The Least Meaningful Time of the Year

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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





Acute Pain Management for the Patient on Chronic Opioid Therapy

Screen Shot 2015-12-01 at 10.24.50 AMPatients benefitting from the therapeutic effects of chronic opioid therapy generally fall into two categories: (1) chronic pain treatment and (2) addiction “medication assisted treatment.” Both groups will at times need additional pain care measures to address acute issues, such as: trauma, surgery, and hospitalizations. Care providers, in trying to find the right balance between too much and too little, can find these situations challenging.


Today (December 1, 2015)  I am traveling to Leitchfield, Kentucky to conduct a seminar at Twin Lakes Regional Medical Center on acute pain management for the patient on chronic opioid therapy. Below are the slides that I prepared, followed by the references. My hope is that, whether you are a healthcare provider or recipient, as you peruse this information and explore the references and links a better understanding will emerge and your comfort level will improve. 

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Guidelines for Perioperative Management of Buprenorphine


ASAM Definition of Addiction


Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy


Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction


Clinical Opiate Withdrawal Scale


Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report


Methadone Dose Conversion Guidelines Adapted from AAHPM Palliative Care Primer, 2010 edition with permission from Timothy Quill M.D.


Buprenorphine Hydrochloride Injection

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