Doctors at some of the largest U.S. hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nation’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain.
Even for people who’ve never struggled with drug abuse, studies are finding that patients are at risk of addiction anytime they go under the knife.
“I had the C-section, had the kiddo,” said Michelle Leavy of Las Vegas. “And then they tell me, ‘It’s OK, you can keep taking the pain medications, it’s fine.'”
Leavy is a mother of three and a paramedic who has dealt with many patients coping with addiction. She welcomed the high-dose intravenous narcotics while in the hospital and, upon her release, gladly followed doctors’ orders to keep ahead of the pain with Percocet pills.
But then she needed stronger doses. Soon, she realized, she was no longer treating pain.
“Before I went to work, I took them, and to get the kids after school, I had to take them,” she said. “Then I was taking them just to go to bed. I didn’t really realize I had a problem until the problem was something more than I could have taken care of myself.”
She said she was becoming like the patients with addiction problems that she transported by ambulance, lying to emergency room doctors to con a few extra doses.
Soon she lost her job and her fiancé, before going to rehab through American Addiction Centers and stitching her life back together.
A 180 On Opioids
Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital. Anesthesiologist David Alfery said he was rarely stingy with the pain medicine.
“If I could awaken them without any pain whatsoever, I was the slickest guy on the block, and it was a matter of enormous pride,” he said.
Alfery is part of a working group at the Nashville-based consulting firm Health Trust behind hospital efforts to set aside rivalry and swap ideas about a top priority: reducing opioid use.
“It starts with patient expectations, and I think, over the years, patients have come to expect more and more in terms of, ‘I don’t want any pain after surgery,’ and it’s an unrealistic expectation,” Alfery said.
Michelle Leavy had emergency gallbladder surgery in June. She refused opioids before, during and after the procedure. “It hurt,” she says, “but I lived.” (Courtesy of Michelle Leavy)
That expectation exists in part because pain treatment was institutionalized. Hospitals are graded on how well they keep someone’s pain at bay. And doctors can feel institutional pressure, and on a personal level.
“I just wanted my patient not to be in pain, thinking I was doing the right thing for them and certainly not an outlier among my colleagues,” said Mike Schlosser, chief medical officer for a division of HCA, the nation’s largest private hospital chain.
Schlosser spent a decade as a spinal surgeon putting his patients at HCA’s flagship facility in Nashville through some of the most painful procedures in medicine, like correcting back curvature. He said he genuinely wanted to soothe the hurt he caused.
“But now looking back on it, I was putting them at significant risk for developing an addiction to those medications,” he said.
Using HCA’s vast trove of data, he found that for orthopedic and back surgeries, the greatest risk isn’t infection or some other complication — it’s addiction.
So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.
“We will treat the pain, but you should expect that you’re going to have some pain. And you should also understand that taking a narcotic [dose so high] that you have no pain, really puts you at risk of becoming addicted to that narcotic,” Schlosser said, recounting the new recommended script for surgeons speaking to their patients.
Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital’s part — trying nerve blocks and finding the most effective blend of non-narcotic medicine. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don’t need potentially addictive drugs, or at least not in high dosage, he said.
There are potential benefits aside from avoiding addiction.
“I’ve had people tell me that the constipation [resulting from opioid use] was way worse than the kidney stone,” said Valerie Norton, head of the pharmacy and therapeutics council for Scripps Health System in San Diego, which is participating in the Health Trust working group.
“There are lots of other complications from opioids — severe constipation, nausea, itching, hallucinations, sleepiness. We really need to treat these drugs with respect and give people informed consent. And let people know these are not benign drugs.”
In California, where 1,925 people died from opioid overdoses and 26.6 million opioid prescriptions were handed out in 2016, hospitals also are changing how they treat patients for pain.
Physician leaders in the massive Kaiser Permanente health system’s Southern California region are working to get clinic and hospital doctors to cut back on opioid prescribing, and they empowered pharmacists to question excessive prescriptions. They’re also pushing colleagues to offer non-drug options to patients. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
Other hospital systems are working on similar initiatives, and a group of 20 San Francisco Bay Area emergency rooms adopted new guidelines to more safely provide opioids to patients, including prescribing smaller amounts after a visit and declining to refill lost or stolen prescriptions.
Managing The Optics
Of course, business-wise, no one wants to be known as the hospital where treatment hurts more.
“You don’t want to portray the fact that you’re not going to treat people appropriately,” said John Young, national medical director of cardiovascular services for LifePoint Health, another player at the table with Health Trust. The Nashville-based hospital chain is putting special emphasis on how it handles people coming into the ER looking for pain medicine.
Young said tightening up on opioids becomes a delicate matter but it’s the right thing to do.
“We really do have a lot of responsibility and culpability and this burden, and so we have to make sure we do whatever we can to stem this tide and turn the ship in the other direction,” he said.
While hospitals get their ship in order, some patients are taking personal responsibility.
Now that she’s in recovery, Michelle Leavy won’t touch opioids. That meant she had emergency gallbladder surgery in 2017 without any narcotics. Leavy said she was nervous about telling her doctors about her addiction, but they were happy to find opioid alternatives.
“I mean, it hurt,” she said. “But I lived.”
This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.
California Healthline Senior Correspondent Barbara Feder Ostrov contributed to this report.