Art Imitates Life Imitates Art

celebration invite screen

On May 19, 2013 the Greater Louisville Medical Society held its annual Presidents’ Celebration at the Kentucky Country Day School Performing Arts Center in Louisville, Kentucky. On that day I was honored by inauguration as president of the medical society. Early in my address to those in attendance I was abruptly interrupted by a “heckler” in the audience. Here is a transcript of that encounter…

 

fraud title pose

 

Fraud

 

A play in one act by James Patrick Murphy, M.D.

gettng the gavel

Characters:

Doctor Murphy (DOCTOR) – A physician who has just been given the gavel and installed as the next president of his medical society.

Patient (PATIENT) – A female audience member.

Voices in unison (VOICES) – A group of people off stage who are never seen, but say the last line in unison.

*

The lights come up to reveal DOCTOR on the stage, addressing the audience. DOCTOR’s first line is somewhere in the middle of his acceptance speech.

doctor address  crowd 1

                                                  DOCTOR

I know there are actually some of my patients out here too. And I won’t ask anybody to raise their hand, because I understand the confidentiality but thank you…

(DOCTOR is interrupted by a voice from the darkened audience)

 

                                                  PATIENT

Thank YOU Doctor Murphy.

(Audience applauds)

silvie full in audience 2

 

                                                  DOCTOR

(Peering out into the audience, sheepishly)

Who was that?

 

                                                  PATIENT

(Raising hand)

Me.

 

                                                  DOCTOR

Do I…?

audience silvie 2

                                                  PATIENT

Yeah, you may not remember me, but I sure remember you. Thank you.

(DOCTOR is smiling, but is clearly rattled by this interruption)

 

                                                  DOCTOR

Thank you. Uh… Just a second. Can I talk to you?

(PATIENT gets up from audience and meets DOCTOR at the corner of the stage. After brief hushed conversation, DOCTOR invites PATIENT up onto the stage)

 

                                                  DOCTOR

(To audience)

This is kind of unusual, but she’s going to say something that really fits into what I’m going to say later on. This is kind of amazing.

first patient 3

                                                  PATIENT

(To audience, holding a microphone)

Well, I was Doctor Murphy’s first patient, ever. I was only eight years old. And he was on his… (Turns to address DOCTOR) You were on your first clinical rounds, your rotation in med school. And you came every morning and looked in on me and checked my pulse and my temperature and my lungs and got me ready for my open-heart surgery. (To audience) I had open-heart surgery. I was so little and so scared.

going to be okay 4

(To DOCTOR) And you just let me know that everything was going to be OK, that I was going to do great. And I did! And I swore I would never forget you. And I haven’t.

 

                                                  DOCTOR

Well, thank you so much. That’s great. (To audience) Isn’t that great? I remember that. Thank you.

(DOCTOR reaches to take the microphone from PATIENT, but at the last moment PATIENT pulls away and continues speaking into the microphone)

microphone 5

                                                  PATIENT

Thank you and I didn’t…I…I…You rotated away after that.

 

                                                  DOCTOR

Yeah, I know. I rotated in medical school.

that's OK navy 7

                                         

                                                  PATIENT

But that’s OK. You don’t have to explain anything, because I understood. I know how those things go. I trusted you and I was grateful for all that you did for me.

dont have to explain 6

                                                  DOCTOR

Thank you.

(DOCTOR attempts to applaud, but is cut off by PATIENT)

 

                                                  PATIENT

(Backing away a little more)

Oh and I remember I saw you at that clinic in the navy hospital in San Diego. Yeah, I was so nervous and you had some really bad news to give me, but you set me up with a specialist. But then after that I never saw you. You left the hospital after that.

 

                                                  DOCTOR

Well, I was in the navy. I had to go out on the ship.

 

                                                  PATIENT

(Backing away a little more)

Yeah, I understand. You don’t have to say anything. You don’t have to explain. I completely understand. I was grateful for all that you did for me. I trusted you.

(Backing away)

And then I remember you were my anesthesiologist before my surgery. I was waiting for my surgery. And you were a little bit under the gun, because the OR was ready and the surgeon was ready and standing by. And right before we were going to leave to go in I asked if I could pray with my pastor. And you stopped everything and let that happen.

pray 8

                                                  DOCTOR

Yeah, I remember that. And I hope you don’t think that you were inconveniencing me at that time.

 

                                                  PATIENT

(Backing even farther away)

Oh no no no. You don’t have to say anything. I understand. I trusted you. And I was grateful for all that you did for me.

And then I had to have all those pain medications because I had five back surgeries. And the insurance company had some doctor I’d never seen before look at my records and not at me. And you did write a letter after they said that the insurance shouldn’t have to pay for my medications. You wrote a letter but they still denied my medicine.

wrote me a letter 9

                                                  DOCTOR

I know. I was going to call, but, you know, the preauthorization takes so much time. And I’m so busy. And I have to see a lot of patients. I have to pay my bills.

 

                                                  PATIENT

(Backing still farther away)

Yeah, I understand. You don’t have to say anything. I trusted you. I was grateful for all that you did for me.

start all over 10

And then I got that letter. I got that letter that started off, “Dear Valued Customer.” And then went on to say that I was going to have to get another doctor because you were not in my plan. You’d been cut out of my plan. Or because you’d started working for this big health care corporation and they didn’t accept my insurance. So I had to go find someone else and start all over.

 

explaining 10.5

                                                  DOCTOR

Well you know there are so many regulations now. There’s so much. There’s laws. And there’s the EMR. I have to document so much stuff. I can’t do it on my own. I have an employer now. I’m part of a corporation. I have corporate policies. (PATIENT is now exiting the stage) You know, I want to be your doctor. I want to be the leader of the health care team.

not okay 11

 

                                                  PATIENT

(No longer on stage, now only a voice on the PA system)

I don’t think that’s OK. I really don’t like your explanation. I’m not sure I trust you anymore. I am not grateful to you. I’m not a person anymore.

 

                                                  VOICES

(Off stage)

I am a population.

population 12

 

                                                     END

 

sad at end

 

*

Postscript: Silvie Zamora played the role of PATIENT. Silvie is an incredibly talented actress and dear friend. She and her equally talented husband, Phil Ward (also a lifelong dear friend), were vital to this little one-act’s artistic value and true message.

 phil and silvie

When you watch the video, keep in mind this was never rehearsed on stage. Silvie is the queen of improvisation!

Initially, the audience was not aware that this was a ruse. From my vantage point on stage it was fun to sense each individual gradually becoming aware that they were taking part in a group theatrical event.

“FRAUD” was written to be a wake up call for all physicians.

And, by the way, the events depicted in the play actually happened.
…and this just scratches the surface.

thumbs up

*

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Here’s the link to the “Fraud” video:

http://vimeo.com/67679697

 

 

*

 

 

 

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.

*

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.

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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

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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

 

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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.

Ya Got Trouble !

11 drugs lik cocaine ladies

At the intersection of emotionally charged trains of thought, lies the potential for hyperbole, hysteria, and high drama. Nowhere is this more evident than in our nation’s debate over the utility of prescription pain drugs. Both sides offer sobering statistics. We cringe hearing that more people die from drug overdoses than from motor vehicle accidents. Then in the next breath we’re saddened by the news now one hundred million Americans suffer from chronic pain. This all may be true, yet still I’m reminded of what Mark Twain wrote, “There are three kinds of lies: lies, damned lies and statistics.” Unfortunately, efforts at finding truth can sometimes become sidetracked by blowhards with hidden agendas.

2 stay here  second one

Twain was a fan of satire, so in that spirit I would like to offer my concept of how The Music Man’s dashing huckster “Professor” Harold Hill might have taken on the pain debate. In the movie, this self-proclaimed music teacher/instrument salesman sounded the alarm over “the presence of a pool hall.” Here is what he might have said, had it been a pain clinic instead. Note, if you’ve never seen the musical, I recommend you watch the video clip first.

3 friend either you are

Friend, 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 pain clinic in your community.

 Well… Ya got trouble, my friends, right here, 
I say, trouble right here in your city.

 Why sure I’m a pain physician, certainly mighty proud to say,  
I’m always mighty proud to say it.

I consider that the hours I spend, needle in my hand, are golden.
Helps you cultivate horse sense, and a cool head, and a keen eye.

 3 g a cool head
Did ya ever try to treat a herniated disk with an epidural steroid shot?

 
But just as I say it takes judgment, brains and maturity 
to place a needle in the spine,
I say that any boob can pull a pad from his pocket.

And I call that sloth, 
the first big step on the road to the depths of deg-ra-da–

I say first, medicinal mar-i-ju-ana, then pills from a bottle.

4 and the next thing you kow 
And the next thing ya know 
your pills are selling for money on a back street route.

And listed on some big out of town KASPER*
showing how they’ve been doctor shoppin’.

Not a wholesome caring place, no! 
But a place where they pay cash right on the spot!

 Like to see some screwed up druggie boy sittin’ in your office?
Make your blood boil? 
Well, I should say. Now friends, let me tell you what I mean.

You got nine – new – pain – regs – that – were passed by the board.**

Regulations that mark the difference between a specialist and a bum, 
with a capital “B” 
and that rhymes with “P” 
and that stands for PAIN!

And all day long that pain clinic bunch will be loitering around, 
I say those addicts will be loitering,
loitering around your up town, middle town, down town too!

 5 here him tell about
Get the pills in their pockets, 
never mind setting functional goals
or the records reviewed
or agreements signed.

 
Never mind taking too many 
so your patients are caught 
with the bottle empty
on a Saturday night,
and that’s trouble.

 
Yes you got lots and lots of trouble.
I’m thinkin’ of the pain pill partiers
old ones, young ones, 
caring not a bit about breaking all the rules.

6 and that stands for pool pointing with crowd 
Ya got trouble, folks! Right here in your city.
Trouble, with a capital “T”
and that rhymes with “P”
and that stands for PAIN!

 Now, I know all you docs have the right kinda patients. 

I’m gonna be perfectly frank.
Would ya like to know what kind of conversation goes on 
while they’re loafing around your halls?

 
They’ll be tryin’ out Oxy, tryin’ out morphine
tryin’ out fentanyl and Zohydro.

And braggin’ all about 
how they’re gonna cover up a bad drug screen with with Clorox.

 8 zyour son and your daughter
One fine night, they leave the clinic, 
headin’ for a chance at the pharmacy.
Desperate men, enabling women! 
Narcotic shameless craving
that’ll make your son and your daughter 
defy every decent societal instinct.

 
 ADDICTION !

 
Friends, the stoner brain is the devil’s playground! Trouble!

 
Oh we got trouble. Right here in your city!
with a capital “T” 
that rhymes with “P” 
and that stands for PAIN!

 
We’ve surely got trouble! Right here in your city.
Gotta figure out a way to treat and not just go insane.

 7 caring not a bit about breakin all the rules

Doctors of this city, heed that warning before it’s too late! 
Watch for the telltale signs of addiction!

 The minute after your patient walks into your office,
does he claim to be paralyzed below the knee?

 10 below the knee
Is there a needle track mark on his index finger? 

 
A dime bag hidden in his butt pack?

Is he starting to visit web sites
like “How to Pass a Whiz test” dot com?

 
Are certain drugs showing up on urine drug screens
Drugs… like cocaine? And… heroin?

 14 the devils tool
Well, if so my friends, ya got trouble, right here in your city!
with a capital “T”
and that rhymes with “C” 
and that ain’t cool.

 
We’ve surely got trouble! Right here in your city! 
Remember that pain clinic doc is a willing fool!

 
Oh, we’ve got trouble! 
We’re in terrible, terrible trouble!
Those pills for the fifteen hundred cash is the devil’s tool.

 
Oh yes we got trouble, trouble, trouble! 
Oh yes we got trouble here, we got big big trouble!

 
With a “T”
Gotta rhyme it with “P”
And that stands for PAIN!

13 is a willing fool

 

*KASPER is the Kentucky All-Schedule Prescription Electronic Reporting system

**The Kentucky Board of Medical Licensure

 

###

Spoiler alert… Professor Harold Hill had nothing against the pool hall. He wasn’t even a music professor. He was a con artist with a hidden agenda. He wanted to make a big score selling band instruments then bolt out of town. In the end though, Harold Hill had a change of heart and found true love.

If we can cool down the hyperbole, hysteria and high drama; if we can look beyond the soaring rhetoric and eye-popping statistics; if we can engage in honest and respectful communication; perhaps we can find meaningful solutions to our nation’s pain medication crisis.

15 last one with statue

Remember my friends,
listen to me,
because I pass this way but once!

It’s only words…

words matter

 

Words matter. So when The Courier-Journal published Laura Ungar’s timely article on “addicted” babies, I seized the opportunity to clarify the terms: physical dependence and addiction. They are not interchangeable and the difference is important…

 

Letter to the editor, published in The Courier-Journal, March 19, 2014:

Every hour a baby is born in this country to a mother who is abusing drugs. Thank you, Laura Ungar, for shedding light on the problem in Sunday’s Courier-Journal. However, the word “addicted” in the title is misleading. Addiction is a chronic disorder involving the reward circuits of the brain, leading to: craving, emotional dysfunction, and continued use despite harm.

A fetus exposed to the mother’s drugs may be born “physically dependent,” which, while horrible, is temporary. Anyone can expect to become physically dependent on a drug they take for a long time.

And withdrawal can be severe, but when it is over it is over. In contrast, the disease of addiction is a chronic condition that, without treatment, is progressive and can result in lifelong disability or death.

Almost all addicts have been physically dependent on drugs, but vastly fewer people who find themselves “physically dependent” on drugs (i.e. pain patients) are addicts. None of the babies born physically dependent can be considered “addicted.”

*

James Patrick Murphy, MD

*

*

My letter was in response to this article:

Kentucky addicted babies increasing despite pain-pill crackdown

by Laura Ungar, lungar@courier-journal.com 9:02 p.m. EDT March 14, 2014

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

The Story of “Doctor Pat”

pat and skeleton

In early 2000 I was toying with the idea of hosting a radio call-in show. Well, the show still hasn’t happened. But that didn’t deter my former college roomie, Phil Ward, from writing the theme song.

A few weeks after hearing of my intentions, he surprised me with “Doctor Pat.” The song was featured on his album “Easily Amused.”

easily amused

Now Phil has graciously given me permission to share “Doctor Pat” on YouTube.

you tube dr pat

(Disclaimer: It was very touching that my talented friend paid me such a tribute… However, the only part of the song I stand by is the FIRST LINE !!!)

“Doctor Pat” by Phil Ward

Chronic pain sufferers all is not lost,

Spinal stimulators at half my cost.

Nerve blocks, epidurals, everything must go,

I must be insane my prices are so low.

 

Take advantage of my craziness before they come and get me,

Doctor Pat, Doctor Pat.

I want to give it away but my wife won’t let me,

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

 

Morphine pumps, facet blocks, trigger point injections,

In flagrant violation of my bookkeeper’s directions.

May I just introduce one little concept at this juncture?

No payments ‘til 2002 on first time acupuncture.

 

And no money down on electronic implants with,

Doctor Pat, Doctor Pat.

Everybody get nuts and do a pain free dance with,

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

 

Take advantage of my craziness before they come and get me,

Doctor Pat, Doctor Pat

I want to give it away but my wife won’t let me,

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

Doctor Pat, Doctor Pat.

Doctor Pat.

ap trail pat and phil Phil and Pat, circa 1982

“Doctor Pat” was written by Phil Ward with a little help from Doctor Pat (P. Ward, J. Murphy) Copyright 2001, ASCAP.

Thanks to Stephen Bassett for helping me with my first ever attempt at posting a YouTube video.

Discover the genius of Phil Ward – entertainment’s true Renaissance Man – by exploring Phil’s website and visiting his Facebook page.

James Patrick Murphy, MD, MMM

jamespmurphymd.com

Twitter @jamespmurphymd

Doctor Pat on YouTube http://www.youtube.com/watch?v=6vuUpSnPXz0

Phil Ward’s Facebook page https://www.facebook.com/pages/Phil-Ward-Live/180936201939986

Download “Doctor Pat” from iTunes https://itunes.apple.com/us/album/easily-amused/id69823459

Phil Ward, Trough Records philwardmusic.com

Easily Amused http://www.rhapsody.com/artist/phil-ward/album/easily-amused/track/doctor-pat

ARE WE IN AGREEMENT?

…One Pain Specialist’s Take on the Controlled Substances Prescriber-Patient Agreement 

 me and c arm

With all of the information and misinformation about pain medicines, addiction, and prescription drug abuse, I thought it might be useful to publish a sample of what a “full-bodied” patient-prescriber agreement looks like. More and more states are requiring these for ongoing treatment with powerful medications that have a substantial potential for abuse (i.e. “controlled substances”). Although this version may not be best for everyone (some may be longer, some shorter), my pain management office uses a document similar to this.

So if you have a little time on your hands and want to know what goes into these agreements, here’s my take on what a thorough prescriber-patient agreement looks like.

 cs agree pic

 

INTRODUCTION:

I understand controlled substances medications (i.e. opioid pain medications, tranquilizers, etc.) have a potential for harm and are therefore closely controlled by the local, state and federal governments. I understand that any medical treatment is initially a trial, with the goal of treatment being to improve my quality of life and my ability to function and/or work. My progress will be assessed periodically to determine the benefits of continued treatment. Continued use is dependent on whether my prescribing provider and I believe that the medication usage benefits me. These drugs can be useful, but have high potential for misuse and are therefore closely regulated. This agreement will help my healthcare provider and me and comply with controlled substance regulations. I agree to use opioids (morphine-like drugs) as part of my treatment plan. The success of my treatment depends on trust, honesty and understanding of how opioids are used. I understand that violation of any part of this agreement may result in this medication being discontinued, as well as termination of my relationship with my provider. I agree to the following conditions:

safe

SECURITY OF THE MEDICATIONS:

I am responsible for keeping my pain medications in a safe and secure place, such as a locked cabinet or safe. I am expected to protect my medications. If my medication is stolen, I will report this to my local police department and obtain a stolen item report. I will also report the stolen medication to my physician. I agree that if my medications are lost, misplaced, stolen, or if I use them up sooner than prescribed, my physician may choose not to replace my medications.  I understand that this opioid medication is strictly for me. I will never give away my medications or sell them to others, because it may endanger that person’s health and is against the law.

FOLLOWING DIRECTIONS:

Unless directed to by my prescriber, I will not alter my medication in any way, and I will take my medication whole. My medication will not be broken, chewed, crushed, injected, or snorted. I am responsible for my opioid medications. I will not allow my medications to be damaged.  I will take my medication exactly as instructed and prescribed. I know that any change in dosage or directions must be approved by my licensed provider. I am responsible for taking the medication in the doses prescribed and for keeping track of the amount remaining. I will not take more than is prescribed.

TIME-LIMITED USE FOR ACUTE CONDITIONS:

I understand that a controlled substance used to treat an acute medical complaint is for time-limited use. I will discontinue the use of the controlled substance when the condition requiring the controlled substance use has resolved.

WHEN OTHER CONDITIONS OR SYMPTOMS ARISE:

I will notify my healthcare provider of side effects that continue or are severe or impair me in any way. I will notify Pain Center by the next business day if I need to visit another physician or need to visit an emergency room due to pain or if I become pregnant.

I agree to not request or accept a controlled substance medication from any other prescriber or individual while I am a patient at Pain Center. However, if another licensed provider, after being made aware of my Pain Center Agreement, still feels it is in my best interest to administer or prescribe a controlled substance for me, I will notify Pain Center by phone by the next business day. I will inform all of my healthcare providers of all medications I am taking, including herbal remedies. I understand that medications, including over-the-counter non-prescription medications can interact with opioid medications and be dangerous.

no_drugs-1331px

NO ILLICIT SUBSTANCES:

I will not use any illicit substances such as cocaine, marijuana, etc. I understand that the use of alcohol together with opioid medications is dangerous and can lead to death. I will promptly inform my Pain Center prescriber if I use or intend to use any of these substances, including alcohol.

KEEPING APPOINTMENTS:

It is my responsibility to schedule appointments for the next refill. I will communicate fully and honestly with my prescriber about my pain level and my activities. I understand that in order to more thoroughly evaluate my plan of care as it pertains to the use of controlled substances, I may have additional visit scheduled at my provider’s discretion. I will keep all my Pain Center appointments.  If I must reschedule, I will notify Pain Center prior to my scheduled time.  If an appointment for a prescription refill is missed, I will request another appointment as soon as possible. I know that immediate or emergency appointments to address medication issues may not be available. However, I understand that I am allowed to seek the services of another healthcare provider in the event of an emergency or acute situation.

REFILLS:

Refills will not be made as an “emergency.” They will be made at planned clinic visits, during regular business hours. I will not expect any medications will be prescribed during the evening or on weekends. I do not expect prescriptions to be written in advance due to vacations, meetings or other commitments. I do not expect my prescriptions to be mailed. I expect that a government issued picture ID will be required to pick up prescriptions.

friendly-pharmacist1

ONE DESIGNATED PHARMACY:

I will designate and use only one pharmacy for all of my controlled substance medications and give the Pain Center full permission to communicate with the pharmacist about my medical care and medications.  Unless I have been given authorization by Pain Center, controlled substance prescriptions can only be filled by a pharmacy in the same state as the Pain Center, even if I am a resident of another state. I will allow my prescriber and his or her associates to send a copy of this agreement to my other healthcare providers and/or to the pharmacy where I obtain my prescriptions.

Urine Sample

DRUG TESTING: 

My prescriber may perform drug testing on me. I agree that I may be called at any time to come in to the clinic for a count of all my remaining medications and/or a drug screen and I agree to come that day. I agree to be responsible for any costs this may incur. If requested to provide a urine sample or other type of sample if necessary. If I decide not to provide a urine sample, I understand that my prescriber may change my treatment plan. This might include discontinuation of my opioid medications or complete termination of our patient-prescriber relationship. The presence of a non-prescribed drug or illicit drug in my urine may be cause for termination of our relationship.

SHARING INFORMATION:

I agree to allow my healthcare provider to contact any healthcare professional, family member, pharmacy, legal authority, or regulatory agency to obtain or provide information about my care or actions if the he or she feels it is necessary. I will allow my prescriber and his or her associates to receive information from any health care provider or pharmacist about use or possible misuse of alcohol and other drugs. I will allow my prescriber and and his or her associates to contact my family and friends to monitor my conditions.  Furthermore, I consent to a criminal background check.

PRIMARY CARE PROVIDER RELATIONSHIP:

I have and will maintain at all times a relationship with a primary care provider and keep him or her informed of all medications I am taking. I agree to and understand the requirement that I have an annual preventive health screening and physical exam by my primary care provider. If recommended, I will see a specialist and/or complete a screening exam to help determine whether I am developing an addiction or psychological illness.  I agree to be responsible for any costs this may incur.

FUNCTIONAL GOALS:

I understand that the main treatment goal is to improve my ability to function. I understand that in general, it is unrealistic for patients to expect complete resolution of their chronic pain with any specific treatment or combination of therapies. I understand that it is important to have a conversation with my provider about my treatment plan and set realistic goals for improvement. I pledge to work together with my provider towards improving my pain control and achieving specific functional goals. I understand that functional goals might include increasing physical activity level, resuming a job/hobby or improving the quality of sleep.

exit-sign

AN “EXIT STRATEGY”:

I understand the concept of an “exit strategy” regarding these medications. I agree that if any of the following goals are not attained this may be evidence of a failure of opioid therapy and discontinuation of some or all of my medications could be the most appropriate plan: (1) meaningful pain control; or (2) acceptable level of function; or (3) tolerable side-effects; or (4) stable and acceptable mental health and behavior: or (5) compliance the plan of care, laws, and regulations.

PATIENT EDUCATION:

I acknowledge that I have been educated on the following matters through verbal or written counseling: (1) proper use; (2) impact on driving and work safety; (3) effect of use during pregnancy; (4) potential for overdose and appropriate response to overdose; (5) safe storage of controlled substances; and (6) proper disposal.

OFF-LABEL USE OF MEDICATION:

All prescription drugs in the US have a label approved by the FDA.  This label provides an indication and dosage for the drug, but neither physician nor patient is legally bound to follow them.  Studies cannot reliably evaluate all the combination treatments in complicated, difficult-to-treat conditions. I understand that my treatment may include “off label” use of medications. 

DISCONTINUATION OF CARE:

I understand that my violation of any of the above conditions may result in re-evaluation of my treatment plan and discontinuation of my medication. I could be gradually taken off these medications or even discharged from the clinic. If my violation involves obtaining controlled substances from another individual, as described above, I may also be reported to my physician, medical facilities and other authorities, including the police.

handshake_between_doctor_and_patient_with_the_sky_background_1341168865

I HEREBY AGREE:

I have read this agreement or it has been explained to me by the Pain Center practitioners and/or staff. If I am not currently receiving controlled substances from Pain Center, this agreement does not apply.  However, I understand that this agreement immediately becomes effective if in the future I do receive controlled substances.  I fully understand the consequences of violating this agreement.  I have been explained the risks and potential benefits of these therapies, including, but not limited to, psychological addiction, physical dependence, withdrawal and over dosage. All of my questions regarding the treatment of pain with opioids have been answered to my satisfaction. I hereby agree to participate in the opioid medication therapy and acknowledge that I have received this document.

Disclaimer: This is not legal advice.  This is not medical advice.  This is my personal opinion and has not been endorsed by any individual or entity.  All persons should consult his or her own legal counsel and/or health care providers for advice and guidance.

job-reference-check

First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain, Version1.0  http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf

Sample Controlled Substance Agreement Developed by The Greater Louisville Medical Society http://kbml.ky.gov/substance-abuse/Pages/default.aspx

Kentucky Board of Medical Licensure, House Bill 1 Ordinary Regulations Effective March 4, 2013 http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx

Medical Licensing Board of Indiana, Emergency Rule (Pain Medications) http://www.in.gov/pla/files/Emergency_Rules_Adopted_10.24.2013.pdf

Indiana Pain FINAL RULE (Effective November 1, 2014):
http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html

 

me close up

James Patrick Murphy, MD, MMM attended medical school at the University of Louisville, interned in Psychiatry at the San Diego Naval Hospital, studied at the Naval Aerospace Medical Institute, and later served as a Naval Flight Surgeon onboard the aircraft carrier U.S.S. Enterprise.  He returned to Louisville for residency training in Anesthesiology after which he completed a Pain Medicine Fellowship at the Mayo Clinic in Rochester, MN. Dr. Murphy is board-certified in Anesthesiology, Pain Medicine, and Addiction Medicine. He is President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, Assistant Clinical Professor at the University of Louisville School of Medicine, and serves on the board of the International Association for Pain and Chemical Dependency. In May 2013 Dr. Murphy earned a Master of Medical Management degree from the University of Southern California Marshall School of Business.

Dr. Murphy’s blog is The Painful Truth. He can be found on TWITTER by searching @jamespmurphymd. His President’s eVoice and other communications & videos can be accessed at the Greater Louisville Medical Society website.

OPIOID EMAIL RECAP

Screen Shot 2014-02-10 at 10.14.19 PM

The premier offering of “Optimal Prescribing Is Our Inherent Duty” concluded on Sunday, February 9th.  I plan on having more to say… soon.

For now, I thought it worthwhile to share the three emails I sent to our staff, participants, and faculty each evening.

It was a sincere privilege to serve with the OPIOID team.

OPIOID picture

FEBRUARY 7, 2014 – DAY ONE

Dear all OPIOID’ers,

Well, day ONE was a great success. All ten participants were energetic and focused. Our GLMS staff was superb. After an overview by yours truly, Dr. Paul Sloan gave a thorough review of pharmacology and guidelines. Then Detective Beth Ruoff did a fantastic job explaining the diversion issues facing prescribers.  Dr. Boz Tabler educated us on the science behind addiction. Lastly, Dr. Heather Tluczek joined the team and facilitated two earnest and brutally honest Healing Place peer mentors offering a gut wrenching account of the toll addiction exacts.

hp

The staff of The Healing Place was great. The room was perfectly outfitted. And the food was delicious.  And we ran on time all day! Thanks to Dr. Mary Helen Davis and Dr. Mark Boswell for stopping by for support…  the day before they present.

Tomorrow (Saturday) we are at the Greater Louisville Medical Society headquarters for DAY TWO. More great lectures, discussions, and experiential learning!  It’s happening! More later…

– Pat

old school now

FEBRUARY 8 – DAY TWO

Dear Friends of OPIOID,

Day TWO has come and gone… and what a day it was!

mhd

We convened bright and early at the Old Medical School Building (GLMS headquarters). After some camaraderie and a hot breakfast, Dr. Mary Helen Davis took us through the inner workings of KASPER, the governmental process involved in making policies, and finished with a discussion on physician motivation in the age of regulatory expansion.

boz

We then had what, to the casual observer, must have looked like group therapy – led by Dr. Boswell Tabler.  I believe this was another major breakthrough moment in the course, as the participants began to open up with personal accounts. At the end, all seemed to be fully motivated to make the changes necessary to be successful.

boz and ken

Then Dr. Ken Kirsh gave an extremely thorough review of the interface between pain and psychological issues. This was followed by Dr. Tabler’s interactive discussion on psychiatric treatment strategies.

After breaking for lunch, Dr. Mark Boswell had us enthralled by his categorical run down of the different types of challenging pain patients. He followed this with a lecture on how to screen for psychological pathology in our patient population.

Then it was on to “Pain Management Meets Speed Dating.” Dr. Heather Tluczek, along with Dr. Patrick Myers and seven other gifted actors posed as various types of challenging pain patient – allowing the course participants private one-on-one mock interviews.  This was a fast-paced, exhausting, and enlightening experiential learning exercise. Everyone had a good time and learned something about themselves.

Tomorrow Dave Hopkins will get us up to speed on KASPER. Then I will be bringing it home with a thorough run down of Kentucky’s laws and regulations. We will conclude by getting familiar with some “tools” and memory aids in order to help the participants apply their new skills efficiently in their own practice setting.

This is going great! Our GLMS staff is fabulous. Our OPIOID faculty is superb. I almost don’t want it to end.

– Pat

really dave and boz

FEBRUARY 9 – DAY THREE

Dear OPIOID friends,

In May of 2012, just after Kentucky passed House Bill One on the last day of a Special Legislative Session, the thought of having a comprehensive educational course for prescribers took root. Well, today that sapling idea bore fruit.

The inaugural OPIOID course concluded today around 1:00 pm. It was three days packed with lectures, group dynamic work, testimonials, didactics, theatre, poetry, and focused engaged effort by ten pioneering participants.

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Today we had breakfast together then nourished our minds with 90 minutes of Dave Kasper, err, I mean Dave Hopkins – the KASPER director. He loaded our heads with vital information about our state’s electronic prescription monitoring program. I then led a discussion on drug screens and compliance monitoring.  During our final two hours we poured over the Kentucky pain regulations in detail and learned strategies on how to incorporate the rules effectively into our daily practice routines.

What was most gratifying to me was seeing how our participants (now to be rightly known as our “partners”) remained focused and underwent a metamorphosis of sorts. But in reality, I don’t believe they were changed in any way by the course. Instead, I believe OPIOID may have rekindled a spark in each of them that was already there – only perhaps a bit beaten down by the regulatory grind. I know I was inspired by what happen over these past three days.

I am grateful to so many people and in the coming weeks I plan on communicating that message in other formats. For now, let me just say that everyone who participated – staff, volunteers, faculty, students, and even our impromptu professor GLMS security guard “Cory” felt something special had happened over the past three days.

…and something special has begun.

Yours in earnest gratitude,

– Pat

juggle dr m

*still juggling…

patient

practice

community

*P.S. You had to be there.

3 balls

 

James Patrick Murphy, MD, MMM  is President of the Greater Louisville Medical Society.

 

OPIOID Possibilities are Limitless

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“What am I supposed to do? I’m over the limit.”

Recently I was visited by a patient “warrior”. I hadn’t known her before, but she had read one of my articles online and wanted to meet me.  I was touched. There in the foyer of our surgical center, she motored up in her electric scooter and smiled the genuine smile of a person seeing a long lost friend.

Are there limits to friendship? No.
Are there limits to prescribing opioids for pain? Maybe.

At the vortex of misinformation swirling around pain regulations is the fact that no state has limited what physicians are allowed to prescribe, although some states make it unwieldy to treat legitimate pain patients compared to other states; some set unsubstantiated quantity limits while others require consultation to a pain specialist if a predetermined (yet not scientifically proven) “morphine equivalent dose is prescribed”.  Nevertheless, no states unilaterally prohibit a prescription at any dose if the regulations are followed.  However, requiring a pain specialist in some cases may become a logistical nightmare because in most instances there are not enough pain specialists to go around.

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To be sure they have created thresholds above which physicians are required to do certain obligatory actions like: drug screens, re-evaluations, treatment agreements, and database queries. But these requirements do not represent ceilings to what can be prescribed – as long as it is medically necessary.

Are these regulatory obligations rational, reasonable, fair, or effective? That is a subject for another article. What is true now, however, is that prescribers are drowning.

“OPIOID” is the acronym used in an upcoming seminar that aims to rescue prescribers from the regulatory maelstrom.

OPIOID picture

“OPIOID” means Optimal Prescribing Is Our Inherent Duty. It is a seminar conceived by physicians, approved by Kentucky’s Medical Board, and produced by the Greater Louisville Medical Society in association with the University of Louisville – February 7 – 9, 2014.   The goal of “OPIOID” is to empower prescribers to optimally care for suffering patients and adhere to the governing regulations.  Clinicians and support staff can register by email: physician.education@glms.org or call: 502-736-6354 or visit online at https://www.glms.org/Home.aspx (and click on the “OPIOID” tab).

My new friend, whose pain had confined her to her motorized chair, wasn’t quite convinced when I assured her that her state’s (Indiana) regulations did not limit what her doctor could prescribe. But in her friendly eyes I saw hope. And her hope gave me strength.

Am I strong enough to climb over the barriers created by these regulations? Are you?

As long as there are patients willing to fight the good fight, then so will I.  And courses like “OPIOID” provide us the tools we need to win. Together, the possibilities are limitless.

nolimits

James Patrick Murphy, MD, MMM

January 26, 2014

Note: This article was originally posted January 27, 2014 on Dr. Jeffrey Fudin’s blog http://paindr.com/opioid-possibilities-are-limitless-2