…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



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:



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.


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.


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.


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.



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.


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 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.



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


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.


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.


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.


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.



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.


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.


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. 


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.



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.


First Do No Harm: The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain, Version1.0

Sample Controlled Substance Agreement Developed by The Greater Louisville Medical Society

Kentucky Board of Medical Licensure, House Bill 1 Ordinary Regulations Effective March 4, 2013

Medical Licensing Board of Indiana, Emergency Rule (Pain Medications)

Indiana Pain FINAL RULE (Effective November 1, 2014):


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.

This Cathedral Won’t Build Itself


It’s Sunday morning February 16, 2014 at the American Medical Association Candidate Workshop. I’m sitting in this Washington, D.C. conference room, listening to one-hundred ways I can get more politically involved, but hearing one-thousand reasons why it would be crazy for me…

And this popped into my mind.



Breaking rocks?

In the closing days of my Master of Medical Management program at USC, Professor Dave Logan introduced to our class the concept of a default future, the future that will happen if nothing is done to change it. He then asked the class – 22 seasoned physicians – to describe what health care would look like in 10 years:

“Everything will be automated and impersonal.”

“You’ll have to wait two years to get a hip replacement.”

“It will be a two, no three tier system.”

“The doctor-patient relationship will be history.”

“Managers will run everything.”

“Doctors will be worker bees.”

“Patient care will suffer.”

“I will finally get to go home at 4:30, because everything will shut down.”

What struck me is that no one mentioned that doctors would be paid less money. This was the Marshall School of BUSINESS, yet none of these professionals put lower income at the top of their list of worries. Which is precisely why these physicians, all physicians, need to be leaders – not just managers, not just worker bees.

I have been a GLMS officer for the past three years, and at every board meeting it stared at me from the backside of my name placard – our mission statement. Only in the past few months have I really taken notice. It is so elegant:

Promote the science, art and profession of medicine.

Protect the integrity of the patient-physician relationship.

Advocate for the health and well-being of the community.

Unite physicians regardless of practice setting to achieve these ends.

Doesn’t this sum up why you and I became physicians? Isn’t this a stark contrast to the default futures predicted by my USC cohorts?

I remember very little about the blur that was my first week of medical school, but I will never forget the question that one of the PhD types posed to our class. He asked us to raise our hand if we went into medicine to save the world. Without hesitation almost every hand enthusiastically went up.

“Then you are in the wrong place,” he smugly blurted into his lavalier mike. “Go learn how to grow corn in the desert. Then you will save the world.”

crops on the desert

This made me think. Why did I want to be a doctor? Was it for the prestige? The respect? The money? The power? Or was it because I wanted to have a profession where I could touch the lives of others? Relieve the suffering of a single individual? Of a multitude?

It has been my privilege to be a physician now for more than twenty-eight years. And while I still can’t fully answer the question of why I wanted to become a doctor, I can definitely say why I want to wake up tomorrow and be a doctor. It is in that mission statement.

Some of you are in the whirlwind that is medical school, others are developing confidence to match the bravado that carries you during the early years in practice, some are grinding away against the current of the faceless third-party, and some are looking back and wondering if they should have tried to grow corn on sand.

There is a default future out there. Somehow, you know what it is. If you pause and think, you can even say it out loud so it seems more real. And it will come to pass, unless you make a decision to act – unless we make a decision to act.

I am asking you to unite with your partner, your mentor, your colleagues, your spouse, your patients and me. Together we can take the first steps to change the default future. It has to start somewhere. It can start here. Right now.

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.

Communication is paramount. And we must communicate passionately and effectively. Connect with your colleagues via tweets and email (find me on Twitter @jamespmurphymd; my email is Join a committee, attend the meetings, call legislators, write letters to the editor, join the GLMS Alliance with your spouse and look to GLMS for leadership development opportunities. As soon as possible, download the new GLMS mobile app and read the alerts, publications and notices.

Lead. Manage if you must, but you must lead.

Breaking rocks?

Dave Logan told us of a band of laborers sweating in the hot sun in some poverty-stricken Third World country. They were pinging away at rocks with small hammers, relentless, sweat pouring, dust choking. But amazingly they seemed happy despite the mind-numbing conditions. When one was asked how he could not be miserable in the mundane task of breaking rocks, he replied, “I’m not breaking rocks, sir. I am building a cathedral.”

oaxaca cathedral

Let’s make a new future.

Let’s build a cathedral.

James Patrick Murphy, MD, MMM
President, Greater Louisville Medical Society

Twitter  @jamespmurphymd


P.S. Have you heard about what happened during my installation speech at the GLMS Presidents’ Celebration? Watch the video here.

Note: This article was first published as the

Greater Louisville Medical Society President’s eVoice,

Louisville Medicine, June 2013

The way we were…

pat and adele at washington

Pat and Adele, Spring 1985


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


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.


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


Dear Friends of OPIOID,

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


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.


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


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.

dave K

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…




*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


“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.


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: or call: 502-736-6354 or visit online at (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.


James Patrick Murphy, MD, MMM

January 26, 2014

Note: This article was originally posted January 27, 2014 on Dr. Jeffrey Fudin’s blog

Weather the Storm with OPIOID

OPIOID Helps Caregivers Weather the Regulatory Storm


Healthcare is engulfed in a torrent of regulations raining down upon caregivers. Nowhere is this more evident than in the delivery of pain care. Perhaps OPIOID is the way to weather this storm.

Allow me to explain…

Recently, I was talking with a sales rep from a drug screen lab, and our conversation naturally veered into a discussion about how states were beginning to require urine drug screens for patients receiving pain medication.

To a drug screen lab these regulations are like liquid gold.

But as easily as regulations are passed, they can be erased. And if the success of a lab is based on the existence of a regulation, then the business model is built on thin ice and for the wrong reasons.  If the regulations dry up, so does lab.

I’m a physician, and – like the lab – I expect compensation for what I do.

What I do is care for people by applying factual knowledge, energized by creativity, in accordance with evidence-based protocols, while remaining cognizant of the mysteries still misunderstood and the mysteries awaiting discovery. It’s a marriage of science and art.

I know that following regulations goes along with the territory. But following regulations does not make me jump out of bed every morning with passion and determination. A regulation never delivered a baby, bypassed a clogged artery, or discovered a cure. People do these things.  People need these things. I’d rather work for people than a regulation.

The delivery of pain care is perhaps the most regulated activity in medicine. And depending on the state, the regulations can seem foreboding to the caregiver.  The message is clear. Either get on board or the Board will get on you.

The thought of abandoning our suffering patients out of fear is bitter. The thought of losing our licenses is chilling. And the thought renouncing our calling as patient advocates to blindly follow regulations we don’t even understand…  is demoralizing.

It doesn’t have to be this way.

Remember my lab rep? My advice to her was to go back to her supervisors and suggest that they promote their product primarily as a means to help patients by helping prescribers. Then they would be serving the best interest of millions of people, as opposed to serving at the pleasure of a few hundred lawmakers. In other words, make improved quality of life the real goal – not adherence to regulations.

OPIOID picture

That’s what OPIOID is all about.   OPIOID means Optimal Prescribing Is Our Inherent Duty – 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.  People can register by email: or call: 502-736-6354 or visit online at: (and click on the “OPIOID” tab).

OPIOID is a prime example of caregivers holding steadfast to their calling in the regulatory storm.  Please spread the word. Together we can weather this.


James Patrick Murphy, MD, MMM

January 26, 2014

Note: This article was first published January 27,2014  on http://www.drjohnmdthe blog by John Mandrola, M.D.


The Urgent Need for OPIOID

two tangential universes: therapeutic and pathologic

tangential u darko

In the therapeutic universe suffering is relieved, lives are enhanced, and hope is restored. Central to this universe are the pain care needs of 100 million suffering Americans.

In the pathologic universe suffering is unleashed, lives are enslaved, and hope is shattered.  Ruler of this realm is drug abuse – now killing even more Americans than automobile accidents.

Common to both universes is the prescriber – and the tangent point is OPIOID.

OPIOID picture

OPIOID means Optimal Prescribing Is Our Inherent Duty – a seminar conceived by physicians, approved by the medical board, and produced by the Greater Louisville Medical Society in association with the University of LouisvilleFebruary 7, 8 & 9.

American Medical Association Board Chair (and Kentuckian) Steven J. Stack, MD says:

Physician education on responsible opioid prescribing is a critical element in addressing the epidemic of prescription drug abuse.

Todd Cook, MD, Chief Medical Officer of St. Elizabeth Physicians (Northern Kentucky) says:

This is one of the times when sending a responsible party proactively may provide a great return on the investment for all of us.

Participants in this two and a half day course will gain insight on how to: (a) best prescribe controlled substances for chronic pain, (b) minimize the risks of drug abuse, and (c) safeguard their communities. These goals are achieved through lectures, coaching sessions, and face-to-face interaction with individuals battling addiction.

louisville skyline

Louisville is a point shared by two states (Kentucky & Indiana) that, like many other states, have recently enacted laws to address prescription drug abuse. When such well-meaning laws give legitimate prescribers the chills, a dose of OPIOID is the right prescription.

Finally, an OPIOID epidemic we can all get behind.

Please make it contagious. Pass along this info, refer someone, or even better – sign up yourself.

OPIOID  February 7 – 9, 2014

Register by


Or call: 502-736-6354

opioid tab

Or visit online at: (and click on the “OPIOID” tab).



Boldly go where no prescriber has gone before.

Take back your universe.

take back universe


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

rx and pen and pad

NIDA & the Facts on Marijuana

The National Institute on Drug Abuse Offers the Facts on Marijuana


From the website:



Use is rampant:

“Marijuana is the most common illicit drug used in the United States.”

brain damage

Has a powerful effect on the brain:

“Marijuana overactivates the endocannabinoid system, causing the high and other effects that users experience. These include distorted perceptions, impaired coordination, difficulty with thinking and problem solving, and disrupted learning and memory.”

Interferes with successful lives:

“Heavy marijuana users generally report lower life satisfaction, poorer mental and physical health, relationship problems, and less academic and career success.”

Damages the brains of young people:

“Research from different areas is converging on the fact that regular marijuana use by young people can have long-lasting negative impact on the structure and function of their brains.”

Permanently lowers IQ:

“A recent study of marijuana users who began using in adolescence revealed a profound deficit in connections between brain areas responsible for learning and memory. And a large prospective study (following individuals across time) showed that people who began smoking marijuana heavily in their teens lost as much as 8 points in IQ between age 13 and age 38; importantly, the lost cognitive abilities were not restored in those who quit smoking marijuana as adults.”

Causes heart disease:

“Marijuana raises heart rate by 20-100 percent shortly after smoking; this effect can last up to 3 hours. In one study, it was estimated that marijuana users have a 4.8-fold increase in the risk of heart attack in the first hour after smoking the drug.” 

car wreck

Causes car wrecks:

“A recent analysis of data from several studies found that marijuana use more than doubles a driver’s risk of being in an accident.”

Damages the lungs:

“People who smoke marijuana frequently but do not smoke tobacco have more health problems and miss more days of work than nonsmokers, mainly because of respiratory illnesses.”

Causes psychiatric illness:

“A series of large prospective studies also showed a link between marijuana use and later development of psychosis. Associations have also been found between marijuana use and other mental health problems, such as depression, anxiety, suicidal thoughts among adolescents, and personality disturbances.”


Damages babies:

“Marijuana use during pregnancy is associated with increased risk of neurobehavioral problems in babies. Consequences for the child may include problems with attention, memory, and problem solving.”


Is NOT a legitimate medicine:

“The FDA requires carefully conducted studies in large numbers of patients (hundreds to thousands) to accurately assess the benefits and risks of a potential medication. To be considered a legitimate medicine, a substance must have well-defined and measureable ingredients that are consistent from one unit (such as a pill or injection) to the next.”

Is definitely addictive:

“Contrary to common belief, marijuana is addictive. Estimates from research suggest that about 9 percent of users become addicted to marijuana; this number increases among those who start young (to about 17 percent, or 1 in 6) and among daily users (to 25-50 percent).”

And is more potent that ever:

“The amount of THC in marijuana samples confiscated by police has been increasing steadily over the past few decades.”

Read more:

drug facts week

Leadership Louisville Comes to The Old Medical School

old school now

On January 7, 2014 the current Leadership Louisville class met at the Greater Louisville Medical Society Foundation’s “Old Medical School Building.” Here is a portion my welcome…

white coat

There is a lot of history in this room.

old_military at med school

The building was opened as a medical school in 1893 and has withstood The Great Depression, floods, two world wars, and the wrecking ball. It stands as a testament to the passion, resiliency and dedication of the medical profession. Today Leadership Louisville adds to that legacy.

Your director, Aaron Miller, asked me if I was “glad to be standing on this side of the podium” since I was a member of last year’s Leadership Louisville class.

“Sure,” I said. But I also enjoyed my time sitting in front of the podium in 2013. My days with Leadership Louisville were great. It was fantastic hanging out with dynamic people, focusing on topics relevant to the success of our city, making new friends outside of my medical cocoon, and taking a break from my cell phone to engage personally with diversely talented people.

So, why here? Why today?

In the last decade Louisville has shifted from an industrial to a service economy; with an emphasis on health care delivery. In fact, six of Louisville’s ten largest employers are in health care.

The Greater Louisville Medical Society is out in front of this transformation.

Our success is tied to our mission: “…to promote the art and science of medicine; to protect the patient-physician relationship; and to ensure the health of our community.” This journey is comprised of advocacy, education, creativity, mission work, public health, and philanthropy.  Our vehicle is our organization. Our structure is built by bonds of trust.  And our engine is fueled by our passion.

There are many illustrations of our commitment to this mission. These include the cutting-edgePulse of Surgery” program for students at the Louisville Science Center; the world-renowned Healing Place Addiction Recovery program; Supplies Over Seas, sending life-saving medical supplies and equipment to impoverished countries; and the OPIOID safe prescribing initiative, combatting prescription drug abuse. These and other efforts were born of GLMS member collaborations.

There is one program in particular of which you should take note – our “Wear the White Coat” internship program. Every year we team community leaders with physicians from various specialties and allow them to spend a day walking in the shoes of a physician. Later the group reconvenes in the very room you are in now to share. We physicians learn as much from our “interns” as they learn from us. At the end, everyone feels connected, hopeful and inspired.  Each of you will be invited this year.

old school postcard

So, there is a lot of history in this room. But there is a lot of future too.

Thanks for being here and being a part of that future.

 me and business with the residents

James Patrick Murphy, MD, MMM is President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and Assistant Clinical Professor at the University of Louisville School of Medicine. He is an alumnus of the Leadership Louisville Class of 2013. On his application to Leadership Louisville, he answered the question: “What is the best kept secret about Louisville?” with The Greater Louisville Medical Society. If you are reading this, hopefully it is not a secret any longer.

A new year… A new name


If you searched the Internet in 2013 for “the painful truth,”  you found a lot of it. However, you probably did not find my The Painful Truth website.

To be fair, my posts are hopefully more truthful than painful.


A new year…  a new name.


In my October 2013 President’s eVoice, the phrase “confluential truth” was coined:

Imagine your message as a sphere with the purest and most intense truth radiating from its center. The recipient interprets your message and develops his or her own truth-sphere. Like the overlap in a Venn diagram, the effectiveness of communication is defined by the degree to which these unique spheres share the same truth. This overlap is the confluential truth.

Search and I doubt you will find “confluential” and “truth” joined in a phrase – probably because “confluential” is not even in the dictionary.

Thus, there is only one definition for “confluential truth” and now only one website using the phrase as its title.

My hope is that when we look for confluential truth, we find it.

Thanks for searching with me.

journey for truth

Greater Louisville Medical Society President’s eVoice, Oct 2013


winter sunrise in indiana

Today is December 15, 2013… For Indiana pain sufferers, and the physicians who care for them, it is the dawn of a new era.

Everyone has an opinion, but the only opinion that matters is that of the Medical Licensing Board of Indiana. Nevertheless, I thought it might be useful to offer the opinion of an Indiana-Kentucky licensed / interventional pain-addiction specialist / full-time Jeffersonville, Indiana-based / Greater Louisville Medical Society President / independent private practice physician (i.e., The Painful Truth).

Regulations provide boundaries. Guidelines provide guidance. As written, Indiana’s Emergency Pain Regulations are instructive as to how physicians should prescribe opioids for chronic pain and would serve as adequate guidelines. However, as regulations they are problematic due to their frequent inclusion of unclear phraseology. These “emergency” regulations are subject to revision and permanent regulations must be adopted by November 1, 2014.

When faced with unclear regulations, prescriber anxiety is heightened. This may deter physicians from prescribing the most appropriate medications, causing patients to endure avoidable pain and unnecessary suffering.

So, I guess I was wrong. If you, or anyone you care about, has been or might be touched by pain, drug abuse, or addiction – and that pretty much includes everyone;

YOUR opinion DOES matter.


Here we go…

The Painful Truth does not wish to over-simplify the matter, but after careful study the regulations one could say that prescribing opioids boils down to:

DRAMATIC at the start (Section 4);

FACE-TO-FACE every 2 – 4 months (Section 6);

INSPECT & DRUG SCREEN annually (Sections 7 & 8);

REVIEW, REVISE & REFER at higher doses (Section 9).

One should begin this journey by understanding the difference between a law, a regulation, and a guideline.

A law is a rule that has been passed by elected officials. Violation of a law may be viewed as a criminal act.

Indiana’s new pain law (a.k.a. additions to Senate Bill 246) is fairly concise and does not directly apply to physicians. Instead, it says the medical board must come up with regulations – which they did.

A regulation is a rule that is usually created by a government agency (i.e. a “bureaucracy”) as opposed to the legislature. Regulation determines how laws will be enforced. Violation of a regulation may not be a criminal act but can incur a wide-range of penalties.

As previously stated, Indiana’s Emergency Pain Regulations go into effect on December 15, 2013 and are subject to revision until November 1, 2014, at which time the permanent regulations are due.

A guideline, especially when endorsed by a governing body, is a set of opinions that offer insight into the manner in which regulations and laws can be properly followed. Violating a guideline may or may not be considered a wrong move, but generally will require a legitimate explanation as to the decision-making process.

The Indiana State Attorney General’s Office has published a detailed set of guidelines, called “First Do No Harm,” which offer insight as to what regulators will consider as proper medical practice, should they be called upon to investigate a controlled substances related issue.

In summary, Indiana physicians who prescribe controlled substances do not need to know details of the new law, as it does not apply directly to them.

However, physicians should clearly understand the Emergency Pain Regulations and how these regulations will affect their practice after December 15, 2013.

Also, physicians are strongly urged to become familiar with the “First Do No Harm” guidelines and to start incorporating as many of the recommended practices as possible.

SECTION-BY-SECTION BREAKDOWN (12 Sections) – The Painful Truth is my opinion.



These REGULATIONS are from the Medical Licensing Board of Indiana and are applicable to PHYSICIANS only; and specifically with regards to OPIOIDS for CHRONIC PAIN.

The Painful Truth: In my opinion, every provider (i.e. dentists, podiatrists, nurse practitioners, physicians, etc.) should understand that the Attorney General’s Office supports the “First Do No Harm” guidelines for every provider.


This section offers definitions, some of which I examine below:

* Chronic Painmeans a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.”

The Painful Truth takes this as meaning any type of pain, for whatever reason, regardless of the severity, that is a problem for two months or longer; even if it is intermittent pain. This encompasses a generous range of chronic pain scenarios.

* Morphine Equivalent Dose “means a conversion of various opioids to a standardized dose of morphine by the use of accepted conversion tables.”

The “First Do No Harm” Toolkit gives some examples of equianalgesic doses to SIXTY MGM of MORPHINE (i.e. hydrocodone 50 mg; oxycodone 40 mg; fentanyl patch 25 mcg/hr), and notes “Equianalgesic tables should only serve as a general guideline to estimate equivalent opioid doses.”

The Painful Truth believes this is an inexact science, and there are many “accepted” morphine equivalent conversion tables from which to choose – none of which are perfect. The Toolkit references an online calculator from GlobalRPH. I also like the one from Practical Pain Management. The state of Washington has a nice one as well. When making these conversions try to err on the low side. Better to underestimate than overestimate (i.e. Once someone takes a medicine it is impossible to get it back). Murphy’s laws:  (1) Start low and go slow; (2) Every dose is a test dose.

* “Outset of an opioid treatment plan” refers only to a patient who has been prescribed: (1) more than sixty opioid-containing pills a month; or (2) a morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three consecutive months.

The Painful Truth believes this is very important, somewhat confusing, and will be discussed again later in SECTIONS THREE & NINE. For now, just realize that there is a definitely a threshold where these regulations become relevant.



This section explains which patients are exempt from the regulations.

(1) With a terminal condition

(2) Living in a licensed health facility

(3) Enrolled in a licensed hospice program

(4) Enrolled in a palliative care program of a licensed hospital

Note: If a non-terminal patient eventually leaves the health, hospice, or palliative facility the opioid use during that time still counts in the threshold calculation (see below).

This section also establishes thresholds that trigger the requirements of the Emergency Regulations.


(1) “More than sixty (60) opioid-containing pills a month.”

(For more than three consecutive months*)


(2) “A morphine equivalent dose of more than fifteen (15) milligrams per day;

for more than three (3) consecutive months.”


The Painful Truth believes with a little creativity and a literal interpretation, these thresholds allow a wide range of unintended prescribing options.

For example: You could prescribe 60 pills for the month and tell the patient to break each pill in half – effectively offering FOUR doses per day without exceeding the 60 pill per month threshold.

You could even prescribe a drug as potent as Oxycontin twice per day for 89 consecutive days and avoid the THREE CONSECUTIVE MONTH threshold.

In contrast, prescribing a relatively benign sixty-one codeine pills for three consecutive months**  exceeds the threshold and triggers all of the requirements spelled out in the regulations.

This should not encourage anyone to “game the system.” It only illustrates how difficult it is to establish dosing thresholds that are clinically relevant and enforceable.

I addressed dosing thresholds in a letter (and blog post) from October of this year. Hopefully there will be some changes to the thresholds when the final regulations are enacted in 2014.

Be advised that the Attorney General’s “First Do No Harm” provider Toolkit does not explore these initial thresholds or the concept of exempted patients in any detail.  The Toolkit seems to imply that any use of opioids carries enough danger to warrant risk stratification, surveillance, and a cautious approach when prescribing.

The Painful Truth advises prescribers to conservatively interpret the measures outlined in the Emergency Regulations.

And stay tuned, because a 60 mgm morphine equivalent dose threshold becomes an important issue in Section NINE (to be discussed later by The Painful Truth).


*  On December 17, 2013 at 2:40 p.m. I spoke by telephone with Michael Minglin, J.D. (Board Director, Medical Licensing Board of Indiana). Regarding the sixty-pills-per-month threshold and the fifteen mgm morphine-equivalents-per-day threshold, he told me: “It is clear; the three consecutive months interval applies to both.”

**  This sentence was updated on 12/17/2013 to reflect the above mentioned clarification (*) by the Board Director.


This section deals with the Physician’s responsibility for performing the initial evaluation, including determination of level of risk.

It is clearly stated that the physician shall do the physician’s OWN evaluation and risk stratification of the patient by doing the following:

  1. Perform an APPROPRIATELY focused history and physical exam
  2. Obtain or order APPROPRIATE tests “as indicated”
  3. Make a DILIGENT effort to obtain and review records & document the effort.
  4. ASK the patient to complete an OBJECTIVE pain assessment tool
  5. Use a VALIDATED screening tool for mental health and substance abuse
  6. Establish a “working diagnosis”
  7. Tailor a plan with MEANINGFUL and FUNCTIONAL goals (to be reviewed “from time to time”)
  8. WHERE MEDICALLY APPROPRIATE use non-opioid options instead of or IN ADDITION TO prescribing opioids.

The Painful Truth believes the requirements of Section Four lend themselves to creation of a checklist. Therefore, at the initial evaluation a Hoosier physician must be DRAMATIC

o          D         diagnosis made (“working diagnosis”)

o          R         records obtained (a diligent effort made to obtain & review)

o          A          assessment of pain

o          M         mental health (and substance abuse) screen

o          A          activity goals established

o          T          tests ordered if indicated

o          I           instead of opioids, use non-opioid options

o          C         conduct focused history and physical

The Painful Truth notes that the terms “appropriate,” “as indicated,” “diligent,” “meaningful,” and “from time to time” are subjective. Physicians are advised to be able to defend his or her interpretation of these terms.

The Painful Truth believes it is acceptable for a prescribing physician to use historical information obtained by sources other than the prescribing physician (i.e., office staff) as long as the physician personally verifies the information with the patient.

The Painful Truth points out that the initial physical exam must be done by the prescribing physician and cannot be delegated.

The Painful Truth notes that a truly “objective pain assessment tool” does not exist, as pain is personal and subjective. Nevertheless, at minimum, a visual analog scale (i.e., 0 to 10) or similar documentation aid should be employed in order to satisfy the regulatory requirement.


The Painful Truth believes that only in rare circumstances would a non-opioid treatment option fail to exist.



This section deals with treatment agreements and informed consent.


Although the term “Informed Consent” (IC) is not mentioned, Section Five clearly deals with elements of informed consent in discussing the requirement for a treatment agreement (TA).

Both the PATIENT and the PHYSICIAN must sign the “agreement.” A copy must be kept in the patient’s chart.


The document(s) must attest to a “simple and clear” explanation of:

  1. Risks and benefits (IC)
  2. Alternatives to opioid treatment (IC)
  3. Consent to drug monitoring and random pill counts (TA)
  4. The requirement to take the drugs as prescribed (TA)
  5. Prohibition of the sharing of drugs (TA)
  6. “That the patient inform the physician about any other controlled substances prescribed or taken”
  7. Treatment goals
  8. Reasons opioid therapy may be changed or discontinued.
  9. COUNSELING FOR WOMEN: Particular attention must be given to “women between the ages of 14 and 55 with child bearing potential” (e.g., has not had a hysterectomy). They must be counseled regarding RISKS TO THE FETUS, specifically including the risks of “fetal opioid dependency and neonatal abstinence syndrome.”

The Painful Truth recommends combining the treatment agreement and the informed consent into one document.



This section deals with periodic scheduled visits – PROGRESS, COMPLIANCE & EXPECTATIONS.


  1. “Stable” regimens need a “face to face” at least once every 4 months.
  2. “If changes are prescribed by the physician” – face to face at least every 2 months.

At the visit:

  1. Evaluate progress
  2. Evaluate compliance
  3. “Set clear expectations

– “such as: attending physical therapy, counseling or other treatment options”




This section deals with INSPECT reports, which must be obtained at the beginning and annually. One must document in the chart if the INSPECT is “consistent with the physician’s knowledge of the patient’s controlled substance use history.”



This section deals with drug monitoring tests, which must be obtained at the beginning and annually.


There must also be a “confirmatory” test for these drug-monitoring tests.

If a test shows “inconsistent medication use” or “illicit substances” there must be documented a discussion, review, and revision of the treatment plan.

The Painful Truth notes that “confirmatory” is not defined in these regulations. However, this probably means that the specimen must be submitted for a more specific evaluation (e.g. gas chromatography – Still, one could argue that repeating the initial drug screen is a type of “confirmation.”).  Note that the regulations do not specify that every drug-monitoring test have a confirmatory test – rather, only the one at the “outset” and at the “annual” screen.

The Painful Truth submitted an opinion on drug-monitoring tests (October 2013).



This section deals with requirements when the morphine equivalent dose (MED) is greater than 60 mgm/day.


When the MED is greater than 60 mgm/day, one must REVIEW, REVISE, & REFER


Note: MED was defined in Section TWO of the regulations.

When the 60 mgm per day MED threshold is exceeded, the following must be done:

  1. A face-to-face REVIEW of the treatment plan.
  2. Document a REVISED ASSESSMENT & PLAN  – including risk of DEATH.
  3. Consideration of REFERRAL to a “specialist.”


The Painful Truth notes that the main goal of the “revised” plan seems to be mitigation of risks (especially DEATH) associated with higher opioid dose regimens.

The Painful Truth notes that while the non-specific wording (i.e., “revised,” “consideration,” and “specialist”) allows application of a physician’s clinical judgment, it remains important that documentation adequately justify therapeutic decisions.


The Painful Truth recommends addressing the increased risks (including death) associated with MED greater than 60 mgm/day in a combined opioid INFORMED CONSENT & TREATMENT AGREEMENT (see section FIVE).



This section deals with Physician Assistants (PA) and Advanced Practice Registered Nurses (APRN).

The Painful Truth notes the EMERGENCY REGULATIONS are from the Medical Licensing Board of Indiana, which only has jurisdiction over PHYSICIANS. Physician Assistants and Advanced Practice Registered Nurses each have separate licensing boards.

Regarding Physician Assistants, Section 10 notes that PA duties and responsibilities must be “within the supervising physician’s scope of practice.”

The Painful Truth believes the Regulations could be interpreted as delineating a physician’s scope of practice. By this interpretation, physician assistants would be required to follow the Board of Medical Licensure’s Regulations.


The Painful Truth also believes that, since they do not place limits on opioid prescribing, the Regulations could be interpreted as not delineating a physician’s scope of practice. By this interpretation, physician assistants would not be required to follow the Board of Medical Licensure’s Regulations.


Regarding Advanced Practice Registered Nurses, Section 10 does not mention “scope of practice.” Thus, APRNs (considered more independent of physician supervision than PAs) would not be required to follow the Board of Medical Licensure’s Regulations.

Lending more credence to the concept that the Regulations do not apply to PAs and APRNs is language from Senate Bill 246 that was passed in this year’s Indiana State Legislature:

The state board of pharmacy or any licensing board, commission, or agency that controls, authorizes, or oversees controlled substance registrations under IC 35-48-3 shall adopt rules necessary to complement the rules adopted by the medical licensing board under this chapter.


If PAs and APRNs were subject to the rules of the Medical Licensing Board, there would be no need for a law requiring their boards to adopt complementary rules. Note: As of today – December 12, 2013 – no other boards have adopted any complementary rules.

The Indiana Board of Pharmacy will consider emergency rules at its meeting in January 2014.

The Painful Truth reminds physicians that requisite supervisory agreements allow PHYSICIANS to place limits on prescriptive practices for the PA’s and APRN’s they supervise. To illustrate this point, The Painful Truth received an email on December 12, 2013 sent by the Indiana Professional Licensing Agency stating:


Professionals that hold a license to practice should review all collaborative agreements with Advance Practice Nurses and Physician’s Assistants to assure that they are in compliance with the new rule.”



This section describes circumstances allowing waivers of the initial INSPECT and initial drug monitoring test.


The Painful Truth believes Section Eleven was included to ease transition to regulatory compliance for patients currently receiving chronic opioid therapy.


The requirement for an initial INSPECT is waived if, prior to December 15, 2013, a patient has reached the thresholds described in SECTION 3

i.e., prescribed more than sixty opioid-containing pills a month; or a morphine equivalent dose of more than fifteen milligrams per day; for more than three consecutive months.

Regardless, an INSPECT must be done by November 1, 2014.

The requirement for an INITIAL drug monitoring test at the outset of an opioid treatment plan (SECTION 8) is waived if, prior to January 1, 2015, a patient has reached the threshold described in SECTION 3

i.e., prescribed more than sixty opioid-containing pills a month; or a morphine equivalent dose of more than fifteen milligrams per day; for more than three consecutive months.


The Painful Truth believes INSPECT reports and drug screens should be done “early and often.” Include reports from border states (e.g. Kentucky’s KASPER) when available. Also note that (as stated in section THREE) if a physicians does a dug screen or INSPECT… “any subsequent requirements are determined by when the initial evaluation would have been required and not at the earlier date it actually was conducted.”

SECTION TWELVE – These Regulations are effective December 15, 2013.



In Conclusion…


The Painful Truth reminds physicians that there are three vital elements to success when prescribing opioids for chronic pain.

  1. The wellness of the patient
  2. The safety of the community
  3. The security of your practice

If any of these three “balls” are dropped, the outcome can be disastrous. Thorough knowledge of these Emergency Regulations and diligent adherence to their conservative interpretation will make the juggling easier.


DRAMATIC at the start (Section 4);

FACE-TO-FACE every 2 – 4 months (Section 6);

INSPECT & DRUG SCREEN annually (Sections 7 & 8);

REVIEW, REVISE & REFER at higher doses (Section 9).

Now go treat some pain.

You may contact the Medical Licensing Board of Indiana by phone at 317-234-2060 or email at

Disclaimer: I represent no organization. All opinions, unless specifically referenced, are my own. This webpage is intended to be a resource. It is NOT intended to be comprehensive or to be legal advice or medical advice. Physicians should always consult with their medical malpractice insurance company for risk management advice and with their private health care attorney for legal advice. If you have a medical condition please seek advice from your personal physician. Every patient, practitioner, and facility should consult its own counsel for advice and guidance. If you rely upon information from this website, you do so at your own risk.