We are more than a decade into what has been called the deadliest drug epidemic in American history. Every medical professional is now educated on the risks of opioids. Nearly every hospital has issued guidelines about careful prescribing. And yet — at the bedside, some things haven’t changed.

This was driven home to me again this week. My husband was admitted to the burn center after suffering a severe scald injury on his arm. His pain was real, his injury was serious — but his history is also complicated. Several years ago, after a catastrophic workplace injury, he was sent home on heavy narcotics and soon developed secondary PTSD, panic attacks, and benzodiazepine dependence. We lived through a difficult withdrawal and recovery period. Since then, he has worked hard to avoid all sedating medications, including opioids.

You would think that his history would have prompted a careful conversation about pain management upon admission. Instead, before he even requested relief, IV dilaudid was brought to his bedside — part of a routine standing order set. I wasn’t there to speak up, and had he not learned to advocate for himself, he could have unknowingly accepted a medication with the potential to reopen one of the most difficult chapters of his recovery.

Thankfully, he spoke up and requested IV acetaminophen and IM ketorolac instead. His choice was respected. But the fact that he had to know to speak up at all is troubling.

But to be fair — this is not just about individual clinicians failing to think. The culture of pain management in American medicine is complicated. For decades, we taught both doctors and patients that zero pain was the goal. Pain became “the fifth vital sign,” and patient satisfaction scores sometimes punished providers who didn’t completely eliminate it. In that environment, offering opioids preemptively can feel like the safest, fastest way to meet both clinical and cultural expectations.

Yet here lies the contradiction. We now know that expecting complete absence of pain in the face of serious injury is unrealistic — and that chasing that goal can lead to harm. Physicians are often caught between pressure to satisfy patients, fear of undertreating pain, and awareness of the risks of opioids. Without system-level guidance and clear protocols, it is easy to default to what has historically been the norm: offering opioids first.

We need to change that culture, too.

In a post-epidemic health care system, we should not be forcing patients to individually navigate whether to accept or decline powerful narcotics. Burn protocols, orthopedic protocols, trauma protocols — all of these should now be built with at least two clear pathways:

• Opioid-based management (when clinically needed, well-informed, and desired by the patient), and
• Opioid-sparing or opioid-free options (for patients with a history of addiction, PTSD, adverse responses, or strong preference).

Having such pathways would normalize the conversation. Patients wouldn’t need to feel ashamed or isolated for declining opioids. Clinicians would have clear evidence-based alternatives ready to offer. And most importantly, we would close the gap between our public messaging about the opioid crisis and our actual bedside practice.

This is not about denying people pain relief. It is about tailoring pain management to the individual in a way that is compassionate, safe, and informed by lessons we have painfully learned over the past two decades.

We say we want to reduce addiction risk. We say we want to respect patient autonomy. Now it’s time for our protocols — and our culture — to reflect 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 brings a unique perspective to the intersection of medicine, family life, and community service. She volunteers with the Medical Reserve Corps and is preparing to apply to medical school in 2026.

Sarah is also the founder of two growing ventures: Wrinkle Relaxer, where she specializes in aesthetic treatments, and Bardot Boutique Aesthetics, a space for curated beauty and wellness services.