Pain control is tricky for doctors. After 14 years practicing medicine, relieving pain continues to be one of the most challenging aspects of what I do. To the casual observer pain control may seem fairly simple: Your patient has pain; you treat the pain. Then, you find out what is causing the pain and treat that, too. Except what happens when you cannot find the cause of the pain? Or, when the cause has no treatment? What about when emotional or psychological problems are causing the pain? What if the only treatment that patient finds acceptable is dangerous, addictive, and could ultimately kill them?

Over the past two decades, for various reasons, regulatory agencies decided that medical providers needed to do a better job controlling pain. They mandated several changes in the way physicians monitor and treat pain. They required that pain be labeled as "the fifth vital sign," requiring us to measure it in all patients and address it in our treatment plans. They placed the "pain scale" next to time honored, objective measures like temperature, heart rate, respiration, and blood pressure. However, unlike the other four vitals signs, we cannot objectively measure pain since it is largely affected by personal experience and emotional state. As with other governmental regulations, the healthcare community could see the error in this approach, but simply had no option but to comply. A generation of new medical trainees were raised with the principles of abolishing pain and the narcotics flowed liberally from pharmacies and hospitals nationwide.

This imperative to control pain better has since resulted in an epidemic of prescription drug abuse, dependency, overdose, and death. Since then, drug overdose deaths have more than tripled, with over 38,000 deaths in 2010 alone. This is roughly equal to a jumbo jet carrying 350 people crashing every day for three and a half months. Emergency room visits for misuse and abuse of prescription painkillers doubled nationally to 475,000 over that same time. And, prescription opiates now cause more overdose deaths than heroin and cocaine combined.

Sadly, this is only the tip of the iceberg: consider the long term impact of drugs in schools, the costs of treating addiction, lost time at work, and insurance claims related to addiction or fabricated medical problems invented to obtain narcotics and perpetuate their use. The cost to society is truly staggering.

Clearly, something had to be done, but what? How can a physician who is meeting someone for the first time tell the patient who has a legitimate need for pain medicine from one who may simply be pretending to get a prescription? How do you weigh the risks of treatment even for those who do legitimately have severe pain? Even after 14 years I still often have difficulty knowing what is right and wrong. Emergency physicians nationwide are now stepping forward to help find a solution. What we needed were guidelines, supported by good evidence. We also needed information to monitor narcotic prescriptions and identify high-risk behavior. Most importantly, we needed support from hospital administrations and government to allow us to find the right balance between managing expectations and requests for narcotics, and our ability to practice sound medicine and protect our patients and communities from drug abuse.

Vermont has taken two important steps to counter this problem. The state has developed a central prescription-monitoring database. The database makes it easier to spot someone who is doctor, hospital, or pharmacy shopping for medications - one sign of prescription abuse. Vermont also enacted its version of a federal program called "Team Care" to monitor high-risk patients and disseminate information to health care providers.

For our part, Southwestern Vermont Medical Center's (SVMC) Emergency Department recently released our Opiate Prescribing Guidelines. These guidelines help us standardize our approach to treating pain without enabling drug abuse or diversion. They also help us identify and refer high-risk patients to treatment programs. Similar guidelines enacted elsewhere in the US have led to a 23 percent drop in pain medicine overdoses.

As the medical director of emergency medicine at SVMC, I am proud of this effort. I know, however, that these are only the first steps in addressing this problem. We will improve our effort to protect our patients and community while continuing to provide thoughtful and compassionate care to all who come through our doors.

Adam Cohen, MD, is the medical director of emergency medicine at Southwestern Vermont Medical Center. A member of Dartmouth-Hitchcock Putnam Physicians, Dr. Cohen is certified by the American Board of Emergency Medicine and the American Board of Internal Medicine. "Health Matters" is a weekly column from Southwestern Vermont Health Care (SVHC) meant to educate readers about their personal health, public health matters, and public policy as it affects health care. To learn more about SVHC, visit svhealthcare.org.