Basic Pain Care Certification

o-WOMAN-CRYING-CLOSE-UP-facebook

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.

Screen Shot 2014-08-05 at 11.10.30 PM

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

cj title

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.

letter to editor

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!

oscar

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.

dispose

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.

trash talk

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Is it the singer or is it the song?

I love music.

I am not what one might call “musical.” I don’t have the pipes of a Whitney Houston (see: The Star Spangled Banner) or the soulfulness of a Bob Dylan (see: Blowing in the Wind), but I appreciate their unique virtuosity.

I am a pain care physician. Pain, like music, is a sensory and emotional experience. I don’t sing or play. I touch and treat.

Sometimes I may hit the perfect note, perform the perfect procedure, compose the perfect plan of care.

Other times, despite being well versed, my plan of care may not strike the right chord. Then creating a pleasant sensory and emotional experience depends upon the passion and conviction with which my care is conducted; my song is sung.

Is it the singer or is it the song?

Is it the caregiver or is it the care given?

Music is not only intertwined with my pain care. It is woven into every aspect of my life, including my Twitter feed.

Begging the question: Is it the tweeter or is it the tweet?

Let’s find out.

For a about a year I have been composing a Twitter message or two per day. Recently, I went back and was able to find forty tweets that were “musical” in some way. It may not be America’s top forty, but I think Casey Kasem would still have been pleased.

casey kasem b and w

There are songs from rock, country, and classical genres; from musicals, commercials, television, and the silver screen. Some are serious; some are silly. Original works, live performances, even parodies.

I now invite you to take a little journey through my musical tweets. Click on the image and the link should take you right to the performance. See if you can guess the song before you link to it. Ponder how it relates to the message. Enjoy the sensory and emotional experience. And decide for yourself…

Is it the tweeter or is it the twuuth* ?

 

* twuuth (definition)

  • noun\ˈtwüth\ the twuuth : the truth in a tweet

 

#40

1 25 oct 13

25 October 2013  How the Ghost Stole Pain Care. Dramatic reading by Phil Ward and music composed by Megan McIver

https://twitter.com/jamespmurphymd/status/393876826809843712/photo/1

http://vimeo.com/77715467

 

#39

2 21 dec 13

21 December 2013  A Winter’s Solstice

https://twitter.com/jamespmurphymd/status/414443104792354816?refsrc=email

https://www.youtube.com/watch?v=kh_sckAUkgE&list=PLe1seBFJFklgHIqjjUUUhxZmL_rchZau9

 

#38

3 10 jan 2014

10 January 2014  Act Naturally

https://twitter.com/jamespmurphymd/status/421697528891854848/photo/1

https://www.youtube.com/watch?v=c-07qmTUi9A

 

#37

4 12 jan 2014

12 January 2014 Les Miserables

https://twitter.com/jamespmurphymd/status/422410734950043648/photo/1

https://www.youtube.com/watch?v=HPIos2mXbUE

 

#36

5 26 jan 14

26 January 2014 I’m Only Sleeping

https://twitter.com/jamespmurphymd/status/427318581399789569/photo/1

https://www.youtube.com/watch?v=8KAsr-hix9s

 

#35

6 10 feb 14

10 February 2014 The Gold and Beyond

https://twitter.com/jamespmurphymd/status/433042987648417792?refsrc=email

https://www.youtube.com/watch?v=2hBB4DPw-h4

 

#34

7 12 feb 14

12 February 2014 ABC

https://twitter.com/jamespmurphymd/status/433632926316515329/photo/1

https://www.youtube.com/watch?v=I8GvDLDYhNM

 

#33

8 12 feb 14

12 February 2014 Hearing Winter

https://twitter.com/jamespmurphymd/status/433655563193286656/photo/1

https://www.youtube.com/watch?v=VaXGGPVNnxU

 

#32

9 17 feb 14

17 February 2014 The Way We Were

https://twitter.com/jamespmurphymd/status/435621354222526464/photo/1

https://www.youtube.com/watch?v=6VhNaXV8K4U

 

#31

10 17 feb 14

17 February 2014 Peace of Mind

https://twitter.com/jamespmurphymd/status/435639476686045184/photo/1

https://www.youtube.com/watch?v=Q5ZL8qvEmR0

 

#30

11 21 feb 14

21 February 2014 Doctor Pat

https://twitter.com/jamespmurphymd/status/437033465536462849/photo/1

https://www.youtube.com/watch?v=6vuUpSnPXz0

 

#29

12 22 feb 14

22 February 2014 Honesty

https://twitter.com/jamespmurphymd/status/437388430465462273/photo/1

https://www.youtube.com/watch?v=R4gOIt-M02A

 

#28

13 2 mar 14

2 March 2014 My Bologna

https://twitter.com/jamespmurphymd/status/440310294867234816/photo/1

https://www.youtube.com/watch?v=rmPRHJd3uHI

 

#27

14 5 mar 14

5 March 2014 Oklahoma

https://twitter.com/jamespmurphymd/status/441273659001286657/photo/1

https://www.youtube.com/watch?v=ZbrnXl2gO_k

 

#26

15 14 mar 14

14 March 2014 Hair

https://twitter.com/jamespmurphymd/status/444682878396293120?refsrc=email

https://www.youtube.com/watch?v=7Qf2R-1saDQ

 

#25

16 29 mar 14

29 March 2014 Stupid

 

https://twitter.com/jamespmurphymd/status/449943660134555649?refsrc=email

https://www.youtube.com/watch?v=ers0YPoMxbk

 

#24

17 4 apr 14

4 April 2014 Words

https://twitter.com/jamespmurphymd/status/452173873299980291?refsrc=email

https://www.youtube.com/watch?v=sr-WW5abcwQ

 

#23

18 7 apr 14

7 April 2014 Oops

https://twitter.com/jamespmurphymd/status/453267038077984768?refsrc=email

http://vimeo.com/54035300

 

#22

19 9 apr 14

9 April 2014 Call On Me

https://twitter.com/jamespmurphymd/status/453922140312440833?refsrc=email

https://www.youtube.com/watch?v=Wh86uSsux1M&feature=kp

 

#21

20 17 apr 14

17 April 2014 Lights Went Out

https://twitter.com/jamespmurphymd/status/456764575258402816?refsrc=email

https://www.youtube.com/watch?v=uSSJwKixbKU

 

#20

21 19 apr 14

19 April 2014 Little Wonders

https://twitter.com/jamespmurphymd/status/457546932161110016?refsrc=email

https://www.youtube.com/watch?v=tWU8_uUJJu0

 

#19

22 28 apr 14

28 April 2014 Undun

https://twitter.com/jamespmurphymd/status/460961322163642368?refsrc=email

https://www.youtube.com/watch?v=QzSLxYLuJhI

 

#18

23 15 may 14

15 May 2014 I’m Sorry 

https://twitter.com/jamespmurphymd/status/467135943741157378?refsrc=email

https://www.youtube.com/watch?v=4a_vhiBxi90

 

#17

24 5 june 14

5 June 2014 Let It Go

https://twitter.com/jamespmurphymd/status/474655637620535296?refsrc=email

https://www.youtube.com/watch?v=EtAG3e3JLNI

 

#16

royals

5 June 2014 We Will Never Be Doctors

https://www.youtube.com/watch?v=mxyNzqQNa50

 

#15

25 7 june 14

7 June 2014 Daniel Boone 

https://twitter.com/jamespmurphymd/status/475246656968200192?refsrc=email

https://www.youtube.com/watch?v=VLMCO-JZqWs

 

#14

26 10 jun 14

10 June 2014 Turn It Off

https://twitter.com/jamespmurphymd/status/476212528289038336?refsrc=email

https://www.youtube.com/watch?v=JjCfE1n6nW4&list=PLf470HqOWw3d8Oj5uAXPV19yJ7E7aGDwX&index=163

 

#13

27 13 jun 14

27 June 2014 Don’t Stop Me Now

https://twitter.com/jamespmurphymd/status/477316980274237440?refsrc=email

http://vimeo.com/30126989

 

#12

28 14 jun 14

 14 June 2014 It’s a Grand Old Flag

https://twitter.com/jamespmurphymd/status/477902903290515457/photo/1

http://fan.tcm.com/_James-Cagney-You39re-a-Grand-Old-Flag/video/1146300/66470.html?createPassive=true

 

#11

29 15 jun 14

15 June 2014 In the Living Years 

https://twitter.com/jamespmurphymd/status/478362296126013440?refsrc=email

https://www.youtube.com/watch?v=bWiwde4z9Qk

 

#10

30 16 jun 14

16 June 2014 Pressure

https://twitter.com/jamespmurphymd/status/478599157926473728?refsrc=email

https://www.youtube.com/watch?v=SJCTgtDU-74

 

#9

31 21 jun 14

21 June 2014 Sunrise

https://twitter.com/jamespmurphymd/status/480542585535352832?refsrc=email

http://vimeo.com/88197078

 

#8

32 27 jun 14

27 June 2014 Listen

https://twitter.com/jamespmurphymd/status/482653910616666112?refsrc=email

https://www.youtube.com/watch?v=K5aRRq9mquo

 

#7

33 29 jun 14

29 June 2014 Rumor Has It 

https://twitter.com/jamespmurphymd/status/483451855125479424/photo/1

http://vimeo.com/41795630

 

#6

34 the letter

1 July 2014 The Letter

https://twitter.com/jamespmurphymd/status/484055472618500096

https://www.youtube.com/watch?v=Vrv9slgO7Ic

 

#5

35 all together now

2 July 2014 All Together Now

https://twitter.com/jamespmurphymd/status/484446529210445824

https://www.youtube.com/watch?v=xFpW8g83g6E

 

#4

36 dialogue

4 July 2014 Dialogue

https://twitter.com/jamespmurphymd/status/484941146976567296

https://www.youtube.com/watch?v=YTL53bmYqzM

 

#3

37 danger zone

4 July 2014 Danger Zone

https://twitter.com/jamespmurphymd/status/484955780253106177

https://www.youtube.com/watch?v=58QOBqAWNzE

 

#2

38 if you want it

6 July 2014 If You Want It Here It Is 

https://twitter.com/jamespmurphymd/status/485956691708477442

https://www.youtube.com/watch?v=KWbTZuEWjnc

 

And the #1 musical tweet in the land is…

39 stipe tweet

7 July 2014 Everybody Hurts 

https://twitter.com/jamespmurphymd/status/486224816618213376

https://www.youtube.com/watch?v=ijZRCIrTgQc

 

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STRENGTH IN NUMBERS

office M

Show up at my office on a typical Friday afternoon and the waiting room generally will be well populated. People in groups of threes, twos, and solitary ones are scattered about, flipping through magazines, glancing at wristwatches, a few even catnapping, waiting to hear their names called.

However, on this Friday everyone was assembled in one end of the room, all facing the same direction, all listening to the same thing, all sharing in the same experience.

talking to

I still don’t have an official name for the happening, but I’ve nicknamed it a “SIN” session, i.e. Strength In Numbers.  However, there’s nothing sinful about it.

Strength in Numbers is geared toward patients, is part classroom, part group therapy, and entirely beneficial to all participants – including me.

I had no trouble selecting the didactic elements. My practice is located on the border between Kentucky and Indiana – two states that have recently enacted laws and regulations for treating pain with controlled substances.

bridge

Both states’ regulations are instructive regarding educational requirements.

Kentucky’s regulations mandate:

A physician prescribing or dispensing a controlled substance shall take appropriate steps to educate a patient receiving a controlled substance.

There’s even a list of educational points to consider on the Kentucky Medical Board’s website.

Not to be outdone, Indiana’s regulations state:

The physician shall discuss with the patient the potential risks and benefits of opioid treatment for chronic pain, as well as expectations related to prescription requests and proper medication use.

Hoosier State regulations go on to list specific educational points that prescribers must cover with patients that include obtaining a patient’s informed consent.

agree

Obviously, to obtain informed consent a patient must be informed.

Indeed, most states’ regulations require that physicians educate their patients. The Federation of State Medical Boards agrees:

The physician’s duty includes not only appropriate prescribing of opioid analgesics, but also appropriate education of patients… inadequate attention to patient education (is a clear) departure from accepted best clinical practices.       

But, aside from the learning part, there is another, less precise, less quantifiable, factor in the equation that produces strength at these Friday afternoon get-togethers.

The numbers.

A group dynamic is quite therapeutic. For some time, psychology researchers have been able to show that group therapy is a “powerful intervention.”

Groups foster a community spirit; a sense that “I’m not in this alone.”

The group offers a sounding board. Members can help each other come up with specific ideas for improving a difficult situation or life challenge and even offer some accountability along the way.

The key therapeutic principles involved in group therapy include:

*Hope: Being with people who are coping or recovering gives hope to others who may be running short on this.

*Universality:  People see that they are not alone.

*Information: They help each other by learning and sharing a consistent message.

*Altruism: Self-esteem and confidence is boosted by sharing and helping others.

*A sense of family: The therapy group is much like a family in some ways. And because the group shares common goals, members gain a sense of belonging and acceptance.

Now, more and more, group sessions are utilized in the treatment of conditions other than purely psychological. The American Academy of Family Physicians has stated their belief that “group visits are a proven, effective method for enhancing a patient’s self-care of chronic conditions, increasing patient satisfaction, and improving outcomes.”

So, on this Friday afternoon we had a group “SIN” session. It started with a little levity and a brief informative video.

dr pat

Next, some definitions were explained, risks and alternatives were discussed along with “SMART” goals and proper stewardship of the medications. Patient responsibilities were explained. The educational points required by the Bluegrass and Hoosier States were covered. Some Q & A was encouraged throughout. It was interactive.

This was not a purely didactic session. There was eye contact and emotional contact. After all, pain is defined as a sensory and emotional experience.

And in the end, the participants didn’t just feel like a number.

And they had more strength to do battle.

As did their doctor.

On this atypical Friday afternoon.

There truly is strength in numbers.

Fireworks-047-screen

The Dream of Pain Care… Enough to Cope. the Seventeenth R. Dietz Wolfe Memorial Lecture

wolfe trophy

On April 12, 2014 my Norton Healthcare colleagues bestowed upon me the 17th R. Dietz Wolfe Education Award. Hopefully my presentation of the Wolfe Lecture adequately honored the legacy of the esteemed and beloved Dr. Wolfe.

For now, I humbly offer this synopsis…

Note: This article was updated on April 1, 2015 to reflect the most recent changes to states’ regulations.

 

The Dream of Pain Care… Enough to Cope

   – the 17th R. Dietz Wolfe Memorial Lecture 

 

karen neck

the algiatrist

 

a private place

study her face

fix on his eyes

feel her sinew

give an embrace

 

innovation

radiation

numb a raw nerve

eradicate

pain creation

 

to interlope

to offer hope

through some relief

tiny solace

enough to cope

 

– James Patrick Murphy

 

caring hands copy 2

Contrary to what one might think, it is generally not difficult to satisfy the needs of patients with chronic pain. Like the poem says, they simply need “enough to cope.” What’s difficult is the juggling act providers must perform to keep three “balls” in the air: patients must do well, regulations must be followed, and drug abuse must be prevented. Drop any of these three balls and you fall as well.

Sometimes the fall is hard. A couple of weeks ago I learned of a pain doctor in northern Kentucky who, on the heels of lawsuits and a medical board investigation, took his own life.

Then there was Dr. Dennis Sandlin, an eastern Kentucky country doctor who was shot and killed in his office by a patient upset because the doctor would not prescribe pain pills to him without first doing a drug screen.

Unfortunately, these scenarios are not our only threat. Federal prosecutors have even tried to use overdose deaths to trigger death penalty statues when seeking indictments against doctors.

And we hear sobering statistics like:

One person dies every 19 minutes from an overdose.

One “addicted” baby is born every hour.

Opioid pain drugs cause more overdose deaths than heroin and cocaine combined.

And now more people die from drug overdose than car accidents.

blame

For this crisis physicians take the brunt of the pundits’ blame, despite the fact that more than two-thirds of the diverted medications are acquired from family, friends, and acquaintances – not from a prescription by their doctor.

So why do it? Why treat chronic pain?

Perhaps because:

Over 100 million Americans suffer from pain, and that number is growing.

Pain affects more Americans than cancer, heart disease, and diabetes combined.

Up to 75% of us endure our dying days in pain.

True. But pain care, perhaps, means a little bit more?

Hypnosis-Pain-Control

To answer that question we must first understand what pain is: an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Second, let’s understand the distinction between addiction and abuse. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Drug abuse describes behavior born of bad decision-making; not the disease of addiction. But indeed, bad choices, bad behavior, and drug misuse lead to crime, accidents, social instability, and addiction. The developing adolescent brain is particularly susceptible to addiction, while the elderly brain is practically immune.

nucleus

Third, let’s understand the risk factors for addiction: (a) environmental, (b) patient-related, and (c) drug-related. We cannot control our patient’s environment, occupation, peer group, family history, or psychiatric issues. But we can gather information and get a feel for his or her risk level. Then we can control what we prescribe – understanding the characteristics of an “addictive” drug include the drug’s availability, cost, how fast it gets to the brain (i.e. lipid solubility), and the strength of the “buzz” it produces.

And thus we can understand how important it is to prescribe the lowest dose possible for the minimum amount of time necessary, based on the level of risk in properly screened patients; then reassess. When in doubt, prescribe even less and reassess more often. Never feel obligated to prescribe more than what you are comfortable prescribing. Pain may be the number one reason a patient visits a doctor and pain care is indeed a patient’s right; however, controlled substances for pain care are a privilege. And just like it is with prescribers, the patients have responsibilities and obligations to meet, lest they endanger their privileges. They must become good stewards of the medications they are prescribed.

eVoice pic

Despite these serious risks to their community, their patients, and their medical licenses, physicians regularly rise to the occasion and treat pain. Over the past year as President of the Greater Louisville Medical Society, I have written a monthly article for our journal, Louisville Medicine. The reasons that physicians so often rise are woven throughout those essays. Here are few selected passages…

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June: We have core values that we share, and when our strategy is in line with achieving the greater good our choice of profession becomes a higher calling.

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July: We can positively affect people’s lives in a dramatic way and on a grand scale if we commit to our shared values, reconnect and work together. It is not only possible. It is our inherent duty.

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August: Think back to when you were happiest as a physician. It was probably when you did something that was completely selfless, without any concern that the benefit outweighed the cost, without consideration of a return on investment. 

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September: It is why we started down this tortuous path. It’s why we gave up our youth to endless lectures, textbooks, labs, insomnia, and stress, risked our health, and stole from our family life. We went into debt, endured ridicule on morning rounds, and exposed our careers to legal ruin – all so we could commit to helping the people important to our profession: our patients.

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October: Her strength, courage and positive attitude have always inspired me. In the cacophony of that noisy mall time stood still as our eyes met. I told her who I was and how inspiring she is to me. She smiled and we hugged. That was a moment of confluential truth. Never take for granted this precious gift.

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November: I can never be 100 percent sure why I do what I do… but I do know the best decision is always the honest decision, regardless.

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December: I have been blessed with the opportunity to connect intimately with people on many levels. I’ve noticed those who preserve their joy despite insurmountable challenges… They have perspective. Humans are the only organisms aware of concepts like the past, the future, beauty, love, death, and eternity.

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January: Every imperceptible moment that passes is not only a new reality; it is rebirth, renewal, and redefinition. How will I define myself?

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February: The place where you started is your true self; the self that is your center; the self that creates your thoughts and actions. Regardless of your life’s circumstances, success is achieved when your thoughts and actions are in harmony with the true you.

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March: Failure can be painful. It exposes vulnerability. Physicians, myself included, can be very hard on ourselves sometimes, thinking that by intense training and adherence to protocol, preparation, and planning we are somehow immune to failure. This is, of course, not true. Failure is painful – necessary pain – providing motivation to change, evolve, and realize your role in nature’s play of perfection. Failure is not a result as much as it is a feeling. Failure is… a conduit to greatness.

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April: I will connect with you as a person – not a diagnosis. …No phone calls, no texting, no social media are allowed to come between you and me. Only then, with laser focus, do I proceed. The job demands this. You deserve this.

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May: There is a shortage in our profession – a shortage of practical dreamers who can remain child, student, explorer, and physician. Your profession and your patients need you to be this physician. And you need you to be this person.

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While becoming this physician requires the acquisition of vast knowledge, no one cares what you know until they know that you care. But even the most caring physicians find it hard to keep aim at the moving target of pain regulations. Still, if we are going to do this (i.e. treat pain) we should do it right; in a manner that keeps our community safe and our medical licenses secure.

EinsteinAtBlackboard-259x300

Throughout my years of medical training I have organized data by creating poems, algorithms, and acronyms. It’s been helpful for me. Maybe they will be helpful for you. Here are some such aids I find useful in the care of pain patients.

AAAA – items to address at pain reassessments

Analgesia level (e.g. a “zero to ten” scale)

Activity level (e.g. functional goals)

Adverse effects (e.g. side effects)

Aberrancy (e.g. worrisome behavior, diversion, addiction, depression)

*

PPPP – the differential diagnosis when they ask for more medication

Pathology (e.g. new or worsening disease)

Psychology (e.g. depression, anxiety, addiction)

Pharmacology (e.g. tolerance, altered metabolism, hypersensitivity, neuropathic pain)

Police-related (e.g. unlawful diversion)

*

Kentucky has adopted (and revised) a law and numerous regulations that address the prescription of controlled substances. Here’s some helpful advice pertinent to prescribers in Kentucky:

Plan to THINK – What to do initially when prescribing for the first 90 days

Plan – Document why the plan includes controlled substances.

Teach – Educate the patient about proper use and disposal.

History – Appropriate history and physical

Informed consent – Risks need to be explained and consent documented.

No long acting – Don’t prescribe sustained release opioids for acute pain.

KASPER – Query the state’s prescription monitoring program.

*

COMPLIANCE – That which needs to be done by the 90 day mark

C          Compliance monitoring (i.e. Query KASPER, check a urine drug screen)

O         Old records (obtain more records if necessary)

M         Mental health screening (i.e. depression, anxiety, personality disorders)

P          Plan (establish specific functional goals for periodic review)

L          Legitimate working diagnosis established (i.e. objective evidence)

I           Informed consent (written) & treatment agreement (recommended)

A         ADDICTION / Diversion Screening

N         Non-controlled medications tried before going to controlled substances.

C          Comprehensive history needs to be obtained and documented.

E          Exam “appropriate” to establish baselines for follow-up.

*

PQRST – That which needs to be ongoing after the ninety-day mark

P          Periodic review (after the first month, up to physician’s judgment)

Q         Query KASPER every three months

R         Refer to specialists and consultants as necessary

S          Screen annually for general health concerns

T         Toxicology screens (i.e. urine) and pill counts randomly and at intervals dependent on the patient’s level of risk.

For more detail please review: THE CHRONIC PAIN PATIENT’S GUIDE TO KENTUCKY’S REGULATIONS” -available at https://jamespmurphymd.com/2015/02/13/pathway-to-partnership

indiana

Let’s not forget Indiana. In December 2013 emergency regulations in the Hoosier state were enacted. These were updated and filed as permanent regulations on October 7, 2014. Indiana’s permanent pain regulations apply when any of the following conditions are met:

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

DAILY MED (“morphine equivalent dose”) 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. My advice: Since 150 mgm of tramadol is equivalent to a FIFTEEN (15) MED, I believe it is more consistent with the other Indiana opioid dosage limits to consider TRAMADOL greater than 150 mgm/day for more than THREE consecutive months as the dosage limit congruent with other opioid dosage limits.

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

For more detail please review: THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATONS” -available at https://jamespmurphymd.com/2015/03/29/pathway-to-partnership-part-ii-in

 

Indiana Physicians have DRIVE

When these thresholds are met, Indiana physicians must DRIVE

  • DRAMATIC at the start;
  • REVIEW the plan, REVISE the plan & REFER if the morphine equivalent dose is greater than 60 mg/day;
  • INSPECT at least annually;
  • VISIT face-to-face with the patient at least every 4 months; and
  • EXAMINE a drug screen if there is any indication.

Drug screening takes up a significant portion of Indiana’s regulations. The regulations actually list eighteen “factors” to consider. But the bottom line is that a drug screen (with lab confirmation) shall be ordered: “At any time the physician determines that it is medically necessary…(for any) factor the physician believes is relevant to making an informed professional judgment about the medical necessity of a prescription.”

 Indiana Physicians are DRAMATIC

At the initial evaluation a Hoosier physician must be DRAMATIC

         Diagnosis (establish a “working diagnosis” of the painful condition)

         Records obtained (a diligent effort made to obtain & review)

         Assessment of pain level

        Mental health (and substance abuse) screening

         Activity (functional) goals need to be established

         Tests should be ordered, if indicated

          Instead of opioids, use non-opioid options first

C          Conduct a focused history and physical

 

Both states emphasize the importance of treatment agreements, informed consent, and patient education. These subjects, along with helpful examples are presented in my article: “Are We In Agreement?” -available for review and download at: https://jamespmurphymd.com/2014/02/19/are-we-in-agreement

*

Regardless of one’s locale, treating pain with controlled substances can be dramatic. I’m reminded of a scene from the movie “The Music Man,” where Professor Harold Hill warned the people of River City:

prof

Either you’re closing your eyes to a situation you do not wish to acknowledge, or you are not aware of the caliber of disaster indicated by the presence of a pool hall in your community.

Well my friends, the same emotional message is often said of physicians who treat pain. This “mass-staria” can be lessened by utilizing REMS (Risk Evaluation and Mitigation Strategies). REMS has been promulgated by the FDA with the goal of decreasing the risk associated with some risky drugs – especially the opioids.

The yin and yang of REMS is education and monitoring. The informed consent, patient agreement, and educational points together serve as a foundation for a medical practice’s effective REMS program.

Two prime examples of efforts to educate prescribers are (a) the OPIOID course sponsored by the Greater Louisville Medical Society and (b) the First Do No Harm Providers Guide from Indiana’s Prescription Drug Abuse Taskforce.

opioid logo

no harm

When both prescriber and patient understand the risks and watch for the telltale signs, early intervention can keep you out of trouble, despite what the Harold Hills of the world might say.

In my experience, most people will do the right thing if they know what the right thing is. President Ronald Reagan’s Cold War policy with the Soviet Union was to “trust but verify.” When you give someone a reputation to live up to, they are positively motivated to deserve that reputation – and deserve that trust. The various measures prescribers take to verify proper use of pain medications provide boundaries that can guide and comfort all parties involved. Beyond the rules, regulations, and guidelines that make up these boundaries, lies the indisputable truth that physicians have an obligation to treat suffering. It’s our calling.

Hess obit

I’m reminded of these words from our departed colleague, Dr. Patrick Hess:

 

All physicians are artists,

not always in disguise.

Our way of looking at a patient,

allowing our minds to roam,

all over those perceptions of our previous life,

often forgotten,

to scan these memories,

and pull something from our unconscious mind,

all with the purpose of creating something,

something to help the patient.

This creation is,

itself,

a work of art.

 

When I decided to include this poem in my lecture presentation, I really had no inkling that Patrick Hess was Dr. Wolfe’s “oldest friend.” Nor was I aware Dr. Wolfe’s first love was journalism, or that he was the “bright” nephew of his beloved uncle, famed novelist Thomas Wolfe. I only knew that there was a message of conviction, hope, and inspiration that needed to be heard. I would like to think that these three kindred spirits were in attendance and that they approved of my message. And I would like to think that you will not merely approve, but will take action so that the dream of pain care, enough to cope, devoid of drug abuse, can be realized.

kel in surf

 

*

This summary is my own opinion and is not legal advice. Each facility and physician should consult its own legal counsel for advice and guidance.

IS THERE METHOD TO THIS MARCH MADNESS?

hamlet_2516701k (1)

To prescribe or not to prescribe Zohydro ER…

In March 2014, Zohydro ER (hydrocodone extended-release) was introduced to the market. Never in my medical lifetime do I recall a medication stirring such angst. Worries of mass overdoses, backdoor FDA conspiracies, and blatant disregard for the public wellbeing abound. Is there method to this March madness?

620px-hydrocodone-svg

Some background…

Zohydro ER is a pain pill that, when taken by mouth, is released slowly over twelve hours. The active ingredient, hydrocodone, is an opioid (i.e. narcotic) that’s been around for decades in a short-acting pill form (e.g. Lortab, Vicodin, Norco) and has historically been combined with APAP (a.k.a. acetaminophen, Tylenol).  The FDA considers hydrocodone-APAP combination pills to be relatively less addictive and designates them as a schedule-three drug. Physicians can prescribe schedule-three drugs over the phone, with up to six refills. By contrast, schedule-two drugs (e.g. morphine, oxycodone, oxymorphone), even when combined with APAP, are considered more addictive, can’t be called in, and can’t be refilled without a new hard-copy prescription.

Because it is effective for pain, relatively well tolerated, and convenient to prescribe, hydrocodone-APAP pills have become the most commonly prescribed opioid in the United States.  It’s therefore not surprising that, since there’s so much in circulation, hydrocodone-APAP pills are frequently the most available opioid for abusers to abuse.  Add to this the legitimate worry about acetaminophen (APAP) overuse causing liver failure, and you can understand our leaders’ concerns surrounding this pain medication.

Enter Zohydro ER, the first extended-release hydrocodone pill without APAP. It’s easy on the liver and lasts twelve hours; so people with around-the-clock pain may need fewer pills per day. Additionally, it’s a schedule-two drug. In summary, Zohydro ER is a long-lasting version of a widely used and effective opioid, which until now had only been available in combination with acetaminophen.  So why the controversy?

Aye, here’s the rub…

Zohydro ER does not have any of the new and popular tamper-resistant technologies; e.g. a matrix that won’t dissolve easily, or a coating that is difficult to crush.  Instead, the makers took advantage of a delivery system (SODAS) already used successfully in a number other of extended-release drugs such as: Ritalin LA, Focalin XR, Luvox CR, and Avinza.

OxyContin and Opana ER are two examples of opioids that manufacturers took off the market briefly for reformulation as tamper-resistant.  However, while the changes have made them more difficult to snort or inject, many addicts still find ways to abuse these drugs or have just moved on to heroin. Tamper-resistant does not mean tamper-proof.

By the way, the generic form of Opana ER (oxymorphone extended-release) was not reformulated and is still available without tamper-resistant technology. Also, consider that Avinza (morphine extended-release), which employs the same sustained-release system (SODAS) as Zohydro ER, has neither been recalled nor been required to undergo reformulation.  In reality, probably 90% of the opioids in circulation do not have tamper-resistant formulations.

That’s why I have difficulty understanding the uproar over Zohydro ER. As a pain specialist, I welcome another effective treatment to offer chronic pain sufferers. Sure, I’d be happier if it had a hard coating or some other “deterrent” to abuse. But in reality, Zohydro ER is, for all practical purposes, neither safer nor more dangerous than many of the drugs I already prescribe with success. So far, tamper-resistant innovations have not been proven to be effective in the big scheme of things. All opioids, regardless of the formulation, must be prescribed with caution and careful monitoring.

According to the American Society of Addiction Medicine, there are four main factors that contribute to a drug being addictive:

  1. How much will it cost me?  All things considered equal, people will choose a drug that is cheaper.
  2. How fast does it get to my brain? Hydrocodone is water-soluble and actually diffuses into the brain slower than many other opioids.
  3. What kind of a buzz will I get? Opioids stimulate the brain’s “reward circuit.” There is no proof that hydrocodone is any worse in this regard than other opioids.
  4. How much of it can I get my hands on? People will abuse what is available to them. Since hydrocodone is the most prescribed opioid, expect it to be one of the most abused. It follows that if Zohydro ER floods the market it will be abused.

Therefore, my recommendations to physicians are:

  1. Prescribe Zohydro ER in the lowest dose possible, for the shortest duration of time, and only if the benefits outweigh the risks.
  2. Monitor regularly for effectiveness, side effects, and patient compliance.
  3. Educate yourself and your patient.
  4. Follow guidelines and regulations faithfully.

By the way, that’s my advice to physicians regardless of which opioid they prescribe.

Zohydro ER may not be tamper-resistant, but tamper-resistant drugs are not super heroes. Do not expect them to save us from the real villain.

The real villain is not the FDA, not the drug company, not the drug, and not the patient.

The villain is the disease of addiction.

Focus on the disease. Prevent the disease. Treat the disease.

This Zohydro hullabaloo is a prime opportunity to shine light on the problems surrounding prescription drug abuse and addiction. Let’s take advantage of it.

And stop the madness.

*

me and c arm

James Patrick Murphy, MD, MMM

Board-certified in Pain Management, Addiction Medicine & Anesthesiology

Can We Make a Deep Run?

It’s March and that means basketball assumes center stage. So I decided to share my most basketball friendly eVoice.  A winning season requires a combination of passion, hard work and talent. But making a “deep run” in the tournament demands teamwork.

brackets

Do we have what it takes?

*****

LeBron, Trust, and the Power to Save our Profession

Recently my son and I made the trip to Indianapolis to see the Pacers play the Heat for a chance to go to the NBA finals.

pacers game

It was do or die for the Pacers, who were going up against the world’s best player, LeBron James. Even from the nosebleed section, it was clear that James was bigger, faster, and stronger.  He ran. He jumped. He rebounded. He dunked. He grabbed the spotlight.

lebron dunking on pacers

And he lost.

murphy speech at pres celeb

In my remarks at our Greater Louisville Medical Society’s Presidents’ Celebration on May 19th, I touched upon the concept that our team, a.k.a. our “tribe,” can reach our winning potential only if the pervasive attitude is “together we can be great.”

we are great

But is this possible?

It is hard to be together. There are so many barriers between physicians these days. We used to hang out in the doctors’ lounges, see each other on rounds, meet each other at seminars, and even pick up the phone and talk to one another. The GLMS roster, affectionately known as the “mug book,” included our picture, address, home phone number, and spouse’s name. A quick flip through its pages and you felt like you belonged to something special and could connect at a moment’s notice. But now we are partitioned into subgroups defined by things like specialty, locale, hospital affiliation, and employer.

It is critical that we reconnect, not just with colleagues but also with our passion. Deserve the privilege of our patient – physician bonds.  Be worthy of the immense trust gifted in this relationship. Trust is inherent to our profession and is born at the intersection of science and art. Trust is powerful yet fragile. Trust must be nurtured, honored, and protected.  By acting in our patients’ best interests, trust is sustained.

Are we powerful enough to save a profession?

Faced with so many dilemmas – where we will work, who we will work for, what we will earn, and how we will collaborate – our temptation is to cling to the status quo – protect our turf.  But the status quo will pit us against other professionals, third party payers, our patients, and even ourselves. If we do not solve these dilemmas, they will be solved for us. If we do not write the stories, they will be written without us. If we do not lead, we will be forced to follow.

I cannot keep from wondering what time will do…                                                                         and I wonder how far away from yourself you will go.

A very special teacher once conveyed these words to me. She understood that life’s living will weather anyone and would invariably change me. Even so, I can steer back toward my true self – the real me – by making a difference in the life of someone else.  No profession facilitates this journey more effectively than the healing arts. And there is no equivalent in the healing arts to the calling of physician.

Individuals we can be great. But together we can be greater.  We can positively affect people’s lives in a dramatic way and on a grand scale if we commit to our shared values, reconnect, and work together. It is not only possible. It is our inherent duty.

And we all win.

cards win ncaa

Note: This article was first published as the Greater Louisville Medical Society President’s eVoiceJuly 2013

eVoice pic

Patrick Murphy, MD, MMM is President of the Greater Louisville Medical Society 2013-14.  Dr. Murphy’s blog is The Painful Truth. He can be found on TWITTER  @jamespmurphymd.  His President’s eVoice and other communications & videos can be accessed at the Greater Louisville Medical Society website. 

View Dr. Murphy’s remarks at the Greater Louisville Medical Society’s Presidents’ Celebration May 19, 2013  http://vimeo.com/68703810