On April 12, 2014 my Norton Healthcare colleagues bestowed upon me the 17th R. Dietz Wolfe Education Award. Hopefully my presentation of the Wolfe Lecture adequately honored the legacy of the esteemed and beloved Dr. Wolfe.
For now, I humbly offer this synopsis…
Note: This article was updated on April 1, 2015 to reflect the most recent changes to states’ regulations.
The Dream of Pain Care… Enough to Cope
– the 17th R. Dietz Wolfe Memorial Lecture
a private place
study her face
fix on his eyes
feel her sinew
give an embrace
innovation
radiation
numb a raw nerve
eradicate
pain creation
to interlope
to offer hope
through some relief
tiny solace
enough to cope
– James Patrick Murphy
Contrary to what one might think, it is generally not difficult to satisfy the needs of patients with chronic pain. Like the poem says, they simply need “enough to cope.” What’s difficult is the juggling act providers must perform to keep three “balls” in the air: patients must do well, regulations must be followed, and drug abuse must be prevented. Drop any of these three balls and you fall as well.
Sometimes the fall is hard. A couple of weeks ago I learned of a pain doctor in northern Kentucky who, on the heels of lawsuits and a medical board investigation, took his own life.
Then there was Dr. Dennis Sandlin, an eastern Kentucky country doctor who was shot and killed in his office by a patient upset because the doctor would not prescribe pain pills to him without first doing a drug screen.
Unfortunately, these scenarios are not our only threat. Federal prosecutors have even tried to use overdose deaths to trigger death penalty statues when seeking indictments against doctors.
And we hear sobering statistics like:
One person dies every 19 minutes from an overdose.
One “addicted” baby is born every hour.
Opioid pain drugs cause more overdose deaths than heroin and cocaine combined.
And now more people die from drug overdose than car accidents.
For this crisis physicians take the brunt of the pundits’ blame, despite the fact that more than two-thirds of the diverted medications are acquired from family, friends, and acquaintances – not from a prescription by their doctor.
So why do it? Why treat chronic pain?
Over 100 million Americans suffer from pain, and that number is growing.
Pain affects more Americans than cancer, heart disease, and diabetes combined.
Up to 75% of us endure our dying days in pain.
True. But pain care, perhaps, means a little bit more?
To answer that question we must first understand what pain is: an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Second, let’s understand the distinction between addiction and abuse. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Drug abuse describes behavior born of bad decision-making; not the disease of addiction. But indeed, bad choices, bad behavior, and drug misuse lead to crime, accidents, social instability, and addiction. The developing adolescent brain is particularly susceptible to addiction, while the elderly brain is practically immune.
Third, let’s understand the risk factors for addiction: (a) environmental, (b) patient-related, and (c) drug-related. We cannot control our patient’s environment, occupation, peer group, family history, or psychiatric issues. But we can gather information and get a feel for his or her risk level. Then we can control what we prescribe – understanding the characteristics of an “addictive” drug include the drug’s availability, cost, how fast it gets to the brain (i.e. lipid solubility), and the strength of the “buzz” it produces.
And thus we can understand how important it is to prescribe the lowest dose possible for the minimum amount of time necessary, based on the level of risk in properly screened patients; then reassess. When in doubt, prescribe even less and reassess more often. Never feel obligated to prescribe more than what you are comfortable prescribing. Pain may be the number one reason a patient visits a doctor and pain care is indeed a patient’s right; however, controlled substances for pain care are a privilege. And just like it is with prescribers, the patients have responsibilities and obligations to meet, lest they endanger their privileges. They must become good stewards of the medications they are prescribed.
Despite these serious risks to their community, their patients, and their medical licenses, physicians regularly rise to the occasion and treat pain. Over the past year as President of the Greater Louisville Medical Society, I have written a monthly article for our journal, Louisville Medicine. The reasons that physicians so often rise are woven throughout those essays. Here are few selected passages…
*
June: We have core values that we share, and when our strategy is in line with achieving the greater good our choice of profession becomes a higher calling.
*
July: We can positively affect people’s lives in a dramatic way and on a grand scale if we commit to our shared values, reconnect and work together. It is not only possible. It is our inherent duty.
*
August: Think back to when you were happiest as a physician. It was probably when you did something that was completely selfless, without any concern that the benefit outweighed the cost, without consideration of a return on investment.
*
September: It is why we started down this tortuous path. It’s why we gave up our youth to endless lectures, textbooks, labs, insomnia, and stress, risked our health, and stole from our family life. We went into debt, endured ridicule on morning rounds, and exposed our careers to legal ruin – all so we could commit to helping the people important to our profession: our patients.
*
October: Her strength, courage and positive attitude have always inspired me. In the cacophony of that noisy mall time stood still as our eyes met. I told her who I was and how inspiring she is to me. She smiled and we hugged. That was a moment of confluential truth. Never take for granted this precious gift.
*
November: I can never be 100 percent sure why I do what I do… but I do know the best decision is always the honest decision, regardless.
*
December: I have been blessed with the opportunity to connect intimately with people on many levels. I’ve noticed those who preserve their joy despite insurmountable challenges… They have perspective. Humans are the only organisms aware of concepts like the past, the future, beauty, love, death, and eternity.
*
January: Every imperceptible moment that passes is not only a new reality; it is rebirth, renewal, and redefinition. How will I define myself?
*
February: The place where you started is your true self; the self that is your center; the self that creates your thoughts and actions. Regardless of your life’s circumstances, success is achieved when your thoughts and actions are in harmony with the true you.
*
March: Failure can be painful. It exposes vulnerability. Physicians, myself included, can be very hard on ourselves sometimes, thinking that by intense training and adherence to protocol, preparation, and planning we are somehow immune to failure. This is, of course, not true. Failure is painful – necessary pain – providing motivation to change, evolve, and realize your role in nature’s play of perfection. Failure is not a result as much as it is a feeling. Failure is… a conduit to greatness.
*
April: I will connect with you as a person – not a diagnosis. …No phone calls, no texting, no social media are allowed to come between you and me. Only then, with laser focus, do I proceed. The job demands this. You deserve this.
*
May: There is a shortage in our profession – a shortage of practical dreamers who can remain child, student, explorer, and physician. Your profession and your patients need you to be this physician. And you need you to be this person.
*
While becoming this physician requires the acquisition of vast knowledge, no one cares what you know until they know that you care. But even the most caring physicians find it hard to keep aim at the moving target of pain regulations. Still, if we are going to do this (i.e. treat pain) we should do it right; in a manner that keeps our community safe and our medical licenses secure.
Throughout my years of medical training I have organized data by creating poems, algorithms, and acronyms. It’s been helpful for me. Maybe they will be helpful for you. Here are some such aids I find useful in the care of pain patients.
AAAA – items to address at pain reassessments
Analgesia level (e.g. a “zero to ten” scale)
Activity level (e.g. functional goals)
Adverse effects (e.g. side effects)
Aberrancy (e.g. worrisome behavior, diversion, addiction, depression)
*
PPPP – the differential diagnosis when they ask for more medication
Pathology (e.g. new or worsening disease)
Psychology (e.g. depression, anxiety, addiction)
Pharmacology (e.g. tolerance, altered metabolism, hypersensitivity, neuropathic pain)
Police-related (e.g. unlawful diversion)
*
Kentucky has adopted (and revised) a law and numerous regulations that address the prescription of controlled substances. Here’s some helpful advice pertinent to prescribers in Kentucky:
Plan to THINK – What to do initially when prescribing for the first 90 days
Plan – Document why the plan includes controlled substances.
Teach – Educate the patient about proper use and disposal.
History – Appropriate history and physical
Informed consent – Risks need to be explained and consent documented.
No long acting – Don’t prescribe sustained release opioids for acute pain.
KASPER – Query the state’s prescription monitoring program.
*
COMPLIANCE – That which needs to be done by the 90 day mark
C Compliance monitoring (i.e. Query KASPER, check a urine drug screen)
O Old records (obtain more records if necessary)
M Mental health screening (i.e. depression, anxiety, personality disorders)
P Plan (establish specific functional goals for periodic review)
L Legitimate working diagnosis established (i.e. objective evidence)
I Informed consent (written) & treatment agreement (recommended)
A ADDICTION / Diversion Screening
N Non-controlled medications tried before going to controlled substances.
C Comprehensive history needs to be obtained and documented.
E Exam “appropriate” to establish baselines for follow-up.
*
PQRST – That which needs to be ongoing after the ninety-day mark
P Periodic review (after the first month, up to physician’s judgment)
Q Query KASPER every three months
R Refer to specialists and consultants as necessary
S Screen annually for general health concerns
T Toxicology screens (i.e. urine) and pill counts randomly and at intervals dependent on the patient’s level of risk.
For more detail please review: “THE CHRONIC PAIN PATIENT’S GUIDE TO KENTUCKY’S REGULATIONS” -available at https://jamespmurphymd.com/2015/02/13/pathway-to-partnership
Let’s not forget Indiana. In December 2013 emergency regulations in the Hoosier state were enacted. These were updated and filed as permanent regulations on October 7, 2014. Indiana’s permanent pain regulations apply when any of the following conditions are met:
- DOSE & DURATION >15 MED for >3 months
DAILY MED (“morphine equivalent dose”) greater than FIFTEEN for DURATION of more than three consecutive months
Or…
- QUANTITY & DURATION >60 pills for >3 months
More than SIXTY opioid pills per month for DURATION of more than THREE consecutive months
Or…
- PATCHES > 3 months
Any opioid skin patches (e.g., fentanyl or buprenorphine), regardless of the dose or quantity, for DURATION of more than THREE consecutive months
Or…
- Hydrocodone-Only Extended Release
Any hydrocodone-only extended release medication that is NOT in an “abuse deterrent” form, regardless of the DOSE, QUANTITY or DURATION
Or…
- TRAMADOL (My advice) >150 mgm for >3 months
Actual language in the regulations state: “If the patient’s tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months.”
This tramadol dose limit seems to be overly generous. My advice: Since 150 mgm of tramadol is equivalent to a FIFTEEN (15) MED, I believe it is more consistent with the other Indiana opioid dosage limits to consider TRAMADOL greater than 150 mgm/day for more than THREE consecutive months as the dosage limit congruent with other opioid dosage limits.
Reference: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm
For more detail please review: “THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATONS” -available at https://jamespmurphymd.com/2015/03/29/pathway-to-partnership-part-ii-in
Indiana Physicians have DRIVE
When these thresholds are met, Indiana physicians must DRIVE
- DRAMATIC at the start;
- REVIEW the plan, REVISE the plan & REFER if the morphine equivalent dose is greater than 60 mg/day;
- INSPECT at least annually;
- VISIT face-to-face with the patient at least every 4 months; and
- EXAMINE a drug screen if there is any indication.
Drug screening takes up a significant portion of Indiana’s regulations. The regulations actually list eighteen “factors” to consider. But the bottom line is that a drug screen (with lab confirmation) shall be ordered: “At any time the physician determines that it is medically necessary…(for any) factor the physician believes is relevant to making an informed professional judgment about the medical necessity of a prescription.”
Indiana Physicians are DRAMATIC
At the initial evaluation a Hoosier physician must be DRAMATIC
D Diagnosis (establish a “working diagnosis” of the painful condition)
R Records obtained (a diligent effort made to obtain & review)
A Assessment of pain level
M Mental health (and substance abuse) screening
A Activity (functional) goals need to be established
T Tests should be ordered, if indicated
I Instead of opioids, use non-opioid options first
C Conduct a focused history and physical
Both states emphasize the importance of treatment agreements, informed consent, and patient education. These subjects, along with helpful examples are presented in my article: “Are We In Agreement?” -available for review and download at: https://jamespmurphymd.com/2014/02/19/are-we-in-agreement
*
Regardless of one’s locale, treating pain with controlled substances can be dramatic. I’m reminded of a scene from the movie “The Music Man,” where Professor Harold Hill warned the people of River City:
Either you’re closing your eyes to a situation you do not wish to acknowledge, or you are not aware of the caliber of disaster indicated by the presence of a pool hall in your community.
Well my friends, the same emotional message is often said of physicians who treat pain. This “mass-staria” can be lessened by utilizing REMS (Risk Evaluation and Mitigation Strategies). REMS has been promulgated by the FDA with the goal of decreasing the risk associated with some risky drugs – especially the opioids.
The yin and yang of REMS is education and monitoring. The informed consent, patient agreement, and educational points together serve as a foundation for a medical practice’s effective REMS program.
Two prime examples of efforts to educate prescribers are (a) the OPIOID course sponsored by the Greater Louisville Medical Society and (b) the First Do No Harm Providers Guide from Indiana’s Prescription Drug Abuse Taskforce.
When both prescriber and patient understand the risks and watch for the telltale signs, early intervention can keep you out of trouble, despite what the Harold Hills of the world might say.
In my experience, most people will do the right thing if they know what the right thing is. President Ronald Reagan’s Cold War policy with the Soviet Union was to “trust but verify.” When you give someone a reputation to live up to, they are positively motivated to deserve that reputation – and deserve that trust. The various measures prescribers take to verify proper use of pain medications provide boundaries that can guide and comfort all parties involved. Beyond the rules, regulations, and guidelines that make up these boundaries, lies the indisputable truth that physicians have an obligation to treat suffering. It’s our calling.
I’m reminded of these words from our departed colleague, Dr. Patrick Hess:
All physicians are artists,
not always in disguise.
Our way of looking at a patient,
allowing our minds to roam,
all over those perceptions of our previous life,
often forgotten,
to scan these memories,
and pull something from our unconscious mind,
all with the purpose of creating something,
something to help the patient.
This creation is,
itself,
a work of art.
When I decided to include this poem in my lecture presentation, I really had no inkling that Patrick Hess was Dr. Wolfe’s “oldest friend.” Nor was I aware Dr. Wolfe’s first love was journalism, or that he was the “bright” nephew of his beloved uncle, famed novelist Thomas Wolfe. I only knew that there was a message of conviction, hope, and inspiration that needed to be heard. I would like to think that these three kindred spirits were in attendance and that they approved of my message. And I would like to think that you will not merely approve, but will take action so that the dream of pain care, enough to cope, devoid of drug abuse, can be realized.
*
This summary is my own opinion and is not legal advice. Each facility and physician should consult its own legal counsel for advice and guidance.
Confluential Truth 
Another great article!
REFERENCES & LINKS OF INTEREST:
*
Norton Healthcare
http://www.nortonhealthcare.com
*
Dr. R. Dietz Wolfe
http://www.legacy.com/obituaries/louisville/obituary.aspx?n=r-dietz-wolfe&pid=144083857
*
the algiatrist
https://jamespmurphymd.com/2013/11/22/the-algiatrist
*
Doctor shows legit side of pain treatment (the juggling act)
http://www.courier-journal.com/article/20120604/NEWS01/107100009
*
Dr. Gary Shearer: Suspended Northern Kentucky pain doctor dies of “suspected suicide”
http://www.wcpo.com/news/local-news/boone-county/florence/dr-gary-shearer-suspended-northern-kentucky-pain-doctor-dies-of-suspected-suicide
*
Dr. Dennis Sandlin
http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/killing-kentucky
http://www.themountaineagle.com/news/2009-12-09/Front_Page/Pillseeking_patient_shoots_kills_doctor_for_not_wr.html
http://capitolwords.org/date/2009/12/11/E2966-2_tribute-to-dr-dennis-sandlin
*
Sobering statistics
Click to access Infographic.pdf
*
Number of painkiller-addicted newborns triples in 10 years
http://usatoday30.usatoday.com/news/health/story/2012-04-29/durg-addicted-painkller-babies/54646654/1
*
Two-thirds of diverted medications come from family and friends
http://usatoday30.usatoday.com/news/health/story/2012-04-24/prescription-drugs-painkiller-abuse/54514368/1
*
AAPM Facts and Figures on Pain
http://www.painmed.org/patientcenter/facts_on_pain.aspx
*
How the Ghost Stole Pain Care (“Pain care, perhaps, means a little bit more”)
*
Definition of Pain (IASP)
https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
*
Abuse vs. Addiction
http://www.hbo.com/addiction/understanding_addiction/113_abuse_vs_dependence.html
*
ASAM definition of addiction
http://www.asam.org/for-the-public/definition-of-addiction
*
Addiction is a brain disease
http://www.attcnetwork.org/explore/priorityareas/science/disease
*
Risk factors for addiction
http://www.healthline.com/health/addiction/risk-factors#1
*
Caring for patients with chronic pain (“Pain is the most common reason a patient sees a physician.”)
http://www.jaoa.org/content/113/8/620.full
*
President of the Greater Louisville Medical Society
Click to access LouisvilleMedicineJune2013.pdf
*
GLMS publication archives
https://www.glms.org/Default.aspx?PageID=139
*
Greater Louisville Medical Society President’s eVoice:
https://www.glms.org/Default.aspx?PageID=569
*
June: http://archive.constantcontact.com/fs105/1101098564175/archive/1113617893458.html
*
July: http://archive.constantcontact.com/fs105/1101098564175/archive/1113925726984.html
*
August: http://archive.constantcontact.com/fs105/1101098564175/archive/1114344399884.html
*
September: http://archive.constantcontact.com/fs105/1101098564175/archive/1114772031297.html
*
October: http://archive.constantcontact.com/fs105/1101098564175/archive/1115193404761.html
*
November: http://archive.constantcontact.com/fs105/1101098564175/archive/1115456070833.html
*
December: http://campaign.r20.constantcontact.com/render?ca=1e4fa05c-3dbe-47ee-ad8a-7c7a8ca7dff6&c=5e86a120-32ce-11e3-905e-d4ae5292b9a6&ch=5feb3a30-32ce-11e3-90ca-d4ae5292b9a6
*
January: http://archive.constantcontact.com/fs105/1101098564175/archive/1116175609238.html
*
February: http://campaign.r20.constantcontact.com/render?ca=0f6fe01d-6096-4233-89d0-09281b480df4&c=5e86a120-32ce-11e3-905e-d4ae5292b9a6&ch=5feb3a30-32ce-11e3-90ca-d4ae5292b9a6
*
March: http://campaign.r20.constantcontact.com/render?ca=6d1fcd26-24fc-41de-8f9a-c6abef28746a&c=5e86a120-32ce-11e3-905e-d4ae5292b9a6&ch=5feb3a30-32ce-11e3-90ca-d4ae5292b9a6
*
April: http://campaign.r20.constantcontact.com/render?ca=94bb2ec6-59fc-4633-8f1e-595496c19a44&c=5e86a120-32ce-11e3-905e-d4ae5292b9a6&ch=5feb3a30-32ce-11e3-90ca-d4ae5292b9a6
*
May: http://archive.constantcontact.com/fs105/1101098564175/archive/1117255603753.html
*
The ABC’s of Pain
http://www.practicalpainmanagement.com/resources/abc-pain
*
Managing Drug Abuse, Addiction, and Diversion in Chronic Pain: The 4 A’s for Ongoing Monitoring
http://www.medscape.org/viewarticle/510856_5
*
Kentucky’s pain law, House Bill 1
http://kbml.ky.gov/hb1/Pages/default.aspx
*
Kentucky’s pain regulations (Kentucky Board of Medical Licensure)
http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx
*
Attorney Roz Cordini’s summary of Kentucky House Bill 1
Click to access HB_1_Update_for_Physicians.pdf
*
Considerations for patient education (KY)
http://kbml.ky.gov/hb1/Pages/Considerations-For-Patient-Education.aspx
*
KASPER
http://www.chfs.ky.gov/os/oig/KASPER.htm
*
COMPLIANCE documentation aid
http://www.readcube.com/articles/10.1111/j.1526-4637.2005.00051.x
*
Considerations for urine drug screening (KY)
http://kbml.ky.gov/hb1/Pages/Considerations-For-Urine-Drug-Screening.aspx
*
Attorney Roz Cordini’s summary of the Indiana emergency pain regulations
Click to access Cordini_IN_Controlled_Substances_Rule.pdf
*
Indiana’s emergency pain regulations
Click to access Emergency_Rules_Adopted_10.24.2013.pdf
*
GLOBALRPh Opioid Analgesic Converter (morphine equivalent dose)
http://www.globalrph.com/narcoticonv.htm
*
Summary of Indiana’s emergency pain regulations – James Patrick Murphy, MD, MMM
https://jamespmurphymd.com/2013/12/15/for-unto-us-pain-laws-are-given-and-the-government-shall-be-upon-our-shoulders
*
From The Music Man: Ya Got Trouble!
*
REMS (Risk Evaluation and Mitigation Strategies)
http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/SignificantAmendmentstotheFDCAct/FoodandDrugAdministrationAmendmentsActof2007/ucm095439.htm
*
One Pain Specialist’s Take on the Controlled Substances Prescriber-Patient Agreement
https://jamespmurphymd.com/2014/02/19/are-we-in-agreement
*
OPIOID (Optimal Prescribing Is Our Inherent Duty)
https://www.glms.org/Default.aspx?PageID=551
*
First Do No Harm – The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain
Click to access First_Do_No_Harm_V_1_0.pdf
*
Here is what “Harold Hill” might have said, had it been a pain clinic instead of a pool hall (from my website: Confluential Truth)…
https://jamespmurphymd.com/2014/04/14/ya-got-trouble
*
President Ronald Reagan’s Cold War policy with the Soviet Union was to “Trust but verify.”
*
How Will You Define Yourself? (including a poem by Dr. Patrick Hess)
https://jamespmurphymd.com/2014/02/03/how-will-you-define-yourself
*
Dr. Wolfe’s “oldest friend” (from obituary)
http://www.legacy.com/obituaries/louisville/obituary.aspx?n=r-dietz-wolfe&pid=144083857
*
Thomas Wolfe’s “bright” nephew
http://www.questia.com/library/journal/1G1-255179181/dr-r-dietz-wolfe-in-memoriam
*
The Thomas Wolfe Society
http://www.thomaswolfe.org
Pingback: THE WAR ON DRUGS HAS BECOME THE WAR ON PHYSICIANS AND PATIENTS | Says Who??
Dr. Murphy’s version of “Ya Got Trouble” on YouTube:
Here is a TOP TEN list I made for publication in the February 2006 issue of “Louisville Medicine.”
I’m amazed at how pertinent the information remains to this day…
*
Author: James Patrick Murphy, M.D.
Chair, Controlled Substances Task Force
*
*
The Top Ten Actions for Avoiding Trouble When Prescribing Controlled Substances for Chronic Non-Malignant Pain – 2006
Whether or not you are the kind of person who makes New Year’s resolutions and regardless of how many you break, it may be a good time to ponder this one:
“This is the year that I get comfortable writing for pain medications.”
In the 1980s the concept of providing pain control to the masses began to take off. In the 1990s the “movement,” fueled in part by our infatuation with Oxycontin, caught fire, only to take a chilling turn as medical boards rose up to squelch the “drug abuse epidemic.” For every action there is a reaction. The reaction by the medical boards, especially Kentucky’s, was robust and continues to this day. For the past six years Kentucky has been ranked among the top five states in disciplinary action against physicians (ref 1).
The learning process is ongoing. Now, well into the first decade of the 21st century, consensus continues to take shape. Guidelines and position statements have been published that have withstood scrutiny and have provided a roadmap for physicians trying to navigate the uncertainty of pain management with controlled substances (ref 2).
The following is a distillation of relevant guidelines, regulations, literature, and clinical experience. A similar article first appeared in the May 2004 Louisville Medicine (ref 3). While many of the basics remain the same, now is an appropriate time for an update: the 2006 version of:
The Top Ten Actions for Avoiding Trouble When Prescribing Controlled Substances for Chronic Non-Malignant Pain
1. Download the Kentucky Board of Medical Licensure guidelines for the use of controlled substances in pain treatment. This is the ultimate roadmap for Kentucky physicians. The website is: http://www.state.ky.us/agencies/kbml . Most board expert reviewers reference this relatively concise document when determining whether or not a physician has violated the Medical Practice Act of Kentucky.
2. Document document document. At first glance, this seems both simple and foreboding. The mnemonic “COMPLIANCE” is useful when determining what needs to be compiled in the chart (ref 4).
Compliance should be monitored (drug screens, KASPER reports, pill counts) with appropriate
repercussions.
Often assessed is pain intensity and functional status.
Medical records are accurate, complete, and accessible.
Plan of treatment has objectives and goals to optimize function.
Legitimate diagnosis of a recognized chronic painful condition.
Informed consent. Treatment agreements (not “contracts”) are also useful.
Addiction assessment (past and current use, family history, psychological issues).
Non-addictive medications have proven inadequate or unacceptable.
Consultation(s) obtained as necessary and other health care concerns are addressed.
Evaluation is thorough (history and physical) reflecting the complexity of the case.
Address the “Four A’s” in follow up notes: Analgesia level, Activity level (function), Adverse side effects, and Aberrant behavior (ref 5). Create a “hard copy” of prescriptions for your records.
3. Prescribe in a logical manner. Start low and go slow with dosing. Avoid writing “breakthrough” opioids for non-cancer pain. Try to stay within the dosage limits outlined in the package inserts (i.e. FDA approved dosages). Consider these three parameters (ref 6):
a. Only one opioid at a time.
b. Only one pill per dose.
c. Only three doses per day (or less).
When it is necessary to stray outside these boundaries, document the reason(s) and have a colleague review your treatment plan. Use an appropriate opioid, not just schedule IIIs and IVs because they are perceived as less addictive (they are not). For continuous pain consider a sustained release opioid instead of handfuls of short-acting pills. Try not to “call in” prescriptions for controlled substances. Never pre-sign prescriptions. Do not prescribe controlled substances for yourself, staff, family, or friends.
4. Do urine drug screens and follow up on the results. These tests can be done in the office for less than six dollars (e.g. Accu-Stat – see below). They are fairly accurate but the potential for false positives and false negatives still exists. A lab can do gas chromatography / mass spectroscopy for confirmation. Regardless, the purpose of drug screens should be to build a therapeutic and trusting relationship between you and your patient. Use abnormal or unexpected results as an opportunity to intervene therapeutically—not punitively. A great monograph on urine drug testing (offering free CME) can be downloaded from the California Academy of Family Physicians website (www.familydocs.org).
5. Obtain KASPER reports. KASPER stands for: Kentucky All Schedule Prescription Electronic Reporting. Kentucky is the first state in the nation to provide a self-service, web-based system for tracking all schedule II – V prescription drugs. The “authorities” are rightfully proud of KASPER, and they expect us to use it. KASPERs are, however, prone to error. Verify the information before making clinical decisions. Remember to not place the KASPER in the patient’s chart or share the report with anyone else (colleagues need to request their own report). With an online account (eKASPER) reports are available to the physician within fifteen minutes. To request an eKASPER web account, physicians can call (502) 573-0361 or log on to:
https://ekasper.chfs.ky.gov/accessrequest/accessrequest.aspx .
6. Get to know your local pharmacists and police. Foster a good reputation. Be friendly. Do not act arrogant or obtrusive. Many physician investigations are triggered by calls from pharmacists and police. Make it clear you want to be part of the solution, not part of the problem. The Louisville Metro Police Department’s “Awareness Through Education” program is aimed at building bridges of understanding and opening crucial lines of communication between police and medical professionals. It is an outstanding program. Contact Sgt. Bill Stivers at (502) 574-2057 or william.stivers@lmpd.loukymetro.org to arrange a seminar for your office staff.
7. Screen patients for abuse potential. Choose carefully which patients can safely be given opioids. Don’t be afraid to ask: “Have you ever abused drugs or alcohol?” No single test exists that is sensitive enough to detect everyone who might abuse opioids.
The CAGE Questionnaire (ref 7) is a simple, validated test that comes highly recommended:
1. Have you ever felt you should cut down on your drinking (or drug use)?
2. Have people annoyed you by criticizing your drinking (or drug use)?
3. Have you ever felt bad or guilty about your drinking (or drug use)?
4. Have you ever had a drink (or drug) first thing in the morning or to get rid of a hangover? (eye opener)
Two out of four “yes” answers = significant risk of alcoholism or drug addiction.
When in doubt, send the patient for a formal psychological evaluation and / or addiction screen. Accept the fact that some patients simply should not receive opioids. Apply a “universal precautions” approach to every chronic pain patient (ref 8). Remove the stigma from drug testing and pill counting by checking everyone at regular intervals and randomly. Addicts come in all shapes, sizes, colors, creeds, and sexes. Even more difficult to detect are those who might be selling their drugs. Therefore everyone should be scrutinized, but in a non-judgmental way.
8. Use treatment agreements and obtain informed consent. Follow up on “breaches” of the agreements. Informed consent is essential, as there are obvious risks inherent to taking controlled substances (e.g. addiction, physical dependence, withdrawal). Do not refer to an agreement as a “contract,” as this puts an added medico-legal burden on the physician. Examples of these documents can be downloaded from the website of the National Pain Education Council (www.npecweb.org).
9. Do not go it alone. As with any complicated disease process, if it is not fully covered in your specialty, ask for help. Find someone you trust who either agrees with your management or whose advice alters your course of treatment for the better. Stay within your comfort zone. Do a critical self-evaluation. Assess the depth of your expertise in chronic pain and addiction, your resources, staff, and ability to provide follow-up and monitoring. Provide the level of care with which you feel comfortable in your practice setting. When you feel you are getting out of your comfort zone, get help from a colleague, or “just say no.”
10. Obtain CME regarding the prescription of controlled substances. Learn from your pharmaceutical reps what resources are available. CME can be earned free of charge from many organizations such as the National Pain Education Council (www.npecweb.org). Consider joining organizations such as: the American Academy of Pain Medicine, the American Academy of Pain Management, the American Pain Society, and the Kentucky Pain Society.
Pain due to cancer often merits a more liberal medication regimen than is usually optimal for non-cancer pain. Chronic pain of any etiology generally responds best to a multidisciplinary approach that may or may not include controlled substances. Kentucky physicians who treat chronic non-cancer (i.e. non-malignant) pain with controlled substances should emphasize the top ten actions presented in this article. A final recommendation is to keep this Top Ten list handy and refer back to it from time to time. Incorporate one concept per month into your practice, and by this time next year writing for pain medications should be painless for you.
Phone numbers / websites:
American Academy of Pain Management http://www.aapainmanage.org (209) 533-9744
American Academy of Pain Medicine http://www.painmed.org (847) 375-4731
American Pain Society http://www.ampainsoc.org (847) 375-4715
Chronic Pain Network http://www.chronicpainnetwork.com
Accu-Stat Diagnostics “Five Panel All in One Cup” urine drug screen: (949) 916-7560
References:
1. Kentucky Board of Medical Licensure Newsletter. Fall 2005. Available at http://www.state.ky.us/agencies/kbml/newsletters/fall2005.pdf .
2. The Use of Opioids for the Treatment of Chronic Pain, Joint Consensus Statement from the American Academy of Pain Medicine and the American Pain Society, 1996. Available at http://www.ampainsoc.org .
3. Murphy, JP. “Controlled Substances Task Force.” Louisville Medicine. Vol. 51, No. 12, May 2004.
4. Murphy, JP. “Letter to the Editor: The COMPLIANCE Documentation Aid.” Pain Medicine. Vol 6, No. 4, 2005.
5. “Pain Assessment and Documentation Tool” available from the “clinical toolbox section” at http://www.npecweb.org (National Pain Education Council).
6. Murphy, JP. “Murphy Pain Center Therapeutic Ladder.”
Presented at conference: Prescription Drug Diversion: Issues
and Prevention Measures for Health Care Benefit Programs
July 26-27, 2005 — The NHCAA Institute for Health Care
Fraud Prevention. Chicago, Illinois.
(email: jpm@mpcky.com or visit
http://www.murphypaincenter.com for details).
7. Ewing, JA. “Detecting alcoholism. The CAGE
questionnaire.” JAMA. 1984; 252:1905-1907.
8. Gourlay, DL, Heit HA, Almahrezi A. “Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.” Pain Medicine. 2005 Mar-Apr;6(2):107-12.
Submitted by James Patrick Murphy, MD
January 8, 2006
Tweet from October 23, 2014
give pain meds the blame
for drug abuse shame
and outlaw their use
to combat abuse
but when drugs are craved
lives will not be saved
and no addiction
is only fiction
so passing the laws
that ignore the cause
may rid us of pills
but won’t solve our ills
On Friday, December 12, 2014, I will be speaking to a larger gathering of my colleagues as part of the Norton Healthcare Internal Medicine Update.
The title of my presentation is: “Pain Management Beyond KASPER.”
I have been able to access a great deal of statistical information regarding the utilization of KASPER (Kentucky’s electronic prescription monitoring program) and data regarding the “unintended consequences” of Kentucky’s pain prescribing law: House Bill 1.
What is lacking is data on prescribers’ attitudes and practices since the law was passed in 2012.
Therefore, I am sending out personal emails to every Family Practice and Internal Medicine physician listed in the roster of the Greater Louisville Medical Society. This is not as scientific as it could be, but at least it is a start. I will try to post the results in January.
– Dr. Murphy
– December 5, 2014
If…
(I) “Complex persistent opioid dependence” (CPOD) is defined a “consequence” of long-term pain treatment;
and…
(II) Kentucky’s pain law (HB 1) defines a “pain management facility” as:
(A) “a facility where the majority of patients of the practitioners at the facility are provided treatment for pain that includes the use of controlled substances and:
(B) The facility’s primary practice component is the treatment of pain; or
(C) The facility advertises in any medium for any type of pain management services
i.e., Pain facility = A + (B or C)
Then…
A clinic in KY that primarily treats CPOD would NOT be defined by KY’s pain law as a PAIN CLINIC ???
From the article in JAMA:
“Dependence on opioid pain treatment is not,
as we once believed, easily reversible;
it is a complex physical
and psychological state that may
require therapy similar to addiction
treatment, consisting of structure,
monitoring, and counseling,
and possibly continued prescription
of opioid agonists.
Whether or not it is called addiction,
complex persistent opioid dependence
is a serious consequence of long-term pain
treatment that requires consideration
when deciding whether to embark
on long-term opioid pain therapy
as well as during the course of such therapy.”
Ref: JAMA Internal Medicine, by Ballantyne, Sullivan, and Kolodny (JAMA Internal Medicine September 24, 2012, Vol 172, No. 17):
http://archinte.jamanetwork.com/issue.aspx?journalid=71&issueid=24963
What’s it all about?
The old conventional wisdom asked us physicians to treat pain as though it was a “Fifth Vital Sign.”
So we treated pain aggressively with a “believe-what-the-patient-tells-you” mentality.
Now, we are being blamed for the prescription drug abuse epidemic and even the recent heroin epidemic because we “overprescribed” pain medications for a decade. As a result, we are now supposed to prescribe pain medication to relieve pain but ONLY if it leads to improved FUNCTION.
Look at what the Cleveland Clinic says on their website regarding opioids:
“These powerful painkillers aren’t only highly addictive. Experts also learned that they:
Don’t provide adequate pain relief long-term. ‘After a while, patients are lucky to get 20 or 30 percent relief,’ says Dr. Rosenquist. ‘Often, improvement in function and general well-being is even lower.’ …For chronic pain, Cleveland Clinic physicians prescribe them only for cancer pain or when other treatments don’t work. Even then, they’re used only in low doses. Plus, they are continued only if the patient’s function (not just their level of pain) improves.’
reference link: http://goo.gl/kkzzhS
Other experts disagree, evidenced by this article in the prestigious journal PAIN:
“…if a treatment is developed to improve pain (or another specific pain related outcome), it may be unrealistic to expect it to have beneficial effects not only on that specific outcome but also on other outcomes that patients would consider important. Just because patients desire change in various pain-related aspects of their functioning does not mean that the efficacy or effectiveness of a pain treatment should be measured by its effects on these other outcomes if the pain treatment was designed, for example, to only have an analgesic benefit.”
Pain 137 (2008) 276–285: Identifying important outcome domains for chronic pain clinical trials: An IMMPACT survey of people with pain.
Click to access Turk%20et%20al.,%202008.pdf
Bottom line: In some people, it may actually be “all about the pain.” And that’s OK, too.
ROUNDING WITH DOCTOR SHAKESPEARE
*
Shylock would have been a fine “Pain Warrior.”
In Act 3, Scene 1 of Shakespeare’s “The Merchant of Venice” the character Shylock lamented about how unfair the Jews were treated when compared to the Christians.
That got me thinking… What if Shylock was a patient with chronic non-cancer pain living in today’s world? Perhaps his monologue would have gone something like this:
*
“They hath disgraced us, and hindered us by the millions; belittled our losses, mocked at our meds, scorned our physicians, thwarted our prescriptions, counted our pills, tested our urine; and what’s their reason? We have chronic non-cancer pain. Hath not we have eyes? Hath not we have hands, organs, dimensions, senses, affections, passions? Fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer, as those with cancer pain? If you prick us, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die? And if you wrong us, shall we not suffer? If we are like them in the rest, we will resemble them in our pain. If a non-cancer patient fails a drug screen, what is his humility? Fired! But if a cancer patient fails a drug screen, what should his sufferance be by state regulations? Why, compassion! The unfairness these regulations teach, doctors will execute, because they are scared of their career’s destruction.”
*
Shylock’s got a point. I mean, physiologically, pain is pain. And for that matter, what is it about having cancer that makes a person less likely to abuse or sell pain medications? Even if you have an answer to that question, I’m certain you can’t prove it by citing a valid clinical study. As Shakespeare’s Juliet said: “What’s in a name? That which we call a rose by any other name would smell as sweet.”
It’s true. Most states exempt cancer related pain from the burden of pain prescribing regulations while coming down hard on prescriptions for non-cancer related pain. However, regardless of how you label pain, it still hurts. And all pain should be treated with equal compassion and conviction, regardless of the cause.
*
Check out “the Bard’s” original version, and you may find you agree with Doctor Shakespeare’s diagnosis:
SHYLOCK
He hath disgraced me, and
hindered me half a million; laughed at my losses,
mocked at my gains, scorned my nation, thwarted my
bargains, cooled my friends, heated mine
enemies; and what’s his reason? I am a Jew. Hath
not a Jew eyes? Hath not a Jew hands, organs,
dimensions, senses, affections, passions? Fed with
the same food, hurt with the same weapons, subject
to the same diseases, healed by the same means,
warmed and cooled by the same winter and summer, as
a Christian is? If you prick us, do we not bleed?
If you tickle us, do we not laugh? If you poison
us, do we not die? And if you wrong us, shall we not
revenge? If we are like you in the rest, we will
resemble you in that. If a Jew wrong a Christian,
what is his humility? Revenge. If a Christian
wrong a Jew, what should his sufferance be by
Christian example? Why, revenge. The villany you
teach me, I will execute, and it shall go hard but I
will better the instruction.