Tag - Pain management

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Pain Management from a Physician’s Perspective
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Addressing Opioid Addiction “Close to Home”
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Expect Some Pain

Pain Management from a Physician’s Perspective

Nicholas Antell, MD, one of Copley Hospital’s orthopaedic specialists, recently testified in front of the Vermont Senate Health and Welfare Committee. Dr. Antell was invited as part of the Committee’s request for feedback from providers on legislation that went into effect last year. The Vermont legislation limited prescribing and increased required education and communication in a statewide effort to address opioid addiction. Below is a transcription of Dr. Antell’s testimony. 

Over the past several days I’ve talked to most of the prescribers in our practice, Mansfield Orthopaedics, including physicians, but more importantly our Physician Assistants (PAs) and Nurse Practitioners (NPs) who do most of the prescribing and fielding of patient phone calls. The overwhelming consensus is that we are able to control our patient’s pain under these rules and that we were likely prescribing more opioids than necessary prior to their implementation. My subspecialty training is in orthopaedic trauma, taking care of patients that have complex fractures. I started with Mansfield Orthopaedics in August of 2016, and the NP I work with and I adopted these rules well ahead of the go-live date to see how it went. There were, of course, a few exceptions, but we were pleasantly surprised with how few patients were calling back requesting more pain medications. Now, I had the benefit of a developing practice, with a little more time to talk to our patients and manage expectations, which I feel was a huge benefit.

There are certainly times where I prescribe less, but most of my fracture patients are prescribed an amount of opioid that falls into the “severe” pain category in addition to recommending other medications such as Tylenol and Advil. My colleagues that perform joint replacement surgeries, such as total hip and total knee replacements, prescribe an amount of opioid that falls into the “extreme” category, and this was a significant cut from what they were used to. The PAs that work closely on that service tell me less than half of patients call back asking for more pain medications, but some still do. My colleagues that specialize in hand surgery, shoulder surgery, and foot and ankle surgery also feel they are able to control their patient’s pain under the current rules.

A point that was brought up by many was that we can use these regulations to help us limit the amount of opioids given to patients we do not feel really need them but are requesting them. In essence, we can blame the rules and the burden does not fall on the provider.

There are concerns amongst physicians in my group about legislation directing medical practice.  We must be allowed to use our clinical judgment when determining how many opioids are prescribed on an individual basis. We do not feel that it is up to lawmakers to decide if our patients fall into the minor, moderate, severe, or extreme pain categories. Although good as guidelines, we should be allowed to place our patients into which category we feel will adequately, and safely, control our patient’s pain so they can successfully recover from their orthopaedic procedure.

The most common complaint I received from our practice was with the Vermont Prescription Monitoring System (VPMS). We all appreciate the need to know if other prescribers are providing our patients with regulated medications, but the prescribers and delegates that use it most find it cumbersome and time-consuming to use. One provider suggested being provided with a reference number for each query that can be placed in the patient’s chart to confirm on our end that a query had been done. Another has found the customer service hours inconvenient while trying to get a password reset. We have also talked about a requirement to check VPMS before the first prescription is given, but then the system notifies us, for example by email, when another provider prescribes a controlled substance to this patient outside of our practice. Then instead of having to spend time rechecking VPMS in the rare circumstance a patient needs a refill, we can either quickly provide a refill knowing we are the only provider prescribing for them, or be able to have a conversation with that patient about the other prescription we are aware has been filled under their name. Most of us think there is certainly room for improvement with VPMS.

The consent form does add time to our preoperative routine, but the majority of the providers in our group don’t find it to be a nuisance, and with a few exceptions, we feel patients appreciate the discussion. A few patients have even taken this opportunity to tell us they don’t want a narcotic prescription following their procedure.

In our group, we have decided to prescribe Narcan to all patients that receive a narcotic prescription. This saves the hassle of having to figure out who needs one and who doesn’t. To save time we had a stamp made for our Narcan prescriptions, which lives in our perioperative area. However, we have noticed that the majority of our patients do not fill this Narcan prescription.

Initially, the morphine milligram equivalent requirement was confusing. We worked with our pharmacy department who put together a table to help guide how much of each specific narcotic medication could be prescribed to comply with these rules. This was extremely helpful in determining our new prescribing habits. I encourage the other providers here today to do the same if they haven’t already.

In conclusion, I want to thank this committee on behalf of Mansfield Orthopaedics for being given the chance to testify today, and for your continued interest in making these rules as operational and functional as possible, while not inhibiting our ability to practice medicine in a thorough and efficient manner.


Dr. Nicholas Antell of Mansfield Orthopaedics at Copley Hospital specializes in treating acute musculoskeletal injuries and total joint replacement.

Addressing Opioid Addiction “Close to Home”

By: Leah Hollenberger

As you have likely heard in the news, Vermont is struggling with an opioid addiction epidemic. Unfortunately, there isn’t just one solution to successfully addressing opioid addiction. It takes individuals and organizations working together to address this complex issue. This pain medicineteam-based approach includes our Medical Staff, clinicians, and collaboration with community resources.

Our providers routinely discuss pain management 1:1 with patients. This includes verbal conversation and print materials outlining options, risks, strategies for pain management, and potential side effects. Providers utilize the Vermont Prescription Monitoring System (VPMS) and the Medical Staff, as a group, continue to discuss the issue and how best to address it.

Within our Emergency Department, providers limit opioid prescriptions, with the goal to get the patient to go to a recommended follow up appointment with their primary care physician. Typically, enough pain medication is prescribed to last less than a day; longer if the patient is seen on a weekend to allow them time to get a follow up appointment.

Our clinicians also refer patients to Lamoille County Mental Health’s Alcohol and Substance Awareness Program (ASAP), the area’s Medically Assisted Treatment (MAT) program, and North Central Vermont Recovery Center.

The Women’s Center and the Birthing Center are active with “Close to Home,” a Blueprint for Health program in collaboration with the area’s Medically Assisted Treatment (MAT) program. “Close to Home” provides high quality, low intervention prenatal, obstetric, newborn, and post-partum care at a local level. It is for mothers-to-be already stable in a medication assisted treatment program. Weekly and quarterly reviews ensure these patients get connected to available resources and the participants meet with anesthesia and pediatric providers prior to birth for education on the program. Newborns of women in this program are required to stay at the hospital for 96 hours as it can take 24-48 hours for symptoms of withdrawal to show up. The Women’s Center and Copley’s Birthing Center also refer patients to the Lamoille Family Center’s Rocking Horse program for families living with substance abuse.

Copley’s Patient and Family Services team routinely work with patients and their families to connect them with a variety of social services. We are collaborating with the Blueprint’s Community Health Team at Community Health Services of Lamoille Valley to add a case worker in our Emergency Department. The hospital also promotes drug safety and awareness in publications and through this blog. Check out an earlier post, “Expect Some Pain,” for suggestions you can use to talk candidly with your physician about pain medication and pain management.


Leah Hollenberger is the Vice President of Marketing, Development, and Community Relations for Copley Hospital. A former award-winning TV and Radio producer, she is the mother of two and lives in Morrisville. Her free time is spent volunteering, cooking, playing outdoors, and producing textile arts. Leah writes about community events, preventive care, and assorted ideas to help one make healthy choices.

Expect Some Pain

By: Leah Hollenberger

I recently listened to an interview on NPR about how doctors are wrestling with helping their patients who are in pain without contributing to the growing levels of opioid-addiction.

pain medicineIt was interesting because they spoke with a physician from Massachusetts who commented that he has changed how he prescribes pain medication. It’s now understood that even a short course of opioids (morphine or Dilaudid for example) for a few days can put some patients at risk for developing drug abuse. Now he tends to try NSAIDs first – ibuprofen or Toradol – and has found them to often be effective for his patients.

The interview finished with him saying “a little pain is going to be necessary,” which the radio host then rephrased as “pain is a part of healing.”

It made me think of Copley’s total joint replacement surgery program, during which it is clearly explained that day two and day three post surgery will be the toughest days. Where each patient signs a narcotic contract that clearly spells out when and how clinicians will prescribe along with when they will not. That, while clinicians will try as much as they can, there will be pain and the goal is to keep each patient’s pain managed in the 1-3 level on a scale of 1-10. So, yes, in this case, pain is part of the healing.

However, I think the radio host did a dis-service by continuing the misconception that everything can be healed, that everyone can be pain free. Certainly, that is true much of the time, but not all of the time. And the truth is, if we as a society are going to really reduce opioid-drug addiction, we are going to have to stop believing that a pill is going to be able to solve everything. We are going to have to expect some pain.

So where does that leave us? As a patient what is our responsibility in managing our pain?
Copley encourages you to:

  • Ask your doctor or nurse what to expect regarding pain and pain management
  • Discuss pain relief options with your doctors and nurses
  • Work with your doctor and nurse to develop a pain management plan
  • Ask for pain relief when pain first begins
  • Help your doctor and nurse assess your pain
  • Tell your doctor or nurse if your pain is not relieved, and
  • Tell your doctor or nurse about any worries you have about taking pain medication

Every clinician wants you to be pain-free, but they cannot guarantee it. Accepting that, expecting a little pain, may help you experience a better outcome in the long run.