June 4, 2015 by jamespmurphymd - 3 Comments

Plan to THINK… How to prescribe controlled substances in Kentucky for the first three months

Kentucky’s controlled substances regulations make clear distinctions between: (1) initial prescribing, (2) prescribing by the three-month mark, and (3) prescribing beyond three months. To make matters even more confusing, the regulations are two-tiered, with specific language pertaining only to schedule II drugs, with schedule V drugs being exempt from the regulations.

Because of some seemingly redundant and contradictory language, understanding Kentucky’s regulations can be challenging. Prescriber uncertainty can interfere with proper patient care. In an effort to simplify this process I have summarized Kentucky’s regulations governing the initial prescribing of controlled substances in a convenient “check list” format. Future articles will look at the three-month mark and beyond.

The bold components of the checklist are required only when prescribing schedule II controlled substances. However, to be safe I recommend checking off all of the requirements when prescribing any schedule II-IV drug.

Note: I am a physician; not a lawyer. This summary is not legal advice. Each facility and physician should consult its own legal counsel for advice and guidance.

P lan to T H I N K

What to do initially when prescribing during the first three months of treatment.

P lan

___ Deliberate decision that it is medically appropriate to prescribe or dispense the controlled substance in the amount specified

___ Written plan stating the objectives of the treatment

____Written plan stating any further diagnostic examinations

T each

___ Safe use

___ A controlled substance for an acute complaint is for time-limited use

___ Discontinue medication when the condition has resolved

___ Proper disposal of any unused medications

___ KBML website resources

Note: Educational materials relating to these subjects may be found on the board’s web site, www.kbml.ky.gov or
http://kbml.ky.gov/hb1/Pages/Considerations-For-Patient-Education.aspx

H istory and physical

___ Appropriate medical history relevant to the medical complaint, including a history of present illness

___ Physical examination of the patient relevant to the medical complaint and related symptoms

I nformed consent

__ Discuss the benefits and risks of prescribing or dispensing a controlled substance to the patient, including:

(a) nontreatment, (b) other treatment, (c) the risk of tolerance and (d) the risk of drug dependence

__ Obtain written consent for the treatment.

N o long-acting opioids

___ No long-acting or controlled-release opioids for acute pain that is not directly related to and “close in time” to a specific surgical procedure

K ASPER

___ Obtain and review KASPER report for that patient for the preceding 12 months

___ Appropriately utilize KASPER information in evaluation and treatment

Additional documentation required for patient prescribed a schedule II controlled substance, as “appropriate”:

___Diagnostics (labs, studies, etc.)

___Evaluations and consultations;

___Treatments and outcomes

___Medications (date, type, dosage, and quantity)

___Instructions

___Agreements

When prescribing “additional” Schedule II, at “reasonable” and individualized intervals review:

___ Plan of care

___ Provide any new information about the treatment

___ Modify or terminate the treatment as appropriate

EXEMPTIONS to Kentucky’s regulations:

The exemptions are very confusing. While the first set of exemptions (see below) are supposed to apply to all controlled substance, there are additional exemptions that pertain only to schedule II controlled substances.

I believe the most important points here are:

Cancer patients are exempted.
In-patients are exempted for Schedule III-IV
In-patients receiving schedule II drugs must have a KASPER, but all the treating physicians can share the report.
Post-op schedule II drugs are exempted for 2 weeks.
Schedule V drugs are always exempted.

Here are the exemptions in detail:

Kentucky’s regulations shall not apply to a physician prescribing or dispensing a controlled substance:

(a) To a patient as part of the patient’s hospice or end-of-life treatment;

(b) To a patient admitted to a licensed hospital as an inpatient, outpatient, or observation patient, during and as part of a normal and expected part of the patient’s course of care at that hospital;

(d) To a patient who is a registered resident of a long-term-care facility as defined in KRS 216.510;

(e) During the effective period of any period of disaster or mass casualties which has a direct impact upon the physician’s practice;

(f) In a single dose prescribed or dispensed to relieve the anxiety, pain, or discomfort experienced by that patient submitting to a diagnostic test or procedure; or

(g) That has been classified as a Schedule V controlled substance.

But wait! There are more exemptions that pertain only when prescribing Schedule II controlled substances…

For each patient for whom a physician prescribes or dispenses a Schedule II these regulations shall not apply to:

A physician prescribing or administering that controlled substance immediately prior to, during, or within the fourteen (14) days following an operative or invasive procedure or a delivery if the prescribing or administering is medically related to the operative or invasive procedure or delivery and the medication usage does not extend beyond the fourteen (14) days; or
For administration in a hospital or long-term-care facility if the hospital or long-term-care facility with an institutional account, or a physician in those hospitals or facilities if no institutional account exists, queries KASPER for all available data on the patient or resident for the twelve (12) month period immediately preceding the query, within twelve (12) hours of the patient’s or resident’s admission, and places a copy of the query in the patient’s or resident’s medical records for use during the duration of the patient’s stay at the facility;
As part of the patient’s hospice or end-of-life treatment;
For the treatment of pain associated with cancer or with the treatment of cancer;
In a single dose to relieve the anxiety, pain, or discomfort experienced by a patient submitting to a diagnostic test or procedure;
Within seven (7) days of an initial prescribing or dispensing under subsection (1) of this section if the prescribing or dispensing:
1. Is done as a substitute for the initial prescribing or dispensing;
2. Cancels any refills for the initial prescription; and
3. Requires the patient to dispose of any remaining unconsumed medication;
Within ninety (90) days of an initial prescribing or dispensing under subsection (1) of this section if the prescribing or dispensing is done by another physician in the same practice or in an existing coverage arrangement, if done for the same patient for the same medical condition; or
To a research subject enrolled in a research protocol approved by an institutional review board that has an active federalwide assurance number from the United States Department for Health and Human Services, Office for Human Research Protections if the research involves single, double, or triple blind drug administration or is additionally covered by a certificate of confidentiality from the National Institutes of Health.

There are additional “Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint” that must be met before a physician commences to prescribe or dispense any controlled substance to a patient sixteen (16) years or older for pain or other symptoms associated with the same primary medical complaint for a total period of longer than three (3) months.

To address this information and much more, there will be another Confluential Truth article coming soon. You may also refer to the regulations as posted on the KBML website (http://kbml.ky.gov/hb1/Pages/House-Bill-1-Ordinary-Regulations.aspx) and in the “comments” section accompanying this article.

***

April 26, 2015 by jamespmurphymd - 1 Comment

The Seven Essentials for Pain Practice Success* …Sailing the Seven C’s

Success is counted sweetest by those who ne’er succeed.
~Emily Dickinson

You treat chronic pain? Thank goodness someone does.
~My physician colleagues … on numerous occasions

I have treated chronic pain in a variety of practice settings, large and small, for almost thirty years. It has not always been easy. But I have found that success in this specialty is possible when the practice foundation consists of seven basic elements:

Cost-effective
Cooperation
Compliance
Consensus
Culture
Cause
Care

Chronic pain is not an exotic clinical niche. It is a chronic illness and should be approached step-wise as one would approach other chronic illnesses:

(1) Gather information;
(2) Make a diagnosis;
(3) Implement a plan of care;
(4) Assess the results; and
(5) Make adjustments.

A physician is generally comfortable with this paradigm when it applies to caring for an individual pain patient. However, regardless of one’s clinical confidence, when the practice’s primary mission is to treat chronic pain, overriding concerns about economic viability, community safety, and regulatory scrutiny become major stressors for a physician. More than just a paradigm is needed.

By embracing The Seven Essentials for Pain Practice Success a healthcare organization of any size or complexity can meet this need and provide quality pain care that is valued by the patient and professionally satisfying to the provider.

The Seven Essentials for Pain Practice Success

1. COST-EFFECTIVE

There’s no escaping the fact that healthcare costs are prodigious and resources are finite. Care providers may feel compelled to offer expensive treatments and order technologically advanced tests, regardless of the cost, out of a desire to provide the best care possible. But “best care” is not equivalent to “most-expensive care.” The success of any pain care practice is dependent upon use of resources – of the patient and the practice- in a manner that optimizes value.

2. COOPERATION

Do not tell patients what you will do to them. Instead, figure out how you can work with them. Providing care in a climate of draconian pain regulations, dogmatic practice guidelines, and dearth of evidence to support treatment options, is optimized by patient-practitioner partnerships. Success requires positive outcomes for the: (1) patient, (2) caregiver, and (3) community. If any of these three stakeholders have bad outcomes, failure is the sum total. With cooperation and teamwork, success is more likely achieved.

3. COMPLIANCE

Be a follower. In addition to an ever-increasing database of clinical guidelines, there are numerous regulations and statutes governing how healthcare providers may treat pain, particularly when treatment involves controlled substances. Some of the rules are federal statutes that apply universally. Other rules are only specific to individual states or communities. Rules governing pain care delivery may not necessarily reflect the best clinical practice, but are usually based upon sound principles. Search for the reason behind the rule. But if all else fails, go ahead and “teach to the test.” Compliance is mandatory. Even if you think “outside the box” do not act outside the box. Know the rules and follow the rules.

4. CONSENSUS

A successful pain practice must agree on how they will operate. Do some providers allow early refills, while others will not? Are some quick to discharge a patient who has an abnormal drug screen, while others give second chances? How often do we drug screen? Do we prescribe drugs on the first visit? Through honest communication the group must reach a consensus on “our way” of doing things.

5. CULTURE

Every organization has its own culture. A successful pain practice understands its culture, knows its weaknesses and knows its strengths. For example, if the group’s dominant culture is intuitive, then it needs safeguards (i.e. objective and detail-oriented policies and procedures) to focus on specifics. Success requires that individuals not only understand their roles, but also are willing to perform in a manner that supports the group’s dominant culture.

6. CAUSE

Successful pain practices know their cause, their mission, the reason the practice exists. Even the most mundane task can be passionately undertaken when team members understand how their actions contribute to the cause. In addition, successful practice managers make sure team members feel appreciated for their efforts.

7. CARE

Caring is the foundation for success. In all decisions, successful pain practices first ask: “Is it in the patient’s best interest?” Beyond that, every human encountered by the organization -patients, family members, hospital administrators, government regulators, insurance brokers, pharmaceutical representatives, colleagues, etc.- is worthy of dignity, respect, and care. The “golden rule” always comes before the rule of gold. Remember that no one cares how much you know until they know how much you care.

Each of the seven essentials for pain practice success is vital. Ignore one and the organization is on thin ice. Embrace them all and the practice, regardless of its size, can be on economical, clinical and ethical solid ground.

Then no one will have to “thank goodness” for what you do.
Instead, you can be thanked for the goodness that you do.

That is sweet success.

https://vimeo.com/channels/glms/68703810

James Patrick Murphy, MD, MMM is a Past President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine and has a Master of Medical Management from the USC Marshall School of Business.

*Note: This article was originally titled: The Five Essentials for Pain Practice Success. “Cost-effectiveness” was added on July 30, 2015; “Cooperation” was added on September 30, 2015; each prompting a change in the title.

April 6, 2015 by jamespmurphymd - 1 Comment

Treating Pain With Truth

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

…Pain free?

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

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

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

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

https://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine.

March 29, 2015 by jamespmurphymd - 4 Comments

Pathway to Partnership, Part II (IN)

THE CHRONIC PAIN PATIENT’S GUIDE TO INDIANA’S REGULATIONS

No man is an island, Entire of itself, Every man is a piece of the continent, A part of the main. – John Donne

The poet, John Donne, knew it. Every Hoosier pain patient and Hoosier pain care provider should take it to heart. No patient or provider is an island. And pain care is best when there is a partnership between the patient and provider. The Pathway to Partnership If you are treated for pain in the Hoosier State the pathway to partnership with your physician passes through Indiana’s pain regulations. Indiana’s entire southern border is Kentucky. And when it comes to patient responsibilities, Kentucky’s pain regulations have much in common with Indiana’s. Therefore, Hoosier patients can begin preparation for their Indiana chronic pain care evaluation by reading my article: Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Available at: https://jamespmurphymd.com/2015/02/13/pathway-to-partnership Particular to Indiana is the Hoosier state’s emphasis on medication dosing limits that trigger mandatory compliance with the regulations. Calculating these dosing limits can be quite confusing and, frankly, patients are not responsible for knowing them. Prescribers are. But to be a good “partner” with your prescriber, you should at least become familiar with these dosing limits. Later in this article I will summarize. But first, in order to hold up your end of the partnership, here are ten items you can prepare:

Your past medical history
Your pertinent medical records
An accurate medication list
Any substance abuse history
Your social and family history
Any other medical issues
Educate yourself for proper informed consent
Your current level of function
Your treatment goals
Complete questionnaires & mental health screens

These ten items are discussed in detail in Pathway to Partnership, Part I (KY) – The Chronic Pain Patient’s Guide to Kentucky’s Regulations. Prepare as described above you will be well on your way to becoming a great partner in your care. As your partnership continues, expect to have contact with your physician on a regular basis and even randomly to:

Review your progress with your treatment plan;
Review the goals of your plan; and
Review expectations (i.e. attending therapy, counseling, tests, etc.)

Insider Information As a partner, you are entitled to some “insider” information. Here it is… A new section of Indiana’s regulations contain a lengthy explanation of what prescribers must consider when ordering drug screens. By doing so, this section offers insight into appropriate patient behavior. The following list, summarized from the regulations, offers an insider’s look at what Indiana expects of a pain patient: “In determining whether a drug monitoring test…is medically necessary, the physician shall consider” if the patient has:

Taken the meds as prescribed?
Taken more meds than allowed?
Given or sold meds to anyone?
Benefitted from the meds?
Taken any other drugs – legal or illegal?
Been honest and up front about past drug use?
Tried to get early refills?
Lost meds? Had them stolen?
Had an abnormal INSPECT state prescription report?
Failed a drug screen?
Been intoxicated?
Been acting aggressive, depressed, anxious, etc.?
Been diagnosed with a psychiatric condition?
Demanded certain specific meds?
Had a major illness? Pregnancy? Hospitalization?
Been resistant to any changes in the care plan?
Refused or failed to follow through with exams/tests?
Just not done well overall?

Bottom line: Be honest, up front and “transparent.” No one likes surprises. A good partnership is all about trust and communication. Understand what your treatment agreement says and live up to it. Dosing Limits Now, about those dosing limits… As I said, it can be confusing, but you should try to understand the concepts and discuss them with your prescriber. Not all pain prescriptions are subject to the Indiana regulations. Therefore, it is important to understand the dosing limits that trigger mandatory compliance. These limits are dependent upon: (1) the dose, (2) the quantity and (3) the duration. The Morphine Equivalent Dose (“MED”) is basically how strong your medication would be if it were to be substituted for morphine. This is very important to INDIANA regulatory agencies. I highly recommend you learn how to calculate your MED. Calculating the MED Step ONE: Calculate the MED for one pill Determine the dose of morphine that would be equal to one of your pills using a standard conversion table (For example: a FIVE mgm hydrocodone pill is the same as a FIVE mgm morphine pill; but a FIVE mgm oxycodone pill would be the same as a 7.5 mgm morphine pill). Indiana officials recommend this website for help with making this determination: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm Step TWO: Calculate your DAILY MED Once you have converted your pill to its “morphine equivalent,” simply add up the maximum number of pills your prescription allows you to take in a day and multiply this number by the morphine equivalent (MED) you determined in step one. (Number of pills per day) x MED/one pill = Daily MED For example: Since a FIVE mgm hydrocodone pill is equal to a FIVE mgm morphine pill, the daily MED of someone taking THREE of these hydrocodone pills per day would be: 5 mgm x 3 pills per day = 15 mgm MED Here are some common ORALLY prescribed opioids that compare to a MED of 15: Hydrocodone (oral) 15 mgm/day = 15 mgm of morphine (oral) Oxycodone(oral) 10 mgm/day = 15 mgm of morphine (oral) Oxymorphone (oral) 5 mgm/day = 15 mgm of morphine (oral) Codeine (oral) mgm/day = 15 mgm of morphine (oral) Hydromorphone (oral) 3.75 mgm/day = 15 mgm of morphine (oral) Tramadol (oral) 150 = 15 mgm of morphine (oral) Note: MED greater than SIXTY If you are on a treatment regimen with a morphine equivalent dose of more than SIXTY (60) MED, the physician may require you to have an evaluation by a specialist. According to the regulations, your physician must explain to you that there is an increased risk of adverse outcomes, including death, when your daily MED is greater than SIXTY. So now that you understand the MED, you are ready to look at the DOSING LIMITS that trigger compliance with the regulations. DOSE, QUANTITY & DURATION When any of the following conditions are met, your physician (and you) must comply with the Indiana pain regulations.

DOSE & DURATION >15 MED for >3 months

DAILY MED greater than FIFTEEN for DURATION of more than three consecutive months Or…

QUANTITY & DURATION >60 pills for >3 months

More than SIXTY opioid pills per month for DURATION of more than THREE consecutive months Or…

PATCHES > 3 months

Any opioid skin patches (e.g., fentanyl or buprenorphine), regardless of the dose or quantity, for DURATION of more than THREE consecutive months Or…

Hydrocodone-Only Extended Release

Any hydrocodone-only extended release medication that is NOT in an “abuse deterrent” form, regardless of the DOSE, QUANTITY or DURATION Or…

TRAMADOL (My advice) >150 mgm for >3 months

Actual language in the regulations state: “If the patient’s tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months.” This tramadol dose limit seems to be overly generous when compared to other MED dosing limits. A SIXTY (60) MGM MED of tramadol is in the range of 300 to 600 mgm of tramadol. Considering that the maximum therapeutic dose for tramadol is only 400 mgm per day, one could potentially exceed the safe upper limit of tramadol and still not exceed Indiana’s dosing limit. This seems to be inconsistent with the regulation’s other opioid dosing limits. My advice: Since 150 mgm of tramadol is equivalent to a FIFTEEN (15) MED, I believe it is more consistent with the other Indiana opioid dosage limits to consider TRAMADOL greater than 150 mgm/day for more than THREE consecutive months as the dosage limit congruent with other opioid dosage limits. Reference: The online opioid calculator from GlobalRPH http://www.globalrph.com/narcoticonv.htm Wait!!! There are EXEMPTIONS !!! Regardless of the dose, quantity or duration, the Indiana pain regulations do not apply to these patients: (1) With a terminal condition (2) Residing in a licensed health facility (3) Enrolled in a licensed hospice program (4) Enrolled in a licensed palliative care program In summary, patients and physicians should travel the pathway to partnership together. Patients can do their part by (1) preparing for the clinical visits, (2) understanding and adhering to their treatment agreements, and (3) educating themselves about risks, side-effects, and legal aspects of their care. It is a real challenge to treat chronic pain in this day and age. Your physician needs your help. Will you leave it all up to your physician? Or will you be a good partner, heeding the words of the poet Donne… And therefore never send to know For whom the bell tolls; It tolls for thee. * James Patrick Murphy, MD, MMM is Chair of the Board of Governors -and Immediate Past President- of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, and an Assistant Clinical Professor at the University of Louisville School of Medicine. Dr. Murphy contributes to numerous publications, has presented before national and international audiences, and consults with a wide spectrum of agencies and individuals regarding pain, addiction, and the future of healthcare in our country. He is board-certified in Pain Medicine, Anesthesiology, and Addiction Medicine. * References and links pertaining to this article are provided in the comments. * This unofficial summary is my personal opinion. A full, official version of the final rule should be consulted for compliance purposes at: http://www.in.gov/legislative/iac/20141105-IR-844140289FRA.xml.html The Indian State Medical Association also has a summary available at: http://www.ismanet.org/pdf/legal/IndianaPainManagementPrescribingFinalRuleSummary.pdf And if you really want to explore the Indiana pain regulations in detail, there is no better source than the online guide: First Do No Harm, The Indiana Healthcare Providers Guide to the Safe, Effective Management of Chronic Non-Terminal Pain. http://www.in.gov/bitterpill/docs/First_Do_No_Harm_V_1_0.pdf * Hey Hoosier! Who’s your partner? * * *

February 13, 2015 by jamespmurphymd - 7 Comments

Pathway to Partnership, Part I (KY)

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

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

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

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

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

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

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

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

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

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

General Recommendations:

Prepare answers to some basic medical history questions.
Obtain copies of pertinent documents and medical records.
Make a list of your healthcare providers along with their contact information.
You may wish to store the data on a flash drive, CD/DVD or upload to a secure website for retrieval by your physician. Be advised, until you give these documents to your physician you are responsible for keeping them private.
Bring a friend or family member with you for support, assistance with questions, and to help verify information.

For the initial visit prepare the following:

Medical history
Medical records
Medications
Substance use
Social and family history
Other medical issues
Education and consent
Ability to function
Goals
Questionnaires / mental health screen

Medical history.

It begins with your “Chief Complaint.” This is where you tell your physician what hurts.

Chief complaint: My pain is _______________________
For example: “My pain is in my low back.”

Next, fill in some DETAILS about your pain:
(i) Cause. Based on what you know about your condition, what do you think is causing your pain?
Examples: a bad disk / pinched nerve / arthritis, etc. Be as specific as you can.
(ii) Location. Where does it start? Where does it go?
(iii) Quality. Sharp? Aching? Electrical? Sensitive to touch?
(iv) Symptoms. Numbness? Tingling? Weakness? Muscle wasting? Skin color changes? Swelling?
(v) Timing. Started when? Is it constant? Variable? Worse at certain times of the day? Lasts how long?
(vi) Aggravating factors. What makes it worse? Bending? Standing? Twisting? Being anxious? Working?
Housework? Sleep?
(vii) Relieving factors. What makes it better? Resting? Heat? Ice? Massage? Medication? Injections? Being
distracted? Sleep?
(viii) Pain scale. Rate your pain on a scale from: ZERO (no pain) to TEN (worst pain imaginable).

Medical records.

Your physician may not need every record, but information about care related to your pain is useful and includes:

Surgery reports related to your pain (back surgeries, etc.);
Laboratory tests (blood tests, urine drug screens, etc.);
Studies (x-rays, MRI, CT, EMG, etc.);
Pain care treatments (epidurals, physical therapy, acupuncture, chiropractic, etc.);
Consultations with specialists (surgeons, pain, chiropractic, mental health).

Make a list of your diagnostic tests, especially the most recent ones; include dates and contact information. Gather the reports. If you wait for your physician to get the reports faxed, your pain care could be delayed significantly. You may want to copy them onto a flash drive, CD/DVD, or to a secure website.

Medications.

(a) An accurate and current medication list is extremely important. Include the date, dosage, quantity, and directions. Bring the medicine bottles with you and/or labels, written prescriptions, etc.

Provide answers to these questions:

Do you find your current medications to be effective?
Are you taking them the way they have been prescribed for you?
How long have you been on your current medications?
When was the last time you had a medication change?
Are they causing you any unacceptable side effects such as: sedation, fatigue, nausea, constipation, etc.?

(b) Your medication “journey.” It is extremely important for your physician to know (and document) how you got to this point. What medications did you use in the past? Did you try some over-the-counter medications? Non-controlled substance prescriptions? Gather records (medical, pharmacy, etc.) to show how your dosages have changed over time.

Substance use.

It is vital to be forthcoming about any substance abuse or any substance abuse treatment involving you or any close relative (especially a mother, father, son or daughter). And report any drug-related arrests?

Do you drink alcohol? Do you smoke?

Remember to drink plenty of fluids before your visit in case you are asked to provide a specimen for a random urine drug screen.

Social and family history.

Where do you live and with whom?
Is your home life a challenge?
What is your occupation? Are you disabled?
Where do you get money to live on?
How much formal education have you had?

Other medical issues.

Are you dealing with any other medical issues such as: diabetes, heart disease, cancer, etc.? When was your last general medical evaluation?

Note: To receive long-term controlled substances for pain in Kentucky, it is mandatory that you have a yearly preventive health evaluation.

Education and consent.

Show that you have educated yourself about controlled substances and prepare to document your “informed consent.”

(a) The Kentucky Board of Medical Licensure has posted educational points of emphasis on their website.

I have prepared an educational summary for both Kentucky and Indiana which is available here: http://goo.gl/IJ4I1l

Or download the Murphy Pain Center New Patient Package. Study the patient education sheet. Print it out. Sign it. And bring it with you.

Watch this outstanding video by Dr. Mike Evans that explains many of the pros and cons of the use of controlled substances for chronic pain care.

(b) Once you have been informed, you are ready to give your “informed consent.” You may download this document and bring it to your physician:

I have written an article about informed consent and treatment agreements, Are We In Agreement, available on my website: Confluential Truth.

Ability to function.

Describe your current ability to participate in life’s activities. This will give your physician a baseline from which to judge your progress. You may visit the website for ICSI (Institute for Clinical Systems Improvement) and download and complete the form in Appendix C: Physical Functional Ability Questionnaire (FAQ-5).

Goals.

Come up with some specific and realistic goals that might be attainable. Think of how you can show when you have achieved them. Within reason, think about what you would like to do that you cannot do now. Be prepared to demonstrate this to the physician; i.e. walk without a cane, bend to pick up something, rise from a chair unassisted.

Set goals that are SMART: specific, measurable, attainable, realistic, and track-able.

Questionnaires / Mental Health Screen

Complete these “screening” questionnaires and bring them to your visit.

You may go to the Kentucky Board of Medical Licensure website, download these self-report questionnaires, fill them out, and bring them to your office visit.

Opioid Risk Tool
Patient Health Questionnaire (PHQ-9), mental health screen

You may also go to the website for ICSI (Institute for Clinical Systems Improvement) and download and complete these two forms:

Appendix A (Brief Pain Inventory); and
Appendix B (Patient Health Questionnaire PHQ-9)

If this all seems a bit overwhelming, you can begin to simplify matters by visiting the Murphy Pain Center website and downloading the “New Patient Package.” In it you will find policies, consent forms, agreements, educational materials, and a “New Patient Evaluation” form. These are the kinds of materials you will likely be filling out at your physician’s office visit. Having this information on hand can make your visit more productive.

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

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

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

It is a partnership.

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

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

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

So now that you know the pathway…

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

December 17, 2014 by jamespmurphymd - 1 Comment

‘Twas the Fight in Our Clinic

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

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

On Morphine, on Codeine, on Oxy, on Contin,
On Soma, on Xanax, and lots of Neurontin!
Don’t stop for the chart. Don’t stop in the hall.
Now right away! Right away! Write for it all !!!

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

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

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

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

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

No prescriptions for you, because we do it right!

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

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

August 26, 2014 by jamespmurphymd - 6 Comments

National Pain Care Providers Day

Every dog has his day, right?

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

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

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

It doesn’t exist.

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

National Pain Care Providers Day
March 20, 2015

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

Why is National Pain Care Providers Day necessary?

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

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

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

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

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

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

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

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

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

And celebrate!

National Pain Care Providers Day
March 20, 2015

August 6, 2014 by jamespmurphymd - 3 Comments

Basic Pain Care Certification

The consequences of pain…

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

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

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

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

With alarming frequency, stories like these touch every family.

All are preventable.

The consequences of pain…

More costly than cancer.

More deadly than car crashes.

More likely than a heart attack.

More common than the common cold.

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

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

Then, we should learn.

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

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

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

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

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

Knowledge is power.

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

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

A Basic Pain Care curriculum might include:

– Wellness and prevention (diet, exercise, stress)

– Acute care (ice, heat, etc.)

– Over the counter medications

– Prescription medications

– Opioids

– Alternative and complementary treatments

– Drug abuse prevention, recognition, and treatment

– Regulations

– Pitfalls and risks

– Emergency procedures (overdose, seizure, etc.)

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

Imagine the suffering that would be eased.

Imagine the resources that would be spared.

Imagine the lives that would be saved.

Imagine the tears that would never be shed.

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

Change the consequences of pain.

* *

* * *

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July 21, 2014 by jamespmurphymd - 1 Comment

Talking Trash

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

Dear Courier-Journal,

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

Trash them!

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

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

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

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

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

July 2, 2014 by jamespmurphymd - 4 Comments

STRENGTH IN NUMBERS

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.

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.

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.

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.

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.

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