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 and long-term pain. Yet, while medications – particularly opioids – have helped us heal patients, we have also seen their detrimental effects, chief among them addiction.
Opioids can be very helpful for patients with conditions such as broken bones and kidney stones, and they are also useful after many types of surgery. They may also be used to treat those with chronic pain – people who experience pain carrying out normal, daily functions of life that others take for granted. Used for short periods of time at the proper dosage, opioids are safe medications and excellent choices for a wide variety of acute painful conditions.
While opioids 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 opioids.
Another devastating side effect is addiction. The body develops a tolerance to opioids and, after only a couple of weeks, may require higher doses to control pain. Over time, increasing doses of opioids may be needed to manage the same level of pain. Patients may develop dependence – their bodies 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 opioids, they will experience withdrawal. This is how opioid use can lead to addiction and all its inherent problems for the individual and society.
As providers, our responsibility is to carefully manage the side effects of opioid therapy. Dependence, tolerance, and addiction must be discussed with patients, and a careful well-planned strategy is crucial for their extended use of opioids.
That is exactly what we are doing at Fletcher Allen Health Care in Burlington, Vermont. 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 processes and tools such as pain agreements with patients and surveys to assess how patients are functioning with their pain and 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 opioids. Research shows that beyond certain doses, patients experience no additional benefit. We know that very high doses of opioids increase the risk of dangerous side effects but offer no additional pain control.
This approach helps ensure that we are more reliable and consistent in our approach to pain in our patients and that our patients will know what to expect from their providers.
Gil Kerlikowske, then-Director of ONDCP, recently visited Fletcher Allen Health Care 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 elsewhere on how to better manage opioid abuse will be productive and lead to changes across the country in how these drugs are prescribed and how acute and chronic pain is managed. Fletcher Allen Health Care is on the leading edge of this transition and could be a model for other health systems managing this complex issue. I hope that sharing our practices here is the first step toward being that model.
Stephen M. Leffler, M.D., is the Chief Medical Officer at Fletcher Allen, former Medical Director of the Emergency Department, and has been a practicing physician for 20 years. He grew up in Brandon, Vermont.