Let’s stop opi­oid ad­dic­tion where it starts: in hos­pi­tals

Milwaukee Journal Sentinel - - Crossroads - Blake Farmer

Doc­tors at some of the largest U.S. hos­pi­tal chains now ac­knowl­ede that 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.

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.

How pain was treated

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.”

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 Life-Point 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. Kaiser Health News (KHN) is a na­tional health pol­icy news ser­vice. It is an ed­i­to­ri­ally in­de­pen­dent pro­gram of the Henry J. Kaiser Fam­ily Foun­da­tion which is not af­fil­i­ated with Kaiser Per­ma­nente.

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