Dear fiends… I mean FRIENDS,

jack o close 

I invite you to hear a painful ghost story, sure to get you in the mood for Halloween:

HOW THE GHOST STOLE PAIN CARE

Feel free to share the terror with others.

Yours ghoulishly,

Pat

James Patrick Murphy, MD, MMM

P.S. If the hyperlink above doesn’t work for you, and you are brave enough, visit the Greater Louisville Medical Society website and click the link: “A Halloween Treat from Dr. Murphy

…or click this link: the evil source.

 

 

 

James Patrick Murphy, MD, MMM attended medical school at the University of Louisville, interned in Psychiatry at the San Diego Naval Hospital, studied at the Naval Aerospace Medical Institute, and later served as a Naval Flight Surgeon onboard the aircraft carrier U.S.S. Enterprise.  He returned to Louisville for residency training in Anesthesiology after which he completed a Pain Medicine Fellowship at the Mayo Clinic in Rochester, MN. Dr. Murphy is board-certified in Anesthesiology, Pain Medicine, and Addiction Medicine. He is President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, Assistant Clinical Professor at the University of Louisville School of Medicine, and serves on the board of the International Association for Pain and Chemical Dependency. In May 2013 Dr. Murphy earned a Master of Medical Management degree from the University of Southern California Marshall School of Business.

Dr. Murphy’s blog is The Painful Truth. He can be found on TWITTER by searching @jamespmurphymd. His President’s eVoice and other communications & videos can be accessed at the Greater Louisville Medical Society website.

Greater Louisville Medical Society: https://www.glms.org/Home.aspx

the evil source: http://vimeo.com/77715467

jpm 10/31/2013

NATIONAL SUBSTANCE ABUSE PREVENTION MONTH 2013: WEEK FOUR

aDrug-Overdose

Here is a summary of WEEK FOUR:

Monday

National Substance Abuse Prevention Month Day 21: Get rid of prescription drugs and heroin use skyrockets. Stop heroin use and what takes its place? In Russia it was Krokodil. This drug is cheaper, more potent, and more deadly than heroin and is coming to a town near you! Unless… Please do something to prevent substance abuse today. A drug has never killed anyone. The disease of ADDICTION kills. Warning, viewing this link is not for the meek:

http://www.huffingtonpost.com/2013/10/09/krokodil-drug_n_4073417.html

Tuesday

National Substance Abuse Prevention Month Day 22: With only two pain specialists per 100,000 veterans & with the majority of new VA patients needing pain care, the system is going to be even more overloaded. There are too many overdoses already! Our veterans deserve better.

http://www.cbsnews.com/8301-18563_162-57603767/veterans-dying-from-overmedication/

Wednesday

National Substance Abuse Prevention Month Day 23:  In the majority of states drug overdoses kill more people than auto accidents, but this legendary NASCAR driver may have died as a result of not having enough pain medication. http://espn.go.com/racing/nascar/cup/story/_/id/9286940

Thursday

National Substance Abuse Prevention Month Day 24: “Molly,” the adulterated-hit-or-miss-knock-off “Ecstasy” (MDMA), is dangerous, causes seizures and deaths – your body and brain burn from the inside out!   Antidepressants, migraine meds, pain meds, seizure meds – and numerous other drugs that increase SEROTONIN – DON’T MIX WITH MOLLY. Halloween is coming & parties are happening.  Please don’t invite Molly. It’s better to dress up like a ghost than to become one.

https://www.deadiversion.usdoj.gov/NTBI/NTBI-PUB.pub?_flowExecutionKey=_c77D951BD-7482-5753-CD82-9A32810403A6_k55C9A193-AF37-0CF4-CB6F-4AB7143858AB

http://www.forbes.com/sites/robertglatter/2013/09/02/recent-concert-deaths-highlight-dangers-of-molly

http://www.nytimes.com/2007/02/27/health/27brody.html?_r=0

Friday

National Substance Abuse Prevention Month Day 25: Tomorrow you can turn in your leftover meds. It’s National Prescription Drug Take-Back Day.  This is a great way to do something positive for your community, your loved ones and yourself. Most abused prescription drugs don’t come from doctors, pharmacies, or “the street.” They come from family, friends and acquaintances. Just go to the link below and put in your zip code to find a take-back location near you.  What’s in your cabinet?

https://www.deadiversion.usdoj.gov/NTBI/NTBI-PUB.pub?_flowExecutionKey=_c77D951BD-7482-5753-CD82-9A32810403A6_k55C9A193-AF37-0CF4-CB6F-4AB7143858AB

Saturday

National Substance Abuse Prevention Month Day 26: Lots of #Halloween parties tonight! Have fun and be safe. NO drinking & driving.  These #zombies know what I mean…

http://zombiesagainstdrunkdriving.com

Sunday

National Substance Abuse Prevention Month Day 27: Buprenorphine can effectively treat opioid addiction. Learn about it here:

http://www.youtube.com/watch?v=dHAj4ibyUkI#t=41

Find a doctor here:

http://buprenorphine.samhsa.gov/bwns_locator

I got the first word…

From:  Greater Louisville Medical Society NEWS

Volume 23 & Issue 10

October 2013

dr m at kma

As President of the Greater Louisville Medical Society, I had the honor of offering the opening remarks and welcome at the start of the Kentucky Medical Association 2013 Annual Meeting. If you are a physician, have a loved one who is a physician, have ever seen a physician, or may ever be in need of a physician, you will probably like this…

“The theme of this year’s meeting is Safeguarding Kentucky’s Health. As I look out upon this gathering – the different specialties, interests and practice models represented – I am impressed by what we do: as skilled professionals, products of years of formal training, specialists in various fields, leaders of our society’s health care system.

And I am intrigued by how we do what we do – the various practice models from private practice to fee for service, private medicine, academic settings, administrative medicine, community health. The diversity is enormous.

But what inspires me is why we do what we do. In the face of continued attacks on all fronts by job stress, legal challenges, regulatory burdens, infringements on our scope of practice and the technological tsunami of electronic data management, we maintain our integrity, drive and resolve to care for the suffering, regardless – to innovate beyond reason and to lead relentlessly. We do it because that’s what physicians do. Caring is at our core.

Safeguarding Kentucky’s health? We are most safe when that which we have cannot be taken from us. And as we now begin our meeting in earnest, let’s recognize that the strength that comes as a product of our shared core values is the greatest safeguard for the health and well-being of our neighbors and loved ones.

No one can change that or take that from us. We care. We put patients first. We cherish and deserve their trust. And trust is the foundation of our strength – our strength as Kentucky’s united physicians.”

James Patrick Murphy, MD, MMM

President, Greater Louisville Medical Society

September 9, 2013

Greater Louisville Medical Society NEWS is a monthly publication of the Greater Louisville Medical Society

101 W. Chestnut Street,

Louisville, KY 40202

(502) 589-2001

Fax (502) 581-9022

https://www.glms.org/Home.aspx

https://www.glms.org/Content/User/Documents/Publications/GLMSNewsOctober2013.pdf

NATIONAL SUBSTANCE ABUSE PREVENTION MONTH 2013: WEEK THREE

aaaaahands

Here is a summary of WEEK THREE:

Monday

National Substance Abuse Prevention Month Day 14: “Clean” by David Sheff is an important book that’s easy to read – hard to stomach – impossible to ignore. Hear the author’s moving NPR interview:

http://www.npr.org/2013/04/03/175939127/a-father-tells-the-story-of-his-sons-struggle-to-stay-clean

Tuesday

National Substance Abuse Prevention Month Day 15: Dr. Murphy talks pain and addiction with Dr. Wayne Tuckson on KET:

http://www.ket.org/cgi-bin/cheetah/watch_video.pl?nola=KKHEA%20000902&altdir=&template=

Wednesday

National Substance Abuse Prevention Month Day 16: Why does the pain doc make you pee in a cup? It may be random, but that’s how I roll…

http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/tumblin-dice-why-does-random-matter?page=0,1

Thursday

National Substance Abuse Prevention Month Day 17: Don’t let KASPER spook you! (Louisville Medicine, page 20). Read about Kentucky’s powerful weapon in the battle to prevent substance abuse.

https://www.glms.org/Content/User/Documents/Louisville%20Medicine/LM%202012/GLMS%20Mag%20Jan%202012.pdf

Friday

National Substance Abuse Prevention Month Day 18: October also means Halloween. Is this poem a trick or a treat? You decide. (This could be my favorite post of all time!) “How the Ghost Stole Pain Care”.

https://jamespmurphymd.wordpress.com

Saturday

National Substance Abuse Prevention Month Day 19: Heroin is on the rise. Substance abuse will never stop unless we get serious about treating addiction as the disease that it is. Thanks to WDRB for spotlighting this issue.

http://www.wdrb.com/story/23721259/heroin-problem-getting-worse-in-louisville

Sunday

National Substance Abuse Prevention Month Day 20: Joe Elliott and I talked addiction, prevention, treatment and pain management on his radio show:

https://docs.google.com/file/d/0B2PLAYRyZSJjYVRVSGxUVHJxbkk/edit?usp=sharing

How the Ghost Stole Pain Care

by Dr James Patrick Murphy

(…with apologies to the beloved Dr Seuss)

ghost

 

Every Loo-ee-ville doctor liked pain care a lot,
But the chilling pain ghost of the clinic did not.

The ghost hated pain pills, no matter the season,
If you want to know why, I will tell you the reason.

The children-proof caps didn’t screw on quite right.
It could be, perhaps, that the threads were too tight.

Or maybe the banshee’s screams were in vain,
‘Cause no one believed that he had phantom pain.

But really the most likely reason of all,
Was that his dose was two sizes too small.

So whatever the reason, the dose or the threads,
He haunted the clinic, so hating the meds.

“And they come from this doctor,” the spook snarled with a sneer.
“But it’s All Hallow’s Eve, I don’t think he is here.”

Then he growled with his ghost fingers nervously drumming,
“I MUST find a way to keep pain care from coming.”

For tomorrow he knew, after paying their bills,
They would line up quite early and pay cash for their pills.

And then oh the pills. Oh the pills, pills, pills, pills.
That’s one thing he hated. The pills, pills, pills, pills.

And then they’d do something he liked least of all.
Every patient in pain, the tall and the small,
Would walk close together, sit down and sit up,
Then go to the bathroom and pee in a cup.

They’d pee and they’d pee, and they’d pee, pee, pee, pee.

And the more it looked like an illegal drug ring,
The more the ghost thought, “I must stop this whole thing.”

Then he got an idea – an awful idea.
THE GHOST GOT A WONDERFUL, AWFUL IDEA.

“I know just what to do.” The spook laughed in his throat.
And he made a quick surgical hat and white coat.

And he snickered and sneered like a sly apparition,
“With this coat they will think that I am a physician.”

“All I need is a pad.” So the ghost looked around.
But since script pads are scarce there were none to be found.

Did that stop the sly spook? No! The poltergeist said,
“If I can’t find a script pad, I’ll make one instead.”

The clerk’s window was closed. She was not in her chair,
So he entered the hall to see who was there.

“Ah, no one’s around,” the fake doctor ghost hissed,
So he slid to the storeroom, and looked at his list.

Then he slithered and slunk, with a smile that was ample,
Around the whole room, and he took every sample.

And he stuffed them in bags, and then fast as a rocket,
Stuffed all the drugs, one by one, in his pocket.

He cleaned out the closet as quick as a scream.
Why, that ghost even took all the cups for drug screens.

And the ghoul grabbed the x-ray, and started to shove,
When he heard a small sound like the coo of a dove.

He turned around fast and heard a “What do?”
From a young ingénue who was new to the crew.

The fake had been caught by this little nurse daughter,
Who’d come from her desk for a cup of cold water.

She asked the old phantom, “Oh doctor, oh my!
Why are you taking our x-ray? Why? Why?”

But you know that old ghost was so smart and so slick,
He thought up a lie, and he thought it up quick.

“Why, my sweet little nurse,” the fake spirit doc lied,
“There’s a screen on this thing that won’t light on one side.
So I’m taking it home to my workshop, my dear.
I’ll fix it up there, then I’ll bring it back here.”

And his fib fooled the nurse. Then he opened her hand,
And stuck in some records and sent her to scan.

The last thing he left was the pain legislation,
To torment and trigger the doc’s resignation.

Then on to his ivory tower he flew,
To judge those below from his smug point of view.

It was quarter past dawn when the patients arrived,
And many soon after with friends by there side.

The doctors and nurses and other commuters,
Found nary a trace of their pens or computers.

The unfriendliest part of the pending disaster,
Was the ghost left no way to check-up on a KASPER.

“Pooh-pooh to the staff,” he was ghoulishly humming.
“They’re finding out now that no pain care is coming.”

“They will just walk away, and that’s what they’ll do.
Their mouths will hang open a minute or two,
And the staff will all cry a crescendo BOO-HOO!”

“That’s a noise,” grinned the ghost, “that I simply must hear.”
So he paused, and the ghost put a hand to his ear.

And he did hear a sound that was not apropos.
It started out low, then it started to grow.

But the sound wasn’t sad. Why, this sound sounded merry.
It couldn’t be so. But it was merry! VERY!

He stared down at the clinic. The ghost popped his eyes.
Then he shook. What he saw was a shocking surprise.

Everyone at the clinic, the tall and the small,
Was treating the pain without pain pills at all!

He hadn’t stopped pain care from coming. It came!
Somehow or the other, it came just the same!

And the ghost, who had back pain from eons ago,
Stood puzzling and puzzling, “How could it be so?”

“It came without money from paying the bills!”
“It came without lidocaine, needles or pills!”

And he puzzled three hours, `till his puzzler was sore.
Then the ghost thought of something he hadn’t before.

“Maybe pain care doesn’t come from a store.
Pain care, perhaps, means a little bit more.”

And the reason’s as clear as the smiles that were there,
No one cares what you know till they know that you care.

And what happened then, well, in this town they say,
His ghoulish bad disk shrunk three sizes that day.

And the minute his back didn’t feel quite so broken,
He flew back inside through the door that was open.

And he brought back the pills, and was nice as a pup
And he, he himself, the ghost peed in the cup.

 

*

 

 

 

 

 

 

Recommended Changes to Indiana’s Emergency Pain Regulations

courthouse corydon

Old Capitol Building – Corydon, IN

 

From Emails Sent to the Medical Licensing Board of Indiana

Re: recommended changes to:

TITLE 844 MEDICAL LICENSING BOARD OF INDIANA Emergency Rule

LSA Document #13-XXX(E)Temporarily adds provisions under P.L. 185-2013 (SEA 246) regarding physicians prescribing opioids for chronic pain.  (Effective December 15, 2013)

Email message sent October 15, 2103

Dear Medical Licensing Board of Indiana:

On September 25th I had the privilege of representing the American Academy of Pain Management, testifying at the Board’s public hearing concerning proposed Emergency Regulations regarding physicians prescribing opioids for chronic pain.

I am now sending two documents with recommendations. The first attached document pertains to the utilization of laboratory analysis (e.g. urine drug screens).  The second attachment pertains to facilitation of physician-led team based care. Note: On October 9, 2013 I sent an email with my recommendations regarding the threshold morphine equivalent dose.

I would appreciate a notification from the Board, indicating the Board’s receipt of all three of my recommendations (i.e. drug screens, team based care, and morphine equivalent dose thresholds).

If at any time the Board wishes to contact me for discussion, I will go to whatever lengths necessary to make myself available.

Sincerely,

James Patrick Murphy, MD, MMM

Jeffersonville, Indiana

 

 

Submitted October 15, 2013:

These recommendations pertain to drug monitoring by laboratory analysis.

Currently Section 8 (a) reads:

(a) At the outset of an opioid treatment plan, and at least annually thereafter, a physician prescribing controlled substances for a patient shall perform a urine or saliva monitoring test, which must include a confirmatory test, on the patient.

The recommended change reads:

(c) During the first 30 days of initiation of an opioid treatment regimen for chronic pain as outlined in Section 3, and at least annually thereafter, a physician prescribing controlled substances for a patient shall utilize a laboratory analysis to aid in determining compliance with the prescribed plan of care.  A confirmatory quantitative laboratory analysis shall be utilized if in the physician’s clinical judgment, such a test is necessary to adequately manage the patient’s opioid treatment regimen.

Discussion:

Analysis of body substances (e.g. urine, saliva, hair, blood) is an important aspect of managing a patient on chronic opioid therapy. These tests are not only useful in establishing boundaries of acceptable behavior, but can alert the physician to signs of addiction, dependence, and drug diversion. There are at least four tissue / body fluid tests that are currently utilized by pain specialists.  More testing options will likely be available to the future.

The drug testing should be a routine part of the treatment plan of a patient using opioids on a chronic basis. These tests are not only useful at the onset of a treatment regimen, but regularly, randomly, and when there is a significant change in the patient’s clinical status.

To encourage and allow adequate use of drug tests, they must be accessible and affordable, else access to care will be hindered. Confirmatory “quantitative” tests are only necessary when the physician in formulating the plan of care requires this information.

Also, the accuracy of expensive confirmatory tests is dependent upon the chain of custody and the manner in which the specimen was obtained (i.e. observing the patient urinate in the cup).

Most times, using a less expensive and readily available “screening” test will be sufficient when coupled with other available data, most important of which is a direct interview of the patient.  Drug screens should build bonds of trust between the physician and the patient. Theses tests should considered “therapeutic” as opposed to “punitive” or “forensic.”

Optimally, a drug screen can be done at the first visit. But if a physician feels it is clinically appropriate to treat the patient at the initial visit, treatment should be allowed as long as early in the course of treatment a drug screen is performed.

References:

  1. 2010 Washington State Agency Medical Directors’ Group Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
  1. Gourlay DL, Heit HA, Almahrezi A.
    Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain
    Pain Med. 2005;6(2):107-12.
  2. http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2005.05031.x/pdf
  3. Murphy, JP. The Compliance Documentation Aid. Pain Medicine. 2005:6(4):329-330  http://www.readcube.com/articles/10.1111/j.1526-4637.2005.00051.x?locale=en
  4. Murphy, JP. Tumblin’ Dice–Why Does Random Matter? Practical Pain Management. May 2006:6(4) http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/tumblin-dice-why-does-random-matter

 

Submitted October 15, 2013:

These recommendations pertain to the requirement that the prescribing physician must perform the physician’s own specific functions (e.g. initial evaluation, drug screens, INSPECT, patient education).

The current draft language in Section 4 is presented below:

Section 4 (a) The physician shall do the physician’s own evaluation and risk stratification of the patient by doing the following in the initial evaluation of the patient:

Most physicians are in group practices and share the same medical records. Also, cross-coverage and on-call duties are the norm. If each physician in the group is required to do his or her own initial evaluation, then access to care will likely be hindered. Also, healthcare costs would rise as initial evaluations are generally more complex (and usually less available) than follow-up or acute care evaluations.

Additionally, the fact that Advanced Practice Registered Nurses can obtain DEA certification and legally prescribe the entire spectrum of available opioids must be taken into consideration.  Physician Assistants can also obtain certification to prescribe Schedule III through IV controlled substances. Therefore, it is very important that the supervising physician remain responsible for defining the prescriptive parameters for APRNs and PAs with whom the physician is collaborating.

The American Medical Association has taken a stand on Physician-Led Team Based Care:

New health care delivery system reforms hinge on a team-based approach to care. In the physician-led team approach, each member of the team plays a critical role in delivering efficient, accurate, and cost-effective care to patients.

Finally, qualified members of prescribing clinician’s staff should be allowed to perform duties within their scope of care (e.g., request INSPECT reports, administer assessment “tools,” educate regarding risks and responsibilities). This concept is echoed in the Federation of State Medical Boards’ text Responsible Opioid Prescribing:

Note that some parts or all of this task might be handled by trained “physician helpers in the office – nurses, physician assistants, or other personnel.

Requiring physicians to perform an abundance of administrative tasks will discourage them from treating chronic pain patients, further limiting access to care.

Recommendation 1:

The first recommendation is to change “physician” to “prescribing clinician.”  “Prescribing clinician” should be defined as:an individual engaged in the care of a patient who is a physician, advanced practice nurse practitioner, or physician’s assistant and whose scope of practice includes prescribing controlled substances and who is legally authorized to prescribe controlled substances.

Recommendation 2:

The second recommendation is to permit prescribing clinicians who are formal members of the same care team to share the responsibilities outlined in these regulations when caring for a patient of their care team. This will allow collaboration and facilitate team-based care.  It should improve access, control costs, and lead to improved clinical outcomes.

Recommendation 3:

Qualified members of the prescribing clinician’s staff should be allowed to perform certain tasks on behalf of the prescribing clinician (e.g. requesting INSPECT reports, educating the patient on risks and responsibilities, processing treatment agreements, administering risk assessment “tools.”). 

Thus, an additional definition in Section 2 (a) would be:

(g) “Prescribing clinician” means an individual engaged in the care of a patient who is a physician, advanced practice registered nurse, or physician’s assistant and whose scope of practice includes prescribing controlled substances and who is legally authorized to prescribe controlled substances.

The recommended language in Section 4 (a) would become:

Section 4 (a) The prescribing clinician shall do his or her own evaluation and risk stratification of the patient by doing the following in the initial evaluation of the patient: …

(With the additional corresponding changes from “physician” to “prescribing clinician” throughout the document as necessary)

In addition, this language is recommended:

It is the prescribing clinician’s responsibility to personally examine the patient, review the available data, assess the level of risk, establish the working diagnosis, and formulate the treatment plan. Other tasks may be delegated to auxiliary members of the care team in accordance with their level of training and responsibility.

References:

  1. Fishman, S.  Responsible Opioid Prescribing, 2nd ed. The Federation of State Medical Boards, Published by Waterford Life Sciences, Washington, D.C. 2012.
  2. American Medical Association: Physician-Led Team Based Care. Available on their website as of 10/14/2013 http://www.ama-assn.org/ama/pub/advocacy/state-advocacy-arc/state-advocacy-campaigns/physician-team-based-care.page

 

 

Submitted October 9, 2013:

These recommendations pertain to thresholds that trigger the measures in the Emergency Rule (i.e. Sections 3 and 9).

Currently Section 3 (c) reads:

(c) The requirements in the SECTIONS identified in subsection (a) only apply if a patient has been prescribed: (1) More than sixty (60) opioid-containing pills a month; or (2) A morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three (3) consecutive months.

The recommended change reads:

(c) The requirements in the SECTIONS identified in subsection (a) only apply if a patient has been prescribed: a morphine equivalent dose of more than 60 milligrams per day at any time during any three consecutive months.

Discussion:

There must be reasonable parameters (e.g. opioid dose) that lawful prescribers can clearly understand and unlawful prescribers (and “doctor-shopping patients”) will not easily be able to circumvent.

MED (Morphine-equivalent dose)

There is no national consensus regarding the most appropriate parameters for increased risk mitigation measures. Likewise, while the physiology of opioid tolerance is well understood, there exists no morphine-equivalent-dose (MED) that defines tolerance.

However, most experts would agree that when a patient’s daily MED reaches 60 milligrams the patient is likely physically tolerant to the opioid (Ref 1).

Furthermore, opioid tolerant patients generally receive opioids on a regular basis.

They are also more susceptible to a withdrawal syndrome than non-tolerant patients. Therefore 60 mg MED would be a logical (and physiological) threshold for requiring increased risk mitigation strategies.

Setting the threshold at a lower level (e.g. 15 MED) has the potential to:

  1. Make physicians wary of treating mild to moderate pain, leading to undertreament; and
  2. Focus a disproportionate amount of attention on patients at lower risk of adverse events, diverting resources needed in treating the higher risk groups.

Temporal parameters:

By convention, three months has been an important interval in the treatment of chronic pain. Some definitions of chronic pain require three months duration. Many prescription plans allow for up to three months supply, usually with a substantial monetary discount for the patient.  Some state controlled substance regulations (e.g. Section 6 of Indiana’s draft) point to three months as a proper interval for surveillance measures and re-evaluation.

If the milligram threshold limit is raised to 60 mg, then the Emergency rules should be triggered if at any time in any three consecutive month interval, a daily MED exceeds 60 mg.

This would be a clear parameter. The requirement to keep track of multiple days with variable dosages not only is cumbersome for the prescriber, but creates opportunity for “gaming the system” by inappropriate prescribers and would-be drug abusers (i.e. “doctor-shoppers”).

The number of pills:

The number of pills (units) dispensed has not been shown to be a significant risk factor in addiction or abuse of opioids. Ever-changing manufacture of potent dosage units allows for a wide range of milligrams per unit, further minimizing the importance of regulating the number of units dispensed. Also many therapeutic regimens require multiples of units for effective titration. Restricting the number of units prescribed would be an impediment to this therapeutic process.

Currently Section 9 reads:

SECTION 9. When a patient’s opioid dose reaches a morphine equivalent dose of more than fifty (50) milligrams per day, a face-to-face review of the treatment plan and patient evaluation must be scheduled, including consideration of referral to a specialist.  If the physician elects to continue providing opioid therapy at a morphine equivalent dose of more than fifty (50) milligrams per day, the physician must develop a revised assessment and plan for ongoing treatment.

The recommendation is to raise the threshold of 50 mg MED, to 120 mg MED.

Discussion:

In this excerpt from his August 27, 2013 letter to the Indiana members of the American Academy of Pain Management, AAPM Director of Policy and Advocacy, Robert Twillman, Ph.D., FAPM explains:

“The concept of setting a threshold to trigger a review of the course of, and plan for, treatment is not new, and seems to me to be entirely reasonable. However, a 50 mg MED threshold is FAR lower than any other existing threshold. The next-lowest threshold is 80 mg MED, in Ohio; other guidelines use thresholds ranging from 90 mg MED to 120 mg MED. I believe that a 50 mg MED threshold is far too low to be practical, and that using such a threshold will result in a substantial chilling effect with respect to prescribing opioids, as prescribers take steps to avoid reaching this dose, avoiding the extra work that results from doing so. Additionally, there is no research supporting the use of a 50 mg MED threshold; in fact, while there is evidence suggesting that 90-120 mg MED might be a reasonable range for a threshold, that research is flawed and thus less than totally convincing.”

Setting this threshold at 120 mg would make Indiana’s parameter consistent with the widely acclaimed 2010 Washington State Agency Medical Directors’ Group’s Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (Ref 2). Prescribers and regulators alike could then draw upon the research and experience of this successful program.

A threshold of 120 mg would logically be twice the recommended 60 mg threshold from Section 3, allowing prescribers to more easily remember the dosage parameters.

References:

  1. Duragesic “Boxed Warning” http://www.duragesic.com
  1. 2010 Washington State Agency Medical Directors’ Group Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf

National Substance Abuse Prevention Month 2013: WEEK TWO

happy pill

Here is a summary of WEEK TWO:

Monday

National Substance Abuse Prevention Month Day 7: An Open Letter to the Medical Licensing Board of Indiana: https://jamespmurphymd.wordpress.com/

Tuesday

National Substance Abuse Prevention Month Day 8 “The mission is definitely not accomplished” (see last paragraph). But there is progress. Together we can overcome this foe. Thanks to Laura Ungar and the Courier-Journal for shining a light on the tragedy and the hope:

http://www.courier-journal.com/article/20131007/PRIME01/310070002/Fatal-drug-overdoses-rank-high-Kentucky-do-efforts-combat-problem?source=nletter-top5

Wednesday

National Substance Abuse Prevention Month Day 9: Prescription drugs are now the most commonly abused drugs among 12 to 13 year olds! Parents, today is a great day to take action. Safeguard your medications & TAKE THE PLEDGE at: http://medicineabuseproject.org

Thursday

National Substance Abuse Prevention Month Day 10: How can your doctor help you avoid being addicted to your pain medications? It helps if your doctor knows how to juggle. I explain here: http://www.courier-journal.com/article/20120604/NEWS01/107100009

Friday

#NationalSubstanceAbusePreventionMonth Day 11 Do you know what addiction really is?  A brain disorder? Bad behavior? A disease? Nora Volkow, MD, our nation’s chief #addiction researcher explains. Thank you HBO for a great webpage:

http://www.hbo.com/addiction/understanding_addiction/18_what_is_addiction.html

Saturday

Substance Abuse Prevention Month Day 12: It’s time for one of Marlyce’s cupcakes. Here’s a sweet story about turning tragedy into triumph! http://kix.com/realizing-a-dream-and-honoring-two-lives/2012/10/

Sunday

National Substance Abuse Prevention Month Day 13: What can Gollum teach us about the disease of addiction and, more importantly, the treatment?    http://www.stratusemr.com/blog/?p=1070