Comparing Apples to Apples ~ The Morphine Equivalent Daily Dose

apples-to-apples-comparison

Not everything that can be counted counts, and not everything that counts can be counted.

~ Albert Einstein (attributed)

In medicine we like to measure.

For example, physicians often ask patients to rate their pain on a scale from zero to ten – despite our knowledge that pain is so uniquely personal that it cannot accurately be measured nor honestly compared to another person’s pain.

Pain_Scale__Arvin61r58

In contrast, an opioid pain drug’s strength (potency) can be measured and considered in determining how much of that opioid a patient might safely use.

There are numerous opioid medications (“apples and oranges”) on the market. And comparisons between opioids can become complicated and difficult. Thus for simplicity’s sake, experts recommend comparing all opioid drugs to a standard, i.e., morphine.

Kratom-vs-Morphine

Calculating the amount of morphine that would equal the dosage of a patient’s opioid medication allows us to compare “apples to apples.” Furthermore, calculating the amount of morphine needed to equal a patient’s TOTAL daily dose of opioid gives us a value called the “Morphine Equivalent Daily Dose,” or MEDD.

Note: For the sake of this discussion, MEDD will refer to the sum total of opioid medication taken orally in a 24 hour day.

Here’s how it works…

If a patient takes 30 mg of MORPHINE each day, the patient’s Morphine Equivalent Daily Dose (MEDD) would be 30 mg.

Similarly, if a patient takes 30 mg of HYDROCODONE each day, the MEDD would still be 30 mg, because hydrocodone and morphine are generally considered to have equal potency.

hydro and morph

Now consider OXYCODONE (which is about one and one-half times more potent than morphine). In this case a mere 20 mg of oxycodone equates to a MEDD of 30 mg.

20 mg x 1.5 = 30 mg

In other words, the patient would need to take 30 mg of morphine to offer the same relief as 20 mg of oxycodone.

There are many formulas, calculations, and tables available online and in texts to help in determining the MEDD such as this one featured in Practical Pain Management:

PRACTICAL PAIN MANAGMENT

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And to paraphrase Paul Harvey

paul harvey

You know what the MEDD is.

Now you’re going to hear the rest of the story.

CDC-Opioids-Pills

Benefits of high-dose opioids for chronic pain are NOT established. 

– Centers for Disease Control and Prevention 03.15.2016

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On March 15, 2016 the Centers for Disease Control released its much-anticipated Guideline for Prescribing Opioids for Chronic Pain, drawing heavily upon the MEDD concept (Note: The CDC called it: morphine milligram equivalents per day.).

Below are some major points regarding the MEDD as featured in the CDC Guidelines:

<50 likely reduces risks

≥50 increases overdose risk without necessarily adding benefits

If ≥50 …(a) implement additional precautions, (b) increase frequency of follow-up, and (c) consider offering naloxone & overdose prevention education

≥90 should not be prescribed without careful justification.

If ≥90 and no improvement in pain and function …(a) discuss other approaches to pain management, (b) consider tapering to a lower dosage and/or discontinue, and (c) consider consulting a pain specialist.

>100 associated with significant risks

According to the CDC and many other experts, the benefits of high-dose opioids for chronic pain are not established. They say that high MEDD is associated with increased risks for serious harms such as: motor vehicle injury, opioid use disorder, and overdose. The CDC advises that despite the anxiety it might produce, patients should be given the opportunity to re-evaluate their use of opioids at high MEDD. However, because of physical and psychological dependence, tapering can be challenging and may need to be done very slowly.

Determining an opioid’s potency and its true Morphine Equivalent Daily Dose is not an exact science. Each person’s body reacts to a drug in a unique way. In medicine we call this “pharmacokinetics and pharmacodynamics.” Nevertheless, more and more experts believe that utilizing a standardized MEDD is a necessary part of the strategy to minimize risks associated with chronic opioid therapy for pain.

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The miserable have no other medicine but only hope. 

~ William Shakespeare, Measure for Measure

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Prescribing Controlled Substances in Kentucky – CME Presentation for Flaget Memorial Hospital in Bardstown, KY. June 21, 2016

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References:

Kentucky Board of Medical Licensure

http://kbml.ky.gov/Pages/default.aspx

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CDC Guideline for Prescribing Opioids for Chronic Pain

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

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Confluential Truth: jamespmurphymd.com

https://jamespmurphymd.com

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The Dream of Pain Care

https://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture

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Kentucky Injury Prevention and Research Center

http://www.mc.uky.edu/kiprc

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KASPER

http://chfs.ky.gov/os/oig/KASPER.htm

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Flaget Memorial Hospital

http://www.kentuckyonehealth.org/flaget

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Copy of Dr. Murphy’s presentation as PDF:

https://www.dropbox.com/s/u8q4a5mebjt5pzo/Prescribing%20Controlled%20Substances%20Flaget%20CME%206.21.16.pdf?dl=0

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Opioid Abuse in Chronic Pain… Another day, another strategy

 

Read and heed.

A recent review article in the New England Journal of Medicine by Nora Volkow, MD and A. Thomas McLellan, PhD, succinctly sums up the state of affairs surrounding the use of opioids for chronic pain.

Yes, I agree with most everything their article says.

And…

As I read their litany of legitimate negatives, I wonder if anyone has recently taken the time to study “successful” chronic pain management with opioids.

Actually, I wonder if anyone in a position of authority believes it is even possible to be successful treating chronic pain with opioids.

Full disclosure: I am not a researcher. I am a clinician. I am on the front line.

As review articles, guidelines, policies, regulations, and laws keep popping up, I keep reading. And as I read it occurs to me that defining “success” is as subjective as defining pain itself.

The International Association for the Study of Pain has defined pain as

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

So maybe success in treating chronic pain with opioids could be defined as:

A regulatory and emotional experience associated with actual or potential benefit, or described in terms of such benefit.

And I’ll offer the other side this definition of failure:

A regulatory and emotional experience associated with actual or potential harm, or described in terms of such harm.

Take home point: All three definitions are subjective.

So, as I prepare for another day on the front line of chronic pain care my inherent duty is to:

Follow the regulations, but

Find the truth contained therein, and use it to

Facilitate my patient’s journey to success.

 

Success is a journey. Not a destination.

 

New England Journal of Medicine, consider this my open invitation to any researcher interested in exploring the possibility that one might be able to successfully prescribe opioids for chronic pain.

The doctor will see you now.

Will you see the doctor?

 

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Success is counted sweetest
By those who ne’er succeed.
To contemplate a nectar
Requires sorest need.
Emily Dickinson

 

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Chronic Pain Management for Survivors of Torture

FullSizeRender (39)

The most preventable form of human pain is that inflicted in the form of torture 
World Medical Association

Pain is a universal human experience, however each human experiences pain uniquely.

So, when I was asked to team with Psychiatrist, Sarah Acland, MD, to talk about pain management for survivors of torture, I thought I could cover the topic well by simply falling back on the standard approach I’ve used in treating all my patients with chronic pain – a BIO-PSYCHO-SOCIAL approach.

biopsychosocial

But as I researched more about the profound struggles survivors of torture face, I began to question whether or not another approach was necessary for this group of patents.

In the end, I returned to the realization that a (1) biological + (2) psychological + (3) sociological approach is well-suited to care for the survivors of torture, as long as caregivers are thorough in evaluating, understanding, and optimizing each of the three elements.

Pain is defined as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP)

Pain is a necessary body system that, while unpleasant, protects us from harm. But in survivors of torture, this “useful pain” can be hijacked by a damaged nervous system, heard through the amplified megaphone of psychological distress, and experienced in a prison of cultural barriers.

To understand how best to help these survivors, one must have some understanding of how the body’s pain system is wired. It’s not as simple as two points connected by a nerve. When trauma is inflicted, pain receptors transmit multiple nerve impulses toward the brain (i.e. the “ascending” pathways). These sensory impulses travel up different tracks at different speeds to not just one, but to several areas of the brain – both “conscious” and “unconscious.” At the same time, the nervous system will try to dampen (“modulate”) the ascending pain impulses by releasing chemicals and sending impulses downward (i.e. the “descending” pathways).

pain pathways

Granted, my explanation grossly oversimplifies the complex interactions between the ascending (pain) and descending (anti-pain) pathways, but it lays the foundation for understanding how we can treat pain.

Use treatments that (a) enhance the descending anti-pain pathways, such as:

  • Some antidepressants
  • Endorphins (exercise)
  • Physical therapy/occupational therapy
  • Psychotherapy

And (b) treatments that dampen the ascending painful pathways:

  • Physical medicine (e.g., ice/heat)
  • NSAIDs
  • Stimulators (e.g. TENS)
  • Some anti-epileptics (e.g., gabapentin)
  • Nerve blocks
  • Opioids

As Bing would say… You have to accentuate the positive and eliminate the negative.

bing

Effective treatment also depends upon knowing the degree to which the pain is nociceptive (“normal”) or neuropathic (“abnormal”).

Types of Pain (IASP)

Nociceptive pain occurs when diseased or traumatized tissue activates the nervous system and its receptors (i.e. nociceptors). On the other hand, neuropathic pain is when disease or trauma (i.e. pathology) to the nervous system itself causes pain. Nociceptive pain is usually sharp, acute, and localized. Neuropathic pain is usually dull, burning, aching, chronic, and poorly localized. Nociceptive pain is usually associated with defined tissue damage. Neuropathic pain can persist long after the traumatized tissue has healed and there are no physical findings.

To varying degrees, all pain syndromes (acute and chronic) have some combination of both neuropathic and nociceptive pain. Neuropathic pain is actually the most prevalent type of pain in developing nations and prominently results from torture. Neuropathic pain is difficult to cure, and generally must be “managed” with measures to augment activity in descending modulating pain pathways.

By design, torture often doesn’t physically “leave a mark” after the acute injuries have healed. Most common is blunt trauma, especially to soles of feet (“falanga”), often leading to chronic neuropathic pain.

Also common is suspension of the body, i.e. stretching nerves, leading to musculoskeletal joint/soft tissue damage and “plexopathy.”

Regardless of the physical signs left by torture, the marks left by psychological trauma is nearly universal, i.e., PTSD.

Obviously, my presentation to this point has primarily focused on biological (i.e., physical) aspects of pain and pain treatment. The psychological and social aspects are equally important, but are beyond the scope of this brief overview. Suffice it to say, effective pain care requires a team approach (i.e., multidisciplinary). Mental health issues (e.g., PTSD, depression, anxiety) almost always co-exist with chronic pain and lead to, or are influenced by, social/family/cultural circumstances. The following lists offer some insight into just how challenging it can be to treat pain in survivors of torture.

Treatment barriers to overcome include:

  1. Language/communication
  2. Cultural barriers
  3. Memories of helplessness fear & shame
  4. Impaired recollection
  5. Survivors may not offer information unless asked
  6. Non-compliance with treatment
  7. Reticent to use meds due to past forced use

Findings suggestive of torture:

  1. Multiple chronic pains
  2. Multiple physical scars
  3. Complex injuries
  4. Musculoskeletal pain
  5. Headaches
  6. Neuritis
  7. Depression
  8. Anxiety
  9. PTSD
  10. Neuropathic pain

Effective treatment augmented by:

– Trust and communication
– Evaluate in a calm atmosphere
– Be thorough
– Offer detailed explanations
– Obtain informed consent
– Allow the patient to have control
– Minimize exhaustive visits for tests & specialists
– Identify potentially treatable disorders
– Ask patients about their beliefs about the pain
(e.g., Pain may be assumed to signal ongoing damage)
– Set realistic and clear goals/expectations
– Stepwise approach to treatment
– Avoid reinforcing/addictive drugs
– Injections might trigger flashbacks

Summary:

In all individuals, to varying degrees, pain has biological, psychological & sociological elements. All three elements feature prominently in torture survivors. Effective treatment must address all three (i.e., a bio-psycho-social treatment model), and is best achieved by using a multidisciplinary approach (i.e., psychotherapy, physical medicine & traditional clinical medicine). Establishing trust and effective communication can be challenging but is crucial.

Pain can be effectively managed in survivors of torture in the same thorough step-wise manner used to treat other patients as long as caregivers work as a team to fully address all three elements in the bio-psycho-social treatment model.

Another final point, among the many, I took away from this interactive presentation with my colleagues on that April Friday morning was this one I initially took for granted, but was so eloquently emphasized by Dr. Acland… That they are victims cannot be overlooked, but that they are survivors can never be forgotten.

 

Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not. 

– Emily Dickinson

 

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Pain Management:
Implications for Caring for Refugee & Immigrant Survivors of Torture
Survivors of Torture Recovery Center
Kent School of Social Work
University of Louisville
April 8, 2016
James Patrick Murphy, MD, MMM
 

CeggdUdW4AIvDvS 

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Beware the GuIDES of March… The CDC Releases Pain Guidelines

caesarCDC recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care

Released: March 15, 2016

Link: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm#B1_down

The following was copied directly from the CDC website:

cdc

Determining When to Initiate or Continue Opioids for Chronic Pain

  1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
  2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
  3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

  1. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
  2. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
  3. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
  4. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use

  1. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
  2. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
  3. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
  4. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
  5. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

* All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except recommendation 10 (designated category B, with individual decision making required); see full guideline for evidence ratings.

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Unlike Marc Antony, I recommend an open mind…

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

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

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

 CDC RECOMMENDATIONS

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

 

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

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

 

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

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

 

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

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

 

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

 

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

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

 

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

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

 

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

This is reasonable as written.

 

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

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

 

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

 

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

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

 

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

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

 

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

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

 

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

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

 

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

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

 

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

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

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The Least Meaningful Time of the Year

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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