STRENGTH IN NUMBERS

office M

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

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

talking to

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

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

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

bridge

Both states’ regulations are instructive regarding educational requirements.

Kentucky’s regulations mandate:

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

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

Not to be outdone, Indiana’s regulations state:

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

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

agree

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

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

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

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

The numbers.

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

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

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

The key therapeutic principles involved in group therapy include:

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

*Universality:  People see that they are not alone.

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

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

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

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

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

dr pat

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

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

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

And they had more strength to do battle.

As did their doctor.

On this atypical Friday afternoon.

There truly is strength in numbers.

Fireworks-047-screen

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

*

*

*

 

Here’s the link to the “Fraud” video:

http://vimeo.com/67679697

 

 

*

 

 

 

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

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.

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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.

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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

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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.

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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.

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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!

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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.

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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.

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

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*still juggling…

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practice

community

*P.S. You had to be there.

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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.

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“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.

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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

NIDA & the Facts on Marijuana

The National Institute on Drug Abuse Offers the Facts on Marijuana

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From the website:

http://www.drugabuse.gov/publications/drugfacts/marijuana

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Marijuana…

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.”

fetus

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.”

Medical-Cannabis

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:  http://www.drugabuse.gov/publications/research-reports/marijuana-abuse

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…

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There is a lot of history in this room.

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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.

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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

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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.

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A new year…  a new name.

evoice

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

http://archive.constantcontact.com/fs105/1101098564175/archive/1115193404761.html