We are over a decade into what has been termed the most lethal drug crisis in American history. Every healthcare provider is now informed about the dangers of opioids. Almost every hospital has established guidelines for cautious prescribing. And yet — at the point of care, certain things remain unchanged.

This was reaffirmed to me again this week. My husband was admitted to the burn unit after sustaining a severe scald injury to his arm. His discomfort was genuine, his injury was serious — but his past is also complex. Several years ago, following a devastating workplace injury, he was discharged with strong narcotics and subsequently developed secondary PTSD, panic episodes, and dependency on benzodiazepines. We went through a challenging withdrawal and recuperation phase. Since then, he has diligently avoided all sedating drugs, including opioids.

One would assume that his background would have led to a careful discussion about pain management upon admission. Instead, before he even asked for relief, IV dilaudid was delivered to his bedside — part of a routine standing order. I wasn’t present to raise concerns, and had he not advocated for himself, he might have inadvertently accepted a medication that could potentially revive one of the most challenging phases of his recovery.

Fortunately, he voiced his preference and requested IV acetaminophen and IM ketorolac instead. His request was honored. However, the fact that he had to know to speak up is concerning.

To be fair — this isn’t solely about individual clinicians failing to think critically. The cultural attitude towards pain management in American medicine is intricate. For many years, we taught both healthcare professionals and patients that complete absence of pain was the objective. Pain became “the fifth vital sign,” and patient satisfaction metrics sometimes penalized providers who didn’t fully eradicate it. In this context, offering opioids preemptively can seem like the quickest, safest way to fulfill both clinical and cultural demands.

Yet therein lies the paradox. We now recognize that anticipating total absence of pain in the face of serious injury is unrealistic — and that pursuing that aim can lead to harm. Physicians often find themselves in the middle of pressures to appease patients, fears of inadequately treating pain, and awareness of the dangers of opioids. Without system-level direction and clear protocols, it is simple to revert to what has been traditionally accepted: providing opioids first.

We need to transform that culture as well.

In a post-epidemic healthcare framework, we should not compel patients to navigate on their own whether to accept or refuse potent narcotics. Burn protocols, orthopedic protocols, trauma protocols — all of these should now include at least two clear pathways:

– Opioid-based management (when clinically justified, well-informed, and desired by the patient), and
– Opioid-sparing or opioid-free alternatives (for patients with a history of addiction, PTSD, adverse reactions, or strong preferences).

Establishing such pathways would normalize the dialogue. Patients wouldn’t need to feel embarrassed or alone for turning down opioids. Clinicians would have clear, evidence-based options readily available. And most crucially, we would bridge the divide between our public discourse concerning the opioid crisis and our actual practices at the bedside.

This is not about denying individuals pain relief. It is about personalizing pain management to the individual in a manner that is compassionate, safe, and informed by lessons we have agonizingly learned over the last twenty years.

We claim to want to diminish addiction risk. We assert that we wish to honor patient autonomy. Now it’s time for our protocols — and our culture — to embody that in every hospital, for every patient, every time.

Sarah White is a nurse practitioner, small business owner, and premedical student based in Virginia. With a background in clinical practice and caregiving, she provides a distinct perspective on the intersection of medicine, family life, and community engagement. She volunteers with the Medical Reserve Corps and is preparing to apply to medical school in 2026.

Sarah is also the founder of two flourishing enterprises: [Wrinkle Relaxer](https://www.instagram.com/wrinklerelaxer/?hl=en), where she specializes in aesthetic services, and [Bardot Boutique Aesthetics](https://www.instagram.com/bardotboutiqueaesthetics/?hl=en), a space offering curated beauty and wellness services.