Pathway to Partnership, Part II (IN)

THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATIONS  Screen Shot 2015-03-29 at 2.19.10 AM

No man is an island, Entire of itself, Every man is a piece of the continent, A part of the main. – John Donne

The poet, John Donne, knew it. Every Hoosier pain patient and Hoosier pain care provider should take it to heart. No patient or provider is an island. And pain care is best when there is a partnership between the patient and provider. The Pathway to Partnership If you are treated for pain in the Hoosier State the pathway to partnership with your physician passes through Indiana’s pain regulations. Indiana’s entire southern border is Kentucky. And when it comes to patient responsibilities, Kentucky’s pain regulations have much in common with Indiana’s. Therefore, Hoosier patients can begin preparation for their Indiana chronic pain care evaluation by reading my article: Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Screen Shot 2015-03-29 at 2.25.49 AM Available at: https://jamespmurphymd.com/2015/02/13/pathway-to-partnership Particular to Indiana is the Hoosier state’s emphasis on medication dosing limits that trigger mandatory compliance with the regulations. Calculating these dosing limits can be quite confusing and, frankly, patients are not responsible for knowing them. Prescribers are. But to be a good “partner” with your prescriber, you should at least become familiar with these dosing limits. Later in this article I will summarize. But first, in order to hold up your end of the partnership, here are ten items you can prepare:

  1. Your past medical history
  2. Your pertinent medical records
  3. An accurate medication list
  4. Any substance abuse history
  5. Your social and family history
  6. Any other medical issues
  7. Educate yourself for proper informed consent
  8. Your current level of function
  9. Your treatment goals
  10. Complete questionnaires & mental health screens

These ten items are discussed in detail in Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Prepare as described above you will be well on your way to becoming a great partner in your care. As your partnership continues, expect to have contact with your physician on a regular basis and even randomly to:

      1. Review your progress with your treatment plan;
      2. Review the goals of your plan; and
      3. Review expectations (i.e. attending therapy, counseling, tests, etc.)

Insider Information As a partner, you are entitled to some “insider” information. Here it is… A new section of Indiana’s regulations contain a lengthy explanation of what prescribers must consider when ordering drug screens. By doing so, this section offers insight into appropriate patient behavior. The following list, summarized from the regulations, offers an insider’s look at what Indiana expects of a pain patient: In determining whether a drug monitoring test…is medically necessary, the physician shall consider” if the patient has:

      • Taken the meds as prescribed?
      • Taken more meds than allowed?
      • Given or sold meds to anyone?
      • Benefitted from the meds?
      • Taken any other drugs – legal or illegal?
      • Been honest and up front about past drug use?
      • Tried to get early refills?
      • Lost meds? Had them stolen?
      • Had an abnormal INSPECT state prescription report?
      • Failed a drug screen?
      • Been intoxicated?
      • Been acting aggressive, depressed, anxious, etc.?
      • Been diagnosed with a psychiatric condition?
      • Demanded certain specific meds?
      • Had a major illness? Pregnancy? Hospitalization?
      • Been resistant to any changes in the care plan?
      • Refused or failed to follow through with exams/tests?
      • Just not done well overall?

Bottom line: Be honest, up front and “transparent.” No one likes surprises. A good partnership is all about trust and communication. Understand what your treatment agreement says and live up to it. cs agree pic Dosing Limits Now, about those dosing limits… As I said, it can be confusing, but you should try to understand the concepts and discuss them with your prescriber. Not all pain prescriptions are subject to the Indiana regulations. Therefore, it is important to understand the dosing limits that trigger mandatory compliance. These limits are dependent upon: (1) the dose, (2) the quantity and (3) the duration. The Morphine Equivalent Dose (“MED”) is basically how strong your medication would be if it were to be substituted for morphine. This is very important to INDIANA regulatory agencies. I highly recommend you learn how to calculate your MED. Screen Shot 2015-03-29 at 10.47.08 AM Calculating the MED Step ONE: Calculate the MED for one pill Determine the dose of morphine that would be equal to one of your pills using a standard conversion table (For example: a FIVE mgm hydrocodone pill is the same as a FIVE mgm morphine pill; but a FIVE mgm oxycodone pill would be the same as a 7.5 mgm morphine pill). Indiana officials recommend this website for help with making this determination: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm Screen Shot 2015-03-29 at 2.30.15 AM Step TWO: Calculate your DAILY MED Once you have converted your pill to its “morphine equivalent,” simply add up the maximum number of pills your prescription allows you to take in a day and multiply this number by the morphine equivalent (MED) you determined in step one. (Number of pills per day) x MED/one pill = Daily MED For example: Since a FIVE mgm hydrocodone pill is equal to a FIVE mgm morphine pill, the daily MED of someone taking THREE of these hydrocodone pills per day would be: 5 mgm x 3 pills per day = 15 mgm MED Here are some common ORALLY prescribed opioids that compare to a MED of 15: Hydrocodone (oral) 15 mgm/day = 15 mgm of morphine (oral) Oxycodone(oral) 10 mgm/day = 15 mgm of morphine (oral) Oxymorphone (oral) 5 mgm/day = 15 mgm of morphine (oral) Codeine (oral) mgm/day = 15 mgm of morphine (oral) Hydromorphone (oral) 3.75 mgm/day = 15 mgm of morphine (oral) Tramadol (oral) 150 = 15 mgm of morphine (oral) Note: MED greater than SIXTY If you are on a treatment regimen with a morphine equivalent dose of more than SIXTY (60) MED, the physician may require you to have an evaluation by a specialist. According to the regulations, your physician must explain to you that there is an increased risk of adverse outcomes, including death, when your daily MED is greater than SIXTY. So now that you understand the MED, you are ready to look at the DOSING LIMITS that trigger compliance with the regulations. DOSE, QUANTITY & DURATION When any of the following conditions are met, your physician (and you) must comply with the Indiana pain regulations.

      1. DOSE & DURATION >15 MED for >3 months

DAILY MED greater than FIFTEEN for DURATION of more than three consecutive months Or…

      1. QUANTITY & DURATION >60 pills for >3 months

More than SIXTY opioid pills per month for DURATION of more than THREE consecutive months Or…

      1. 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…

      1. 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…

      1. 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 when compared to other MED dosing limits. A SIXTY (60) MGM MED of tramadol is in the range of 300 to 600 mgm of tramadol. Considering that the maximum therapeutic dose for tramadol is only 400 mgm per day, one could potentially exceed the safe upper limit of tramadol and still not exceed Indiana’s dosing limit. This seems to be inconsistent with the regulation’s other opioid dosing limits. 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 Wait!!! There are EXEMPTIONS !!! Regardless of the dose, quantity or duration, the Indiana pain regulations do not apply to these patients: (1) With a terminal condition (2) Residing in a licensed health facility (3) Enrolled in a licensed hospice program (4) Enrolled in a licensed palliative care program microphone 5 In summary, patients and physicians should travel the pathway to partnership together. Patients can do their part by (1) preparing for the clinical visits, (2) understanding and adhering to their treatment agreements, and (3) educating themselves about risks, side-effects, and legal aspects of their care. It is a real challenge to treat chronic pain in this day and age. Your physician needs your help. Will you leave it all up to your physician? Or will you be a good partner, heeding the words of the poet DonneAnd therefore never send to know For whom the bell tolls; It tolls for thee.  * podium thumbs up James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine. * References and links pertaining to this article are provided in the comments. * This unofficial summary is my personal opinion. A full, official version of the final rule should be consulted for compliance purposes at: http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html The Indian State Medical Association also has a summary available at: http://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf no harm And if you really want to explore the Indiana pain regulations in detail, there is no better source than the online guide: First Do No Harm, The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain. http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf * Hey Hoosier! Who’s your partner? handshake_between_doctor_and_patient_with_the_sky_background_1341168865 * * *

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4 thoughts on “Pathway to Partnership, Part II (IN)

  1. References and links of interest:
    *

    John Donne
    http://www.poetryfoundation.org/bio/john-donne

    Pathway to Partnership – The Chronic Pain Patient’s Guide to Kentucky’s Regulations
    https://jamespmurphymd.com/2015/02/13/pathway-to-partnership

    Indiana Pain Regulations
    http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html

    ISMA Summary of Indiana Pain Regulations
    http://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf

    The Indiana Scheduled Prescription Electronic Collection and Tracking (INSPECT)
    http://www.in.gov/pla/inspect/2338.htm

    Are We in Agreement: One Pain Specialist’s Take on the Controlled Substances Prescriber-Patient Agreement
    https://jamespmurphymd.com/2014/02/19/are-we-in-agreement

    The Morphine Equivalent Dose
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069064

    Kentucky Pain Regulations
    http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx

    First Do No Harm, The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain
    http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf

    The online opioid calculator from GlobalRPH
    http://www.globalrph.com/narcoticonv.htm

    Meditation XVII by John Donne (“No man is an island…”)
    http://www.online-literature.com/donne/409

    • From:
      PATHWAY TO PARTNERSHIP, PART I (KY)
      THE CHRONIC PAIN PATIENT’S GUIDE TO KENTUCKY’S REGULATIONS

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

      General Recommendations:
      1. Prepare answers to some basic medical history questions.
      2. Obtain copies of pertinent documents and medical records.
      3. Make a list of your healthcare providers along with their contact information.
      4. You may wish to store the data on a flash drive, CD/DVD or upload to a secure website for retrieval by your physician. Be advised, until you give these documents to your physician you are responsible for keeping them private.
      5. Bring a friend or family member with you for support, assistance with questions, and to help verify information.

      For the initial visit prepare the following:
      1. Medical history
      2. Medical records
      3. Medications
      4. Substance use
      5. Social and family history
      6. Other medical issues
      7. Education and consent
      8. Ability to function
      9. Goals
      10. Questionnaires / mental health screen

      1. Medical history.
      It begins with your “Chief Complaint.” This is where you tell your physician what hurts.
      Chief complaint: My pain is _______________________
      For example: “My pain is in my low back.”
      Next, fill in some DETAILS about your pain:
      (i) Cause. Based on what you know about your condition, what do you think is causing your pain?
      Examples: a bad disk / pinched nerve / arthritis, etc. Be as specific as you can.
      (ii) Location. Where does it start? Where does it go?
      (iii) Quality. Sharp? Aching? Electrical? Sensitive to touch?
      (iv) Symptoms. Numbness? Tingling? Weakness? Muscle wasting? Skin color changes? Swelling?
      (v) Timing. Started when? Is it constant? Variable? Worse at certain times of the day? Lasts how long?
      (vi) Aggravating factors. What makes it worse? Bending? Standing? Twisting? Being anxious? Working?
      Housework? Sleep?
      (vii) Relieving factors. What makes it better? Resting? Heat? Ice? Massage? Medication? Injections? Being
      distracted? Sleep?
      (viii) Pain scale. Rate your pain on a scale from: ZERO (no pain) to TEN (worst pain imaginable).

      2. Medical records.
      Your physician may not need every record, but information about care related to your pain is useful and includes:
      • Surgery reports related to your pain (back surgeries, etc.);
      • Laboratory tests (blood tests, urine drug screens, etc.);
      • Studies (x-rays, MRI, CT, EMG, etc.);
      • Pain care treatments (epidurals, physical therapy, acupuncture, chiropractic, etc.);
      • Consultations with specialists (surgeons, pain, chiropractic, mental health).
      Make a list of your diagnostic tests, especially the most recent ones; include dates and contact information. Gather the reports. If you wait for your physician to get the reports faxed, your pain care could be delayed significantly. You may want to copy them onto a flash drive, CD/DVD, or to a secure website.

      3. Medications.
      (a) An accurate and current medication list is extremely important. Include the date, dosage, quantity, and directions. Bring the medicine bottles with you and/or labels, written prescriptions, etc.
      Provide answers to these questions:
      • Do you find your current medications to be effective?
      • Are you taking them the way they have been prescribed for you?
      • How long have you been on your current medications?
      • When was the last time you had a medication change?
      • Are they causing you any unacceptable side effects such as: sedation, fatigue, nausea, constipation, etc.?
      (b) Your medication “journey.” It is extremely important for your physician to know (and document) how you got to this point. What medications did you use in the past? Did you try some over-the-counter medications? Non-controlled substance prescriptions? Gather records (medical, pharmacy, etc.) to show how your dosages have changed over time.
      (c) If you have a prescribing “agreement” with another physician, bring a copy.

      4. Substance use.
      It is vital to be forthcoming about any substance abuse or any substance abuse treatment involving you or any close relative (especially a mother, father, son or daughter). And report any drug-related arrests?
      Do you drink alcohol? Do you smoke?
      Remember to drink plenty of fluids before your visit in case you are asked to provide a specimen for a random urine drug screen.

      5. Social and family history.
      Where do you live and with whom?
      Is your home life a challenge?
      What is your occupation? Are you disabled?
      Where do you get money to live on?
      How much formal education have you had?

      6. Other medical issues.
      Are you dealing with any other medical issues such as: diabetes, heart disease, cancer, etc.? When was your last general medical evaluation?
      Note: To receive long-term controlled substances for pain in Kentucky, it ismandatory that you have a yearly preventive health evaluation.

      7. Education and consent.
      Show that you have educated yourself about controlled substances and prepare to document your “informed consent.”
      (a) The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website.
      I have prepared an educational summary for both Kentucky and Indiana which is available here: http://goo.gl/IJ4I1l
      Or download the Murphy Pain Center New Patient Package. Study the patient education sheet. Print it out. Sign it. And bring it with you.
      Watch this outstanding video by Dr. Mike Evans that explains many of the pros and cons of the use of controlled substances for chronic pain care.
      (b) Once you have been informed, you are ready to give your “informed consent.” You may download this document and bring it to your physician:
      I have written an article about informed consent and treatment agreements,Are We In Agreement, available on my website: Confluential Truth.

      8. Ability to function.
      Describe your current ability to participate in life’s activities. This will give your physician a baseline from which to judge your progress. You may visit the website for ICSI (Institute for Clinical Systems Improvement) and download and complete the form in Appendix C: Physical Functional Ability Questionnaire (FAQ-5).

      9. Goals.
      Come up with some specific and realistic goals that might be attainable. Think of how you can show when you have achieved them. Within reason, think about what you would like to do that you cannot do now. Be prepared to demonstrate this to the physician; i.e. walk without a cane, bend to pick up something, rise from a chair unassisted. Set goals that are SMART: specific, measurable, attainable, realistic, and track-able.

      10. Questionnaires / Mental Health Screen
      Complete these “screening” questionnaires and bring them to your visit.
      You may go to the Kentucky Board of Medical Licensure website, download these self-report questionnaires, fill them out, and bring them to your office visit.
      • Opioid Risk Tool
      • Patient Health Questionnaire (PHQ-9), mental health screen
      You may also go to the website for ICSI (Institute for Clinical Systems Improvement) and download and complete these two forms:
      Appendix A (Brief Pain Inventory); and
      Appendix B (Patient Health Questionnaire PHQ-9)
      *
      If this all seems a bit overwhelming, you can begin to simplify matters by visiting the Murphy Pain Center website and downloading the “New Patient Package.” In it you will find policies, consent forms, agreements, educational materials, and a “New Patient Evaluation” form.

      http://www.murphypaincenter.com/louisville

      These are the kinds of materials you will likely be filling out at your physician’s office visit. Having this information on hand can make your visit more productive.

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