Over the course of my more than 20 years as an emergency physician, I have seen thousands of patients with painful conditions. During that same time, I have witnessed the remarkable evolution of modern pain medication – its potential and its pitfalls. We can now help patients manage both short-term pain and long-term pain. Yet, while medications – particularly opiates – have helped us heal patients, we have also seen their detrimental effects, chief among them being addiction.
Opiates can be very helpful for patients with conditions such as broken bones, kidney stones and also useful after many different types of surgery. They may also be used to treat people with chronic pain, those who experience pain carrying out the normal daily functions of life that you and I may take for granted. While opiates work well for pain control, they have a number of potentially serious side effects: they can hinder or stop breathing, cause constipation, result in drowsiness, and act as central nervous system depressants. That’s why your doctor tells you it is not safe to drive after taking opiates.
An even more critical – and devastating – side effect is addiction. Your body develops a tolerance to opiates. After only a couple weeks, it may require higher doses to control your pain. Over time, you may need increasing doses of opiates to manage the same level of pain. Patients may develop opiate dependence – their body will crave it. They will exhibit a strong desire or compulsion to take the drug for reasons beyond simple pain control. At this stage, if they stop taking opiates, they will experience withdrawal. This is how opiate use can lead to addiction and all its inherent problems for the individual and society. (Note: To be clear, for short periods of time, opiates are safe medications and excellent choices for a wide variety of acute painful conditions. Short courses of opiates will not lead to dependence or addiction.)
As providers, our responsibility is to carefully manage the side effects of opiate therapy. Dependence, tolerance, and addiction must be discussed and a careful well-planned strategy is crucial for extended use of opiates by patients.
That is exactly what we are doing at the University of Vermont Medical Center. Recently, providers and pain management experts from multiple specialties (Anesthesia, Emergency Medicine, Family Medicine, Internal Medicine, and Surgery) converged to standardize how we care for patients with painful conditions and to develop best practices for our patients.
What did we do? Here is an overview:
- Systems Approach. We built standardized protocols so that patients will get similar treatment in various settings. We believe this standardization will help our patients and providers. There will be clear, defined expectations and goals for treating our patients’ pain.
- New Rules & Tools. We use tools, such as pain agreements with patients, surveys to assess how patients are functioning with their pain, and processes to measure their risk for addiction.
- Defining Maximum Daily Dosage. We are one of the first hospitals in the country to define the maximum daily dose of opiates. Research shows that beyond certain doses patients experience no additional benefit. We know that very high doses of opiates increase the risk of dangerous side effects, but offer no additional pain control.
This approach will ensure that we are more reliable and consistent in our approach to pain in our patients – and our patients will know what to expect from their providers.
Recently, Gil Kerlikowske, Director of the Office of National Drug Control Policy, visited us to discuss our new approach and tools. He lauded our systems-level strategy and our standardized protocols.
I believe that the current dialogue in Vermont and the United States on how to better manage opiate abuse will be productive and lead to changes across the country in how opiates are prescribed and how acute and chronic pain is managed. the University of Vermont Medical Center is on the leading edge of this transition and could be a model for other health systems managing this complex issue.
Stephen M. Leffler, MD, is the Chief Medical Officer at the UVM Medical Center, former Medical Director of the Emergency Department, and has been a practicing physician for 20 years. He grew up in Brandon, VT.