no viable option other than to taper your medications. If tapering happens too quickly, the possibility of uncomfortable (and perhaps life-threatening) drug withdrawal exists.


Here is some of what the Centers For Disease Control (CDC) says about tapering:

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).

The CDC has published: POCKET GUIDE: TAPERING OPIOIDS FOR CHRONIC PAIN which includes this advice about how to taper:

cdc taper pocket

Screen Shot 2018-08-01 at 10.03.10 AMAnd here is some additional advice from the Mayo Clinic

If you’ve taken opioids for less than two weeks, you should be able to simply stop these medications as soon as your prescribed course of pills runs out, if not before.

Don’t try to go cold turkey on your own. When it’s time for you to stop taking opioids, ask for your doctor’s help to develop a medication withdrawal plan (called a taper) that gradually reduces the amount of medication you take. 

Opioid withdrawal can be dangerous, and symptoms can be severe. Depending on the type and dose of drug you’ve been taking, it may take weeks or even months to gradually and safely reduce your dose and get off your opioid medication.

Stopping opioids can be difficult, but you can do it. You’re much more likely to succeed if you partner with your doctor, plan your taper schedule, manage your symptoms and learn alternative ways to cope with pain.

A step-by-step reduction in your dose helps this process go smoothly and helps ease the discomfort you may feel when you stop taking opioids. It also allows you to practice new skills to manage pain and other chronic symptoms.

Some people experience withdrawal when they stop or reduce use of medication or other substances. Signs and symptoms of withdrawal include:

Restlessness or anxiety
Increased pain
Trouble sleeping
Nausea, vomiting or diarrhea
Sweating or fevers
Rapid heart rate
Blood pressure changes
Hallucinations — seeing, hearing or feeling things that are not present — or seizures

If you experience withdrawal symptoms, tell a member of your health care team right away. Follow all instructions you receive about managing withdrawal symptoms. Unless you are instructed otherwise, you may also find these tips helpful:

Drink more water or other liquids than usual.
Eat regular nutritious meals.
Use deep-breathing and stretching exercises, as instructed.
Exercise in moderation (for example, walking).
Do something to relax (for example, practice relaxation techniques, listen to music or read).
Use distraction (for example, humor, talking to someone with a positive outlook).
Use positive self-talk. Tell yourself “I can do this” or “This is only temporary.”

REF: Tapering off opioids: When and how – by Mayo Clinic Staff


Your pharmacist should be able to steer you toward non-prescription medications to help with the symptoms listed above, such as: pain and fever (e.g. ibuprofen and acetaminophen); nausea and vomiting (e.g. Kaopectate, Pepto-Bismol, diphenhydramine, Dramamine); diarrhea (e.g. loperamide). Always take the dose of over-the-counter medications as directed by your health care professionals or according to the label. Taking more than prescribed or listed on the label can be dangerous.


IMPORTANT: Do not take anyone else’s medications. Do not acquire prescription drugs (or illicit drugs) off the street (Aside from committing a crime, you might get a counterfeit drug that will kill you. Do not resort to the numerous “home remedies” you’ll find on the Internet. Do not use Kratom or marijuana or alcohol as side-effects or drug interactions might be lethal, especially in a person going through withdrawal from pain medications.

Some evidence is emerging that would indicate cannabinoids have a role in attenuating opioid withdrawal symptoms. Marijuana is still illegal in most states (including Kentucky and Indiana) and is not recommended, however industrial hemp products (e.g. hemp oil extracts high in CBD) are becoming readily (legally) available and could be useful. Ask your physician for guidance.

(B) Continuity of Care


Getting your medical records (numerous sources)

It may be easier to get care from a different health care provider if you have your medical records. Do not panic. There are many sources of your health records.

  • Contact your pain clinic and request a copy (If they say it will take a long time, ask if you can at least have the most recent office notes).
  • Your insurance company may have records.
  • Hospitals where you have had care recently will have records you may request.
  • Labs and drug screening facilities will have records.
  • Facilities where you had tests (e.g. MRI, CT scans, ultrasounds) have records.
  • Other specialists or clinicians (e.g. surgeons, physical therapy) have records.
  • Your pharmacy will have records on your medication history.

Accessing Pain Management Care

Your best bet initially might be asking your primary care provider for help.

  • If you have a primary health care provider, contact them for care or for a referral for care.
  • If you don’t have a primary health care provider, contact your health insurance company.
  • To find pain clinics who may be taking patients, you can go on the Kentucky Board of Medical Licensure website and access the link to the Physician Profile/Verification of Physician Licensure


kbml finder

Here you can search for every Pain Management or Pain Medicine physician (and an array of other specialties) licensed to practice in the state of Kentucky. You can even narrow the search down by county. The listing will provide an address and phone number (as well as any disciplinary actions assigned to the physician).

A group of local pain specialists, the Kentuckiana Coalition of Pain Experts (Kentuckiana COPE), have come together to help in the event a pain clinic suddenly closes and patients find themselves suddenly without access to care or advice. Please understand that this humanitarian effort is voluntary on the part of the providers, at the discretion of the provider, and there is no guarantee that care or advice will be offered. However, the group believes that we should come together as a community to help our neighbors when they, by no fault of their own, suddenly find themselves medically orphaned due to the sudden closure of their pain clinic.

Kentuckiana COPE toll free number: 1-844-593-4354

Note: This toll free number is not manned. It is not a crisis hotline. It is not a general referral service for patients. And there is no guarantee you will get a call back. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately.

This blog post will be updated with, lists, phone numbers, and additional resources when new information becomes available. Please check back on a regular basis.

UntitledAnd don’t give up hope. This situation may be difficult, but it may also be a chance for a new beginning.



Part Two – For Clinicians


Note: All clinicians should be familiar with the information in Part One (above) as this is what your patients are reading.

Primary Care practices will likely shoulder the majority of continuity of care issues brought about by the sudden closure of a large pain clinic. Two groups of patients will emerge: (a) current patients of the practice and (b) those seeking to become patients. Three questions become paramount:

  1. Do you continue the current regimen?
  2. Do you change the regimen (e.g. taper or devise a new plan)?
  3. Do you decide not to prescribe any medications and deal with the withdrawal?

The answers to these questions can only come from the individual care provider. Of course, we want to alleviate suffering. But we also must practice medicine in a manner for which we feel adequately prepared. Some prescribers may feel comfortable with higher doses and specialty formulations of medications. Others may be willing to prescribe (within a narrower set of personal boundaries) commonly prescribed medications with which they have familiarity. And there will be some clinicians who honestly feel they are not equipped (i.e. training, experience, manpower) to prescribe controlled substances at all. These are personal choices to be made after an honest critical self-evaluation.

Let’s begin with some advice from the Washington State Department of Health (a leader in addressing opioid prescribing issues):

wash pain clinic adviceClinicians should empathically review benefits and risks of continued high-dosage opioid therapy and offer to work with the patient to taper opioids to lower dosages.

Experts note 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.

Unless addiction or drug diversion is apparent, or if there is an elevated risk of overdose, rapidly stopping opioids is not recommended.

The U.S. Centers for Disease Control and Prevention specifically advises against rapid taper for people taking more than 90 mg MED per day.

Clinicians should assess patients on more than 90 mg MED or who are on combination therapy for overdose risk. Prescribe or provide naloxone. More on this topic is in the New England Journal of Medicine.

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Here is a graphic from the website: U.S. Pharmacist noting various withdrawal metrics:

Opioid-T1 timeline table

Perhaps the best treatment for withdrawal is to give the patient the medication from which they are withdrawing. Often a lower dose than they are accustomed to taking will be sufficient.

One method I have found to be effective for treating opioid withdrawal is to calculate the patient’s MEDD (morphine equivalent daily dose) and then provide the patient with a percentage of this MEDD (e.g. 80-90%), in the form of immediate release medication, for a few days and then re-evaluate. Since there is cross-tolerance among the various opioids, a clinician does not necessarily have to refill the patient’s current prescription. Instead the clinician may prescribe opioids with which he or she feels more comfortable (i.e. Percocet instead of Oxycontin) and still treat the patient’s withdrawal effectively. Note: This does not apply to tapering with methadone. Methadone taper protocols should only be prescribed by a physician experienced with treatment with methadone. Tapering with Suboxone (i.e. buprenorphine/naloxone) requires a special DEA registration and is beyond the scope of this article.

Fortunately, there are a number of well-vetted protocols to guide us. An effective plan of care is born of knowledge about the patient (e.g. H&P, studies, medical records), knowledge about the medications, and knowledge about medication withdrawal.

The Mayo Clinic published a great basic primer on opioid tapering:

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Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice

And the Washington State Agency Medical Directors’ Group has a very nice step-by-step guide to tapering:


REF: Part V. Reducing or Discontinuing Chronic Opioid Analgesic Therapy (COAT)

For primary care providers who do not want to write the medications, they may have to deal with treating withdrawal. I found an excellent and easy to use guide to treating opioid withdrawal in chapter 4 (and other medications in other chapters) from the World Health Organization.

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As noted above in Part One, the  CDC has published a concise “pocket guide” to tapering. This is perhaps the best reference for the busy Primary Care provider to quickly get up to speed on a proper course of action.


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Realistically, even the most conscientious tapering plans can miss the mark, and withdrawal symptoms of varying severity can occur. Also, as stated above, some clinicians will make the decision not to prescribe any controlled substances in treatment of their patients’ withdrawal. In either instance, clinicians need to be aware of what is available (over-the-counter as well as by prescription) to treat withdrawal symptoms.

The Oregon Pain Guidance Group has published clinical tools, and even what they call their “Opioid Withdrawal Attenuation Cocktail.”


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The World Health Organization has guidance on medication management of withdrawal as well.

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And for those clinicians interested some of the more intense pharmacologic approaches to treating withdrawal, consider this article from Dialogues in Clinical Neuroscience:

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Clonidine: The antihypertensive, α2-adrenergic agonist drug clonidine has been used to facilitate opioid withdrawal in both inpatient and outpatient settings for over 25 years.1821 It works by binding to α2 autoreceptors in the locus coeruleus and suppressing its hyperactivity during withdrawal. Doses of 0.4 to 1.2 mg/day or higher reduce many of the autonomic components of the opioid withdrawal syndrome, but symptoms such as insomnia, lethargy, muscle aches, and restlessness may not be adequately handled.22

Compared with methadone-aided withdrawal, clonidine has more side effects, especially hypotension, but is less likely to lead to post-withdrawal rebound. Dropouts are more likely to occur early with clonidine and later with methadone. In a study of heroin detoxification, buprenorphine did better on retention, heroin use, and withdrawal severity than the clonidine group.12 Since clonidine has mild analgesic effects, added analgesia may not be needed during the withdrawal period for medical opioid addicts.

Lofexidine: Hypotensive effects may limit the optimal dosing of clonidine for opioid withdrawal. Lofexidine, an analogue of clonidine, has been approved in the UK and may be as effective as clonidine for opioid withdrawal with less hypotension and sedation.23,24 Combining lofexidine with low-dose naloxone appears to improve retention symptoms and time to relapse. (Dr. Murphy’s addendum: Lofexidine has now been approved in the US, trade name Lucemyra.)

Supportive measures: Insomnia is both common and debilitating. Clonazepam, trazodone, and Zolpidem have all been used for withdrawal-related insomnia, but the decision to use a benzodiazepine needs to be made carefully, especially for outpatient detoxification.

Treatments for ancillary withdrawal symptoms include nonsteroidal anti-inflammatory drugs (eg, ibuprofen or ketorolac tromethamine) for muscle cramps or pain; bismuth subsalicylate for diarrhea; prochlorperazine or ondansetron for nausea and vomiting; and a2-adrenergic agents (eg, clonidine) for flu-like symptoms. Vitamin and mineral supplements are often given.

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A note on regulations:

When prescribing, remember that Kentucky now has imposed a three-day limit for treatment of acute conditions with Schedule II controlled substances. If your patient has chronic pain, and your treatment addresses this chronic condition, then the three-day limit should not apply. However, if the patient presents to you in acute withdrawal, then the three-day limit may apply. Here is the language in Kentucky’s pain regulations:

In addition to the other standards established in this administrative regulation, for purposes of treating pain as or related to an acute medical condition, a physician shall not prescribe or dispense more than a three (3) day supply of a Schedule II controlled substance, unless the physician determines that more than a three (3) day supply is medically necessary and the physician documents the acute medical condition and lack of alternative medical treatment options to justify the amount of the controlled substance prescribed or dispensed.

Regardless, all physicians need to adhere to their state regulations. The mnemonic “Plan to THINK” (see below) can help physicians remember what Kentucky requires in order to initially prescribe controlled substances for chronic pain:

plan to thinkDocument a plan (P) that explains why and how the controlled substance will be used. Teach (T) the patient about proper storage of the medications and when to stop taking them. Perform an appropriate history and physical exam (H). Obtain informed consent (I). Note: consent must be in writing, if prescribing a Schedule II drug. No use of long acting (e.g. extended release) meds initially (N). And run an initial KASPER query (K) of the state’s prescription database – and at least every three months thereafter. Indiana’s electronic prescription database is called INSPECT.

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For the sake of brevity, I recommend Indiana prescribers do the same as Kentucky prescribers, although the initial prescription in Indiana may be for up to 7 days.

Below is a link to a concise guideline outlining initial steps one might take:


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In closing, my hope is that this blog post has provided enough guidance to alleviate some of the fears and anxiety associated with this convoluted problem, enough so that we may live up to our calling, well stated in the AMA Code of Medical Ethics

The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.

The relationship between a patient and a physician is based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others, to use sound medical judgment on patients’ behalf, and to advocate for their patients’ welfare.

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Disclaimer: This is for informational purposes only, does not constitute medical advice or a patient/provider relationship, and is not a substitute for seeing your medical provider. I have made every effort to cite references where applicable, however the opinions expressed are my own and have not been endorsed by any organization. Links to references or other materials are taken at your own risk. The content provided here is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately.

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James Patrick Murphy, MD, MMM, FASAM is a board-certified Pain Medicine and Addiction Medicine specialist who represents the American Society of Addiction Medicine on the American Medical Association’s newly formed Pain Task Force.


Addressing a subject of this nature can only approach adequacy with the help of my colleagues, confidants & patients. To all who have contributed, I am profoundly grateful. That being said, the opinions expressed in this article are my own.




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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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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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CDC Guideline for Prescribing Opioids for Chronic Pain


Washington State Opioid Taper Plan Calculator


Tapering Long-Term Opioid Therapy in Chronic Noncancer Pain

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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:



Related links of interest:

Kentucky Board of Medical Licensure (KBML website)



Considerations for Patient Education (KBML)

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








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



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A Letter in Support of a Support Group


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:

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
SEAK Directory listing:

The Development and Impact of a Chronic Pain Support Group. J of Pain and Symptom Mgmt., 1999, Vol 7, Issue 5

Mayo Clinic Website:

CDC Guideline for Prescribing Opioids for Chronic Pain

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Flyers, courtesy of Marylee James, a.k.a.