In the medical field, pain is often considered the fifth vital sign — along with heart rate, temperature, respiration rate and blood pressure — and needs to be treated immediately.
That thinking led to overprescription of pain relievers, many of them opiates, says Dr. John Macy, an orthopedic surgeon at Mansfield Orthopaedics in Morrisville.
A person with a migraine would often get four to five Percocet pills from the emergency room, Macy said.
After surgery or a bad injury, “we used to give 30, 60, 90 Percocet to the patient, and they’d go home and maybe use 10 or 20 pills,” Macy said. “We did this for years. It was a knee-jerk reaction that lead to more pills on the streets.”
Fifteen to 20 years ago, treatment of pain became very liberal, recalls Jackie Bromley, a certified nurse midwife at the Women’s Center at Copley Hospital.
“There are so many pain-management options, but the culture was to take a pill,” Bromley recalled.
Over time, doctors were feeding the habit.
If the patient became addicted to the medication, but couldn’t get a refill on the prescription, they’d go to another doctor — or get the drug off the streets. That trend sometimes led to a shift from Percocet to heroin, because it was more readily available.
“The culture was to believe that pain was abnormal, and we should treat it to go away,” Macy said. “But pain never killed anyone and a little can be tolerable. …We understand (doctors) are part of the problem, and we want to make sure that we don’t cause as many issues as we have in the past.”
Limits and coaching
Now, after an operation, the number of pills surgeons prescribe has since dropped to 10 or 20, and doctors spend more time coaching their patients about surgical pain and the dangers of narcotics.
Before surgery, every patient signs a narcotics contract explaining use and abuse. Patients also get naloxone, an overdose-reversing drug, if they’re given a high dose, or if they’re taking opiates with other medications.
And pharmacies will no longer accept a phoned-in narcotics prescription. The script has to be written and physically delivered to the pharmacist before it’s filled.
“It helps limit when and how a patient can get pain meds,” Macy said.
Mansfield Orthopaedics also works with primary care physicians on pain management plans; one single doctor becomes a patient’s prescriber of narcotics. That way, multiple doctors aren’t giving the same patient a prescription.
Last year, the state instituted the Vermont Prescription Monitoring System, which provides an electronic, up-to-date record of everyone who has received or is currently receiving a prescription, and who prescribed it — to make sure that patients don’t doctor-shop.
The system, online since last July, has made a big difference, Macy said. Previously, the only way to know if someone had been prescribed an opiate was to check electronic medical records — and Vermont has 20 different medical record systems.
Bu the biggest thing that’s reducing the opioid crisis is the education that patients get about the dangers of narcotics. Now, they’re asking for them less.
“I do total shoulder replacements, and about 50 percent of my patients don’t take any narcotics post-op, besides the few given in the hospital before discharge,” Macy said. “Many don’t even fill their scripts.
“That’s a big change from 10 years ago, when they’d go directly from the hospital to the pharmacy, fill it, and take as prescribed, regardless of their pain level.
“More and more people are seeking alternatives to narcotics.”
In case of emergency
The emergency department at Copley Hospital is taking a similar approach, and if a patient is sent home with any narcotics, it’s only enough for 24 hours, says Michael Brigati, director of emergency services.
If the patient is still in pain, a follow-up visit with a primary care physician is advised.
About 5 percent of Copley’s emergency room patients have a problem primarily related to substance abuse. In others, the opioid dependency is discovered during treatment of another injury or illness.
The hospital partners with Lamoille County Mental Health, Behavioral Health and Wellness, the local alcohol and substance awareness program. The hospital social worker provides additional support for those patients.
“We’ve been using a lot more non-opioid pain medications to make the patient more comfortable, too,” Brigati said.
Tylenol has become the first line of defense for pain.
“People these days often pop Tylenol like candy, but it can still be effective if given (intravenously), and can reduce the amount of need for opioid pain meds,” Brigati said.
Over the past two years, nitrous oxide gas has become more popular as well. It can be self-administered, is short-acting, and doesn’t spike blood pressure.
Midwives in the birthing center now offer nitrous oxide as an option to help women through contractions. When a contraction hits, breathe in the nitrous oxide, and exhale.
The birthing center at Copley doesn’t treat addiction, and rarely prescribes narcotics.
“We manage the pregnancy side of things, and work with prescribers to get copies of drug screens,” said Kipp Bovey, certified nurse midwife.
“To be in our program, patients have to be in stable recovery. If they’re new to or not in recovery, we send them to (Central Vermont Medical Center or University of Vermont Medical Center), because they’ve been doing it a lot longer.”
For mothers in medically assisted treatment who need a caesarean section, which normally requires medication after the procedure, the staff will consult with the anesthesiologist on other pain-management options.
“They won’t be pain-free, but we manage their expectations,” Bovey said.
For infants, if a baby was exposed to narcotics during its mother’s pregnancy, the hospital will require that infant to stay in the hospital for at least 96 hours, under observation for signs of drug withdrawal.
If the baby goes into withdrawal, it will be taken to UVM Medical Center for methadone treatment.