Treating Pain With Truth

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Then you will know the truth, and the truth will set you free.
~ John 8:32 (NIV)

…Pain free?

Confluential Truth blog posts address various issues, and many share a healthcare theme. Often the focus is on chronic pain. The following collection of Confluential Truth offers my views on how chronic pain may be effectively and safely treated, especially when the treatment involves controlled substances. Each essay is like a chapter in a mini-textbook about treating chronic pain. They are offered here hoping to provide insight into improving quality of life for pain sufferers and pain care providers.

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PROLOGUE:  The Algiatrist – To set the tone, a poem about treating pain and being “useful.”

INTRO ALGIATRIST https://jamespmurphymd.com/2013/11/22/the-algiatrist

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CHAPTER ONE:  The Dream of Pain Care – A transcript of my address to the physicians and staff of Norton Healthcare – the what, why & how. If you only have time to read one essay, this is the one.

1 wolfe 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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CHAPTER TWO:  Pathway to Partnership, Part 1 (KY) – Here is how we do it in Kentucky when we do it right.2 ky path  https://jamespmurphymd.com/2015/02/13/pathway-to-partnership

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CHAPTER THREE:  Pathway to Partnership, Part 2 (IN) – Here is how we do it in Indiana when we do it right.

Screen Shot 2015-07-17 at 12.33.44 PM

https://jamespmurphymd.com/2015/03/29/pathway-to-partnership-part-ii-in

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CHAPTER FOUR:  Are We In Agreement? – Expectations, edification and enlightenment result from properly implemented patient-physician “agreements.”

agree

https://jamespmurphymd.com/2014/02/19/are-we-in-agreement

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CHAPTER FIVE:  Treating Pain Patients Like Addicts – There is ample overlap between optimal treatment for addiction and optimal treatment for chronic pain. Utilizing this knowledge can enhance the effectiveness and mitigate the risks inherent to treating chronic pain with controlled substances.5 tx like addicts https://jamespmurphymd.com/2014/11/21/treating-pain-patients-like-addicts

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CHAPTER SIX:  Basic Pain Care Certification – It’s a sad fact the number of deaths associated with drug overdose is roughly equivalent to the number of motor vehicle fatalities. Imagine how many might die on our roads if, instead of a driver’s license, all you needed to drive a car was a prescription from a doctor. Now, imagine how many less might die of drug overdose if you had earn a “license” to use controlled substances…

4.5 pain care certhttps://jamespmurphymd.com/2014/08/06/basic-pain-care-certification

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CHAPTER SEVEN:  Strength in Numbers – Successful chronic pain treatment involves: (a) medical care; (b) counseling; and (c) a support system. Find all three and you have probably found…

6 str in num https://jamespmurphymd.com/2014/07/02/strength-in-numbers

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CHAPTER EIGHT:  It’s Only Words – Over the years I have given many presentations concerning medication management for chronic pain. Often I have said that if there is only one concept I want the group to take away it’s that “addiction” and “physical dependence” are not the same thing.

8 words https://jamespmurphymd.com/2014/04/03/its-only-words

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CHAPTER NINE:  Talking Trash – We spend much time worrying about the acquisition of pain medications but too often don’t know what to do with them when we are done.

7 talk trash     https://jamespmurphymd.com/2014/07/21/talking-trash

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CHAPTER TEN:  Is There Method To This March Madness? – Too often our focus is on a specific drug, when in reality the culprit is the disease.

9 march madnesshttps://jamespmurphymd.com/2014/03/18/is-there-method-to-this-march-madness

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EPILOGUE:  Proclaim Pain Care Providers Day! – Don’t just provide great pain care… Proclaim it!

10 PCPD https://jamespmurphymd.com/2015/01/22/proclaim-pain-care-providers-day

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westminster podium

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.

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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 * * *

Pathway to Partnership, Part I (KY)

THE CHRONIC PAIN PATIENT’S GUIDE
TO KENTUCKY’S REGULATIONS
pathway rainbow

Even though I’m on the lowest dose possible to keep my chronic pain under control I still worry this too will be taken away. At each appointment I get scared I will be told my doctor can no longer prescribe what little medication I do get. I appreciate the pain relief I do get, it means more to me than people can imagine.
~Samuel
October 1, 2014 at 7:47 PM

People with pain must recognize that they have a role to play in making sure these medications remain available, as needed, to all.
~Steven D. Passik, PhD

Abstract: This is a summary of how chronic pain patients can effectively prepare for a productive and meaningful visit with their Kentucky physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that patients and physicians will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.

karen neck

Pain is the most common reason patients see physicians. We all feel pain, but everyone experiences pain in a unique way. There are many ways to treat pain, but treatment is best when tailored to the needs of the individual. Sometimes adequate pain treatment requires drugs (i.e. “controlled substances”) that expose users to risks of addictions, abuse and misuse. In these cases, patients and physicians must work together to minimize these risks.

It has been estimated that in the U.S. there is only one pain specialist for every 26,000 patients with chronic pain. Thus the majority of chronic pain treatment remains in the hands of primary care physicians.

Treating chronic pain can be straightforward when the primary focus is providing relief. But inescapable concerns about potential drug abuse and regulatory scrutiny can make treating chronic pain very complex and stressful for patients and physicians.

Most states have specific prescribing regulations that sometimes are inadequately communicated and poorly understood. This contributes to physician anxiety and adds to the physicians’ clinical, legal, and administrative burdens.

The patient-physician relationship must be a true partnership based on respect, trust, honesty, and clear communication. The following is a summary of what patients can do to help their physician partners.

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The Chronic Pain Patient’s Guide to Kentucky’s Regulations

write rx

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).

  1. 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.

  1. 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.

  1. 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.

  1. 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?

  1. 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 is mandatory that you have a yearly preventive health evaluation.

  1. 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.

  1. 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).

  1. 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.

  1. 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)

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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. 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.

In conclusion: Due to growing concerns about drug abuse, coupled with layer upon layer of regulations, physicians are becoming increasingly anxious about prescribing controlled substances for patients suffering in chronic pain.

Gen rec and initial

This has been a summary of how a chronic pain patient can effectively prepare for a productive and meaningful visit with his or her physician to address pain care options -especially when care involves the use or potential use of controlled substances. The goal is that both parties will work together to maximize the therapeutic benefits and minimize the inherent risks to patients, physicians, and society.

When patients are adequately prepared, physicians can feel more comfortable, and patients can more likely receive safe, effective, and proper pain care.

It is a partnership.

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Note: For the purposes of this summary “controlled substances” refers to CSA scheduled drugs 2 – 4 (Schedule 5 drugs are exempt from Kentucky’s regulations).

Note: Kentucky’s regulations do not apply if the patient is being treated:

(a) in hospice or “end-of-life” treatment;
(c) for cancer pain or pain associated with the treatment of cancer;
(b) in a licensed hospital as inpatient, outpatient, or observation status
(d) as a registered resident of a long-term-care facility
(e) during a disaster or mass casualty situation
(f) as a single dose for a diagnostic test or procedure

So now that you know the pathway…

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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.

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References and links pertaining to this article are provided in the comments.

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‘Twas the Fight in Our Clinic

orange jumpsuit

It was right before clinic and all through morn,
Not a patient was hurting, nor feeling forlorn.
The stocking of meds on the shelves was with care,
In hopes that ridiculous pain would be rare.
The front desk was nestled all snug in their seats,
Collecting the copays while smiling so sweet.
And I in my lab coat, scrub top, and a glove,
Had just settled in for the job that I love.

When out in the hall there arose such a clatter,
I sprang from my chair to see what was the matter.
Away to the window I flew like a flash,
Tore open the shutters and covered the cash.
A man on a quest, who did not like a “no,”
Gave bluster and chaos to our status quo.
When what to my watering eyes did appear?
But my signature forged on a pad that was near.
The villain prescriber had written so quick,
I knew in a moment it must be some trick.
I asked him his name and just why he had come,
But all he could say was he had to be on…

On Morphine, on Codeine, on Oxy, on Contin,
On Soma, on Xanax, and lots of Neurontin!
Don’t stop for the chart. Don’t stop in the hall.

Now right away! Right away! Write for it all !!!

As dry heaves that before a wild emesis fly,
When I met this intruder I thought I could die.
So onto the restroom I coerced him to…
Pee into a cup that might give me a clue.
But then, in his tinkling, I heard through his bleating,
The faucet, the flushing and knew he was cheating.
As I pulled back my hand and was turning around,
Through the window the specimen came with a bound.

I was stressed by his sight, and I thought for a while,
That his clothes were an orangey prisoner style.
A stencil of words were in print on his back,
When I asked him about it he called me a quack.

His lies, how repugnant; how simple his tally –
Prescription pain pills to sell in the back alley !!!

He had a clear package tied up with a bow,
And the powder inside was as white as the snow.
A piece of lead pipe he held tight in his hand,
And he swung it at me as he started to stand.
He had a gaunt face and not much of a belly,
And I shook when he laughed ‘cause his breath was so smelly.
He was stealing prescriptions, I thought to myself,
And I cringed when I saw him reach into the shelf.

A wink of his eye and a poke to my head,
Soon gave me to know I had something to dread.
He said he had come to us straight from his “work,”
And turned ’round to face me and called me a jerk.
He gave me the finger, then fingered my nose,
‘Til both of my nurses, they stomped on his toes.
He sprang to his car when we asked about jail,
And away he did run with the cops on his tail.
But he heard me exclaim, ‘ere he drove out of sight,

No prescriptions for you, because we do it right!

022812 police-chase

 

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While drug diversion is certainly no laughing matter, I couldn’t resist poking a little fun at some of the bumblers who have chosen this “career” path.

Here’s hoping that you have a joyous and pain-free holiday season!

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National Pain Care Providers Day

meryl

Every dog has his day, right?

In our culture, groups, individuals, and even inanimate objects are frequently honored with their very own special twenty-four hours. These days of recognition give us pauses to examine their meanings and further their causes.

But there’s a compassionate and deserving group of people who have not yet made the list…the caring people who treat our pain. 

For now, National Pain Care Providers Day is only a dream.

It doesn’t exist.

It should.
It can.
And it will…with your help.

National Pain Care Providers Day
March 20, 2015

npcpd hands screen

It’s time to recognize all who generously and selflessly strive to alleviate suffering. This includes physicians, dentists, nurses, therapists, emergency responders, trainers, masseuses, pharmacists, caregivers, mothers and anyone who gives of her or himself to ease pain.

Why is National Pain Care Providers Day necessary?

Pain is universal. It is the most common medical complaint. There is no escaping it. Pain touches every life. And as our population continues to age, pain is occurring in epidemic proportion.

Pain care is sometimes simple and sometimes extremely complicated. Caregivers can feel tremendous pressure from government agencies, police, lawyers, administrators, addicts, abusers, patients, families, administrators, insurance providers, and the media. As a result, caregivers are too often reduced to feeling “You’re damned if you do and damned if you don’t.”

In reality, they should be praised because of what they do.

Caregivers who persevere deserve our support, gratitude and, at the very least, a day of recognition.

Popular opinions regarding pain care and treatments are evolving rapidly. Taking a special day to spotlight best practices and inspire possibilities would not only bolster the advancement of this vital field of medicine, it would encourage the legions of those who suffer in lonely silence. Less suffering and better lives for all are the goals.

Celebrating National Pain Care Providers Day on March 20, 2015 – the first day of spring – is akin to celebrating hope. From this day forward, the vernal equinox, light overcomes darkness.

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So let’s join together and recognize the first day of spring, March 20, 2015, as National Pain Care Providers Day. Let’s make this day special for the special people who treat our pain. Start by sharing your comments and ideas on this blog and/or emailing paincareprovidersday@gmail.com. Pass along the message on social media (Twitter, Facebook, etc.) and contact your civic leaders. Be a vital part of this movement.

Let Hercules himself do what he may,
The cat will mew and dog will have his day.
~ William Shakespeare’s Hamlet

You are the playwright now.
The parchment is blank.
Imagine.
Create.

And celebrate!

National Pain Care Providers Day
March 20, 2015

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Basic Pain Care Certification

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The consequences of pain…

A young mother is terrified helplessly watching her child spiral toward death in anaphylactic shock, because she did not know that an allergy to aspirin could also mean an allergy to ibuprofen.

An elderly man is no longer breathing, because he mistakenly thought he could break his pill in half to save money; when in fact, this caused the immediate release of a lethal dose from his time-release pill. He will die before the ambulance can arrive but could have been saved by a simple subcutaneous injection.

A business executive is transfused her tenth unit of whole blood, but it will not save her from dying from the hemorrhaging ulcer caused by excessive over-the-counter pain medications.

A young football star slumps silently in a corner at his high school friend’s party. Pills acquired from various unlocked medicine cabinets are coursing through his arteries. In three days his grieving parents will be struggling with the decision to remove him from life support.

With alarming frequency, stories like these touch every family.

All are preventable.

 

The consequences of pain…

 

More costly than cancer.

More deadly than car crashes.

More likely than a heart attack.

More common than the common cold.

 

With pain being so ubiquitous, so serious, so PAINFUL, why do we still not know how best to deal with the pain epidemic?

Perhaps, it is precisely because we don’t know?

Then, we should learn.

We should become knowledgeable, skilled, competent, and even certified.

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By “we” I mean everyone – not only health care providers. Pain and pain’s consequences touch every life. We all have a stake.

Lifeguards, plumbers, electricians, firemen, police, pilots, engineers, lawyers, nurses, pharmacists, physicians, etc., etc., etc., must earn certifications. Similarly, by the millions, people of all ages achieve certification in Basic Life Support – and we regularly hear stories of how a bystander stepped in to save a life. A standardized and universal understanding of pain, its treatments, complications, emergencies, and prevention could have similar results.

This point is bolstered by a recent letter from the American Society of Addiction Medicine calling upon the White House to:

…focus holistically on provider and community education, overdose death prevention and increased access to treatment, in order to effectively manage the (opioid) epidemic.

Knowledge is power.

It is time we, as a community, put that power to work.

The roadmap is clear. Like the American Heart Association’s Basic Life Support certification, Basic Pain Care (BPC) can be taught in a standardized algorithmic manner. Learning can be didactic and hands-on. For most, it would only take a few hours to master the skills, earn the certification, and acquire the confidence.

 

A Basic Pain Care curriculum might include:

– Wellness and prevention (diet, exercise, stress)

– Acute care (ice, heat, etc.)

– Over the counter medications

– Prescription medications

– Opioids

– Alternative and complementary treatments

– Drug abuse prevention, recognition, and treatment

– Regulations

– Pitfalls and risks

– Emergency procedures (overdose, seizure, etc.)

 

Imagine how confident you would feel if you knew the best and safest way to treat pain, regardless of the situation – acute, chronic, traumatic, post-operatively, and palliative. Imagine that everyone knew.

 

Imagine the suffering that would be eased.

Imagine the resources that would be spared.

Imagine the lives that would be saved.

Imagine the tears that would never be shed.

 

Now make it real. Join with me in establishing the Basic Pain Care Certification. We can start by getting connected. Share this article. Offer your comments. Follow my Confluential Truth blog and the Twitter account @jamespmurphymd. Email your thoughts to basicpaincare@gmail.com.

Change the consequences of pain.

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Talking Trash

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On July 8, 2014, the Louisville Courier-Journal ran a front-page article about how hard it is to find a drug disposal drop-off in Louisville.  No mention was made of trashing the leftover meds.  Here is the letter to the editor I sent in response on July 10, 2014.

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Dear Courier-Journal,

Drug abuse is epidemic.  So no one should trash talk about Martha Elson’s excellent article, Drug Disposal Boosted by Boxes.  But the trash is exactly where leftover abusable drugs can go.  Ms. Elson exposed the number one suppliers of abused pills, and surprisingly, it’s not the doctors. It’s you and me. In fact, about two-thirds of all abused pills come from family and friends, often right out of unlocked medicine cabinets.  As a specialist in Pain Medicine and Addiction, I require my patients to lock up their medications and properly dispose of any leftovers.  But with so few drug drop-off boxes available, what’s a responsible person to do?

Trash them!

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Yes, if you can’t get to a drop-off box, the FDA says it is acceptable to throw your old medications in the trash, provided you first “doctor them up” a bit. Simply mix the pills with kitty litter or coffee grounds.  Seal it in a leak-proof bag (like a zip-lock) and toss it in the garbage.  Easy.

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The more potent the drug is, the greater the need for disposal of the unused leftovers.  The FDA has even determined that the danger from keeping unused powerful narcotics is so ominous, that flushing leftovers down the toilet is acceptable when a drop-off box is unavailable.ty d bol

The Environmental Protection Agency is OK with this policy.  And the FDA says there has been no indication of adverse environmental effects due to flushing leftover pills.

However, leftover pills do contribute to adverse societal effects.  About one-fourth of high school age youth have abused prescription drugs. Approximately three Americans die every hour of every day from a drug overdose.  More Kentuckians die from overdose than die in automobile accidents.  A very large percentage of these overdose deaths involve prescription drugs.

Ms. Elson’s timely article brought to light the progress we are making.  More and more drug drop-offs are becoming available.  We should take advantage of them when we can.  But please do not let your busy schedule, your concern for the environment, or your unfamiliarity with regulations deter you from properly disposing your unused medications.  We are battling a drug abuse epidemic.  People are dying.  Make sure you are not an unwitting supplier. You may save the life of someone you love…  And that’s not talking trash.

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