This is an elephant*

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There is an Indian fable about a group of blind wise men asked to describe an elephant. Each felt only the part of the pachyderm closest to him and thus came up with vastly different truths as to what an elephant is.

Our country has an elephant in our room and it’s called the OPIOID CRISIS. And many of our wise men and women are trying very hard to slay this colossus. Sadly, like the blind men in the fable, they often take aim at only what’s in front of them, missing the heart of the matter and making the beast more angry.

For many, the opioid crisis is primarily perceived as a prescribing problem. Thus, their weapon of choice is PAIN REGULATIONS.

One example of this is House Bill 333, passed this summer by Kentucky’s legislature and later turned into regulations by the Kentucky Board of Medical Licensure on November 15, 2017. These new regulations are have been advertised as (a) merely imposing a three-day limit on prescribing controlled substances for acute pain, because (b) the CDC Guideline demands it. In fact, the clearly voluntary CDC Guideline falls way short of demanding anything…Screen Shot 2017-12-08 at 10.25.53 AM

…And the new Kentucky regulations dictate more than has been advertised.

Even before House Bill 333 came along, embedded in the many pages of Kentucky pain regulations was this dictum:
“The physician shall discontinue controlled substance treatment or refer the patient to addiction management if: There has been no improvement in function and response to the medical complaint and related symptoms, if improvement is medically expected.”

And, as pointed out earlier, Kentucky physicians have been led to believe that the only new regulation is a three-day limit on prescribing schedule two controlled substances to treat acute pain. But there’s more. Much more.

For starters, Kentucky has added a new definition of “high risk” regimens: “dosages greater than or equal to fifty (50) MME/day or opioids with benzodiazepines, without evidence of benefit.” (MME = morphine milligram equivalent)

Now, going forward if a patient meets these criteria…

Or: “Controlled substance therapy has produced significant adverse effects, including instances such as an overdose or events leading to hospitalization or disability”

Or: “The patient exhibits inappropriate drug-seeking behavior or diversion”

Then the physician shall “taper controlled substances.”

But wait, you can’t just taper someone anyway you want to anymore. Now you must taper the medications “in a manner slow enough to minimize symptoms and signs of opioid withdrawal.”

And, hold on, we aren’t done with these new tapering regulations yet. While you are slowly and carefully tapering you must also, “Collaborate with other specialists as needed to optimize nonopioid pain management and psychosocial support for anxiety related to the taper.”

So, let’s review what you have learned about this new regulatory elephant gun:

(1) We are now prohibited (with some exceptions) from giving more than three days of schedule two meds for acute pain.

(2) We’d better find a way to adequately document that there is benefit to our “high risk” regimens.

(3) If virtually anything goes awry, we now must taper very carefully (and with the help of specialists to relieve the patient’s anxiety) to minimize withdrawal symptoms.

(4) And I have failed to mention that, inexplicably, there is now the requirement that a physician “shall stop prescribing or dispensing any controlled substance taken less frequently than once a day.” So if you are somehow able to get your patient to take less pain medication, and it becomes needed less frequently than everyday, your wonderful patient gets rewarded by you having to stop prescribing pain meds altogether? Seriously, what part of the elephant were they feeling when they wrote that regulation?

In conclusion, my purpose in writing this article is not to be overly critical of the well-meaning people who write our regulations. I simply want my colleagues in Kentucky to know that there is much more to the opioid crisis elephant than simply the prescribing component and much more to Kentucky’s new pain regulations than just a limit on acute pain meds. Please don’t get trampled.

Disclaimer: This is not medical or legal advice. This is my personal opinion. Please read the regulations yourself and get a lawyer if you want legal advice.

References:
Indian fable:https://wildequus.org/2014/05/07/sufi-story-blind-men-elephant
OpioidCrisis:https://www.cdc.gov/drugoverdose/epidemic/index.html
CDCGuideline:https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
KBML Pain Regs:https://kbml.ky.gov/board/Pages/krs-amendment.aspx

*This is Water. Commencement Speech to Kenyon College class of 2005 written by David Foster Wallace:  https://www.youtube.com/watch?v=8CrOL-ydFMI

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CORE VALUES

ATTENTION – all clinicians who engage in the noble, but angst-engendering, practice of prescribing opioids for chronic pain…. For those prescribers who wonder how or if they can ever get their patients to use less opioid, this blog post is for you.

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Do you want your patients on fewer opioids?

Announcing!

Murphy Pain Center’s

Chronic Opioid Reduction Empowerment Program

C. O. R. E.

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“Established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence. However, these patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk.” – CDC Prescribing Guideline

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* KENTUCKY’s PAIN REGULATIONS require PHYSICIANS to refer the patient to addiction management if: (1) There has been no improvement in function; (2) Therapy has produced significant adverse effects; or (3) The patient exhibits inappropriate drug-seeking behavior or diversion.

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**INDIANA’s ATTORNEY GENERAL directs PRESCRIBERS to “Develop a personal relationship with a PAIN PHYSICIAN. The pain specialist can act as your THERAPEUTIC SHIELD.”

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As a PAIN and ADDICTION specialist I can assess your most challenging patients and develop plans to reduce or eliminate the need for opioids. My C. O. R. E. program can act as your “therapeutic shield.”

Dr Murphy Pain and Addiction

C.O.R.E. is a collaborative approach to caring for the pain patient on chronic opioid therapy. The goal is to reduce dependence on opioid pain medication. The program begins with an evaluation by Dr. James Patrick Murphy – Pain and Addiction Specialist. Then, a plan to minimize opioids is developed that both the patient and referring physician find acceptable. At the conclusion of the C.O.R.E. program the patient returns to the referring physician with Dr. Murphy providing support and guidance as needed. This ongoing relationship with Dr. Murphy has been described by Indiana’s Attorney General as the prescribing physician’s THERAPEUTIC SHIELD, but you will come to think of it as your peace of mind.

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BEFORE WRITING ANOTHER Rx FOR OPIOIDS YOU OWE IT TO YOURSELF TO CALL

(502) 736-3636

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James Patrick Murphy MD

720 Rolling Creek Drive, Suite 101

New Albany, IN 47150 

References:

* 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances

** First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain

 

New: Indiana’s Pain laws, limiting opioid prescribing to seven days (added to post on 6.29.17) http://iga.in.gov/static-documents/b/9/5/2/b9523207/SB0226.05.ENRH.pdf

Pain Management Opioid Taper Decision Tool A VA Clinician’s Guide:
https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf

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Links of interest:

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When Breath Becomes Air…Becomes Me

WBBA

I knew I would love this book.

When I learned that a young doctor had written about his journey to the end of his life, I thought I would probably find his words meaningful. Individuals who are keenly aware of their mortality and are willing to talk about it, usually can find something important to say.

What I didn’t expect was how much this important book, When Breath Becomes Airwould become me.

Dr. Paul Kalanithi died on March 9, 2015, only weeks after completing his Neurosurgery residency at Stanford. Tragically, he had been diagnosed with lung cancer 22 months earlier as he was entering his final year of residency. But rather than curl up in a corner, he cried, grieved, embraced his wife Lucy, and lived every remaining moment on his own terms.

Even if I’m dying, until I actually die, I am still living.

Through multiple rounds of chemotherapy, physical therapy, endless tests, and unrelenting pain, Paul (I call him “Paul” because I feel like I really know him) cared for patients, loved his family, had a baby, and wrote a book.

When Breath Becomes Air has five distinct parts: Foreword, Prologue, Part I, Part II and Epilogue. Each part could stand alone as fantastic literature, but when taken together the whole becomes transcendent.

The foreword was written by Dr. Abraham Verghese, Paul’s Stanford colleague who, like the reader, really didn’t know Paul very well until after his death.  Dr. Verghese eloquently sets the stage for the reader’s journey and perfectly ends his foreword with: Let me not stand between you and Paul.

Paul’s writing begins with the prologue, where we witness this young man’s life being completely broadsided by his cancer diagnosis. But it’s not just Paul’s story that draws you in, it’s how he tells his story, the images his words create.

Now I lay there, wide awake. A young nurse, one I hadn’t met, poked her head in.  
“The doctor will be in soon.”
And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

The reader cannot help but feel sorry for Paul’s plight. But we are just beginning to know him. After the prologue, Part I is Paul’s account of growing up in the remote town of Kingman, Nevada. His father was a cardiologist, his mother a tireless advocate for Paul and the other young would-be scholars in that desert town.

And while I was highly interested in Paul’s story, it’s his account of medical school -especially his cadaver lab- that made me feel like I had found a kinsman. I can’t imagine any doctor reading Part I and not coming away with the same feeling of connectedness.

And it just gets better and better, as we are there with Paul through the ups and downs of medical school and residency. Being a doctor, with all the responsibility and pressure, can be lonely. Paul’s writing not only made me feel connected to him, but to all doctors as well. All doctors go through many of the same crises, deal with the same emotions, and struggle with the same problems that Paul describes in Part I.

Then, after Part I left me feeling like Paul and I were family, along comes Part II and a kick to the gut. In language that is pure poetry, Paul recounts the series of events encompassing his head-on struggle with cancer and tries to put them into context. Near the end of Part II his language is noticeably more thick with meaning and metaphor. He was clearly more ill and suffering when he authored his final pages. Parts I and II are Paul’s voice, and when Part II ends we fear the worst and feel the loss.

The epilogue comes next, authored by Paul’s wife Lucy, also a nascent physician. Her job is to tell us the details of how Paul died and how she and their daughter, Cady -to whom the book is dedicated- are getting along. We need to know, because after all, by this time the reader feels like one of their family, needing closure, needing consoling, needing comfort.

I knew I would love this book, but I didn’t know that I would feel so close to Paul, Lucy, and Cady. It might be because Paul died just over a year ago. The emotions are still at the surface. Lucy and Cady still live in the San Francisco area. They are real people (I know because Lucy “favorited” one of my Twitter posts about the book). This is not fiction.

It also might be due to the shared experiences that Paul and I (and every other doctor) have in common.

But I’m certain that a major reason I love this book is that it is so well written. Dr. Verghese’s foreword aptly declared: The prose was unforgettable. Out of his pen he was spinning gold.

I agree. There are many passages in Paul’s book that could stand on their own and glisten with poignancy. Did I mention that I love this book? I could offer numerous examples of how wonderfully When Breath Becomes Air is written, but being a physician I think I’ll end my review with Paul’s take on the physician’s duty:

The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

When Breath Becomes Air should be required reading for any premed or medical student, resident, attending physician, retired doctor, patient, future patient, or mortal human being. It’s that good.

Thank you Paul and Lucy. Because of When Breath Becomes Air, this beautiful literary gift, we can all come a bit closer to making sense of our own existence.

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From the website: PaulKalanithi.com:

Paul Kalanithi, M.D., was a neurosurgeon and writer. Paul grew up in Kingman, Arizona, before attending Stanford University, from which he graduated in 2000 with a B.A. and M.A. in English Literature and a B.A. in Human Biology. He earned an M.Phil in History and Philosophy of Science and Medicine from the University of Cambridge before attending medical school. In 2007, Paul graduated cum laude from the Yale School of Medicine, winning the Lewis H. Nahum Prize for outstanding research and membership in the Alpha Omega Alpha medical honor society. He returned to Stanford for residency training in Neurological Surgery and a postdoctoral fellowship in neuroscience, during which he authored over twenty scientific publications and received the American Academy of Neurological Surgery’s highest award for research.

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Video: A Strange Relativity: Altered Time for Surgeon-Turned-Patient

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Comparing Apples to Apples ~ The Morphine Equivalent Daily Dose

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

~ Albert Einstein (attributed)

In medicine we like to measure.

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

Pain_Scale__Arvin61r58

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

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

Kratom-vs-Morphine

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

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

Here’s how it works…

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

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

hydro and morph

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

20 mg x 1.5 = 30 mg

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

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

PRACTICAL PAIN MANAGMENT

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And to paraphrase Paul Harvey

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You know what the MEDD is.

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

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

– Centers for Disease Control and Prevention 03.15.2016

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

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

<50 likely reduces risks

≥50 increases overdose risk without necessarily adding benefits

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

≥90 should not be prescribed without careful justification.

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

>100 associated with significant risks

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

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

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The miserable have no other medicine but only hope. 

~ William Shakespeare, Measure for Measure

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

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References:

Kentucky Board of Medical Licensure

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

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CDC Guideline for Prescribing Opioids for Chronic Pain

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

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Confluential Truth: jamespmurphymd.com

https://jamespmurphymd.com

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The Dream of Pain Care

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

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Kentucky Injury Prevention and Research Center

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

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KASPER

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

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Flaget Memorial Hospital

http://www.kentuckyonehealth.org/flaget

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Copy of Dr. Murphy’s presentation as PDF:

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

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Opioid Abuse in Chronic Pain… Another day, another strategy

 

Read and heed.

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

Yes, I agree with most everything their article says.

And…

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

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

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

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

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

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

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

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

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

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

Take home point: All three definitions are subjective.

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

Follow the regulations, but

Find the truth contained therein, and use it to

Facilitate my patient’s journey to success.

 

Success is a journey. Not a destination.

 

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

The doctor will see you now.

Will you see the doctor?

 

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

 

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Chronic Pain Management for Survivors of Torture

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

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

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

biopsychosocial

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

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

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

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

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

pain pathways

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

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

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

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

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

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

bing

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

Types of Pain (IASP)

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

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

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

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

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

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

Treatment barriers to overcome include:

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

Findings suggestive of torture:

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

Effective treatment augmented by:

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

Summary:

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

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

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

 

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

– Emily Dickinson

 

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

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