I didn't want heavy painkillers after surgery — but my hospital pushed opioids on me anyway

Hospitals want to keep their patients happy, but too often doctors treat pain like a disease and push opioids even when people explicitly say no.

Recently, a member of the Health Rosetta community (Emma Passe) shared a harrowing story in the USA Today that could have led to her death. When we learned of Emma's story, we reached out to the USA Today as it was an important story that had to be told. Emma's op-ed is excerpted below. As Congress just passed a large opioid bill that is going to the President's desk to sign, it's important to recognize that most are greatly over-simplifying the opioid crisis.

Until Congress and employers recognize the 12 major drivers of the opioid crisis, "solutions" will only nibble around the edges. I've excerpted 3 of the 12 major drivers I outlined in The Opioid Crisis Wake-Up Call: Health Care is Stealing the American Dream. Here’s How We Take it Back (follow for a free download). These drivers are the backdrop to Emma's story. The key take-away is that the opioid crisis isn't an anomaly -- it is our healthcare system. The corollary take-away is that, unlike other great public health crises, it can't be solved without employers changing their ways since employers became the key unwitting enabler on 11 of the 12 major drivers. After all, most people negatively impacted by the opioid crisis are working age or their dependents. In other words, employers are funding and fueling the crisis by not paying close attention to this issue.

Increasingly, employers are being held legally liable for the opioid epidemic. There are 15 lawsuits against employers that I know of where the plaintiff makes the case that there was employer negligence to allow such high opioid prescriptions. With very few exceptions (see the Rosen case study in The Opioid Crisis Wake-up Call), there are two types of employers. 1)Those who know there's a problem and are doing something about it. 2)Those who have a problem but don't know or are willfully blind to the opioid issue in their health plan.

If you are a big fan of the opioid crisis, you are a fan of status quo health plans.

Three of the twelve major drivers that created the near-tragedy outlined below

See all 12 major drivers in Chapter 1. Drivers #1, 9 & 10 are listed below.

1) Undertreated pain leading to a 5th vital sign and increased prescribing: This concept was initially promoted by the American Pain Society to elevate awareness of pain treatment among health care professionals. The Veteran’s Health Administration made pain a 5th vital sign in 1998, followed by their creation of the “Pain as the 5th Vital Sign Toolkit” in 2000. This made pain equal to things like blood pressure—a number to be managed with medications or lifestyle changes. In 2001, the Joint Commission established standards for pain assessment and treatment in response to the national outcry about widespread undertreatment, putting severe pressure on doctors and nurses to prescribe opioids.

9)Patient satisfaction scores’ influence on hospital income: Results from HCAHPS and Press Ganey patient satisfaction surveys, which directly impact hospital income, further amped up the pressure. Administrators harangued nurses and doctors to make patients happy by giving them opioids. Data from approximately 52,000 adults was assessed from 2000 to 2007 via the Medical Expenditure Panel Survey; a 26 percent increase in mortality rates was observed among those who were most satisfied. CMS announced it will remove pain management from its determination of hospital payments beginning in 2018, but that doesn’t undo the damage that has been done.

10)Patients looking for a quick fix: An unfortunate part of American culture is seeking quick fixes. Patients want a pill for instant pain relief and advertising has conditioned them to expect one. This tendency is exacerbated by doctors looking for a quick fix during their short appointments with patients. The reality is that most patients hear more from pharmaceutical companies (16-18 hours of pharma ads per year) than from their doctor (typically under 2 hours per year). With this “instant-fix” conditioning from players across the health care system, many patients aren’t willing to invest time in cognitive behavioral therapy, mindful meditation, or a regular program of PT/exercise. At the same time, we’ve forgotten that some pain is a good indicator of a problem to solve and shouldn’t be instantly numbed.

Emma Passé has 14 years experience in the insurance industry. She is currently at Employee Benefit Management Services, Inc., an independent Third Party Administrator (TPA) where she helps employers and their employees incentivize higher value care at lower costs.

This is Emma's story...

This is a story about how the health care industry effectively forces patients into opioid use. I know, because this recently almost happened to me. And it could have cost me my life. 

A few weeks ago, I had a major abdominal surgery. I have had two similar surgeries before, which taught me how well I tolerated both pain — and painkillers. Pain, while uncomfortable, was not unbearable. Far worse were the drugs, which caused uncontrollable nausea, dizziness, vomiting and overall malaise. That was not something I was keen on dealing with again, least of all following a stomach surgery. Before my procedure, I made sure to have these requests documented in my medical records.

That’s where the trouble started.

During the month before my surgery, every professional I met with did their utmost to assure me that this time would be different. This time, they emphasized, I should expect the very worst in terms of pain. Time and again, I gave them the same answer I had given in my initial consultation and had written in my medical file: “I prefer not to use any heavy narcotics outside of the necessary anesthesia.” And time and again, I was met with the same slack-jawed expression and incredulous response.

Oh no, they all assured me. No, no, no — I really didn’t understand just how painful this surgery would be.

I really did, I insisted, and began to explain that I had had similar surgeries — only to be immediately cut off and told that my prior surgeries hadn’t been anywhere near as serious as this one, and that I was going to need something quite strong to make the pain go away.

Make the pain go away. As though the pain itself were a disease or disorder. The physicians were emphatic, as though my future pain was more of an issue than the current tear in my abdomen. 

“I understand I’m going to be in pain,” I repeated, equally emphatically, and now to the point of frustration. “The pain is not the issue.”

My surgeon was the only individual who did not disregard my decision to manage without prescription painkillers, and in my file noted that my post-discharge pain management plan would consist of standard, over-the-counter Tylenol. 

That note was later updated to read Tylenol 3 — with codeine (an opioid) — by the hospital staff. No one believed that I could manage without something stronger. Sure enough, upon discharge, I was given a prescription for 40 tablets of codeine.

Forty.

Pain is a symptom, not a disease

Later I sat at home, the flimsy piece of dull blue paper trembling in my hands, its 4 and 0 scrawled out in sharp black ink. Forty tablets of codeine. For what? For an otherwise healthy woman, who had insisted on her preference of not using anything stronger than over-the-counter Tylenol? A woman who had made sure her choice was indicated in her medical file?

Why had it been so difficult for me to not obtain narcotics? In my head, I replayed the events of the past 18 or so hours: Over the course of a one-night hospital stay, I had been offered and denied narcotics at least half a dozen times. It began immediately following my surgery. Not long after I had awakened, a nurse entered my room and attempted to administer Dilaudid through an IV. When I stopped her, I learned I had already been given Dilaudid once, while unconscious.

I began to dread the thought of falling asleep.

Every few hours, another nurse would appear and attempt another dose of Dilaudid. When I explained effects that these painkillers tended to cause for me, one nurse seemed to listen at first, then replied that the staff would give me the Dilaudid to manage my pain, and then give me yet another drug, an anti-emetic, to cope with the nausea.

Even my indirect interactions with the hospital were marked by the medical industry’s near-militant insistence on eviscerating pain. All the questionnaires I received before and after my surgery were all centered around pain management. On the wall of my hospital room, a stark white sign blared in large block letters: "Pain management is a patient right. Please tell us about your pain." 

Pain management was a patient right. Painkiller refusal, it seemed, was not.

"It’s about you, our patient," the sign added, in smaller script underneath. But was it? Too often, the incentive structure that pervades the industry sets things up so that health care professionals work harder to serve drug companies and hospitals than actual patients and policyholders.

There are other incentives at work, as well. Patient satisfaction scores now play a role in hospital reimbursement rates. As an Annals of Family Medicine study reported this year, patients who are prescribed high doses of opioids were more likely to report high satisfaction with care — meaning higher rates of Medicare reimbursements for their providers.

Similarly, in 2014 a Patient Preference and Adherence survey indicated that nearly half of doctors admitted to prescribing inappropriate narcotic medication because of the incentive to acquire higher satisfaction scores. The misalignment can have deadly consequences.

Incentive should be to save lives, not sell drugs

Three days after my surgery, I experienced a sharp, persistent pain in my right calf. In the emergency room, an ultrasound located a blood clot just below my right knee. Post-surgical clots can quickly travel through the body and into the lungs, where a pulmonary embolism could have catastrophic consequences for a patient.

I reflected on my experiences and had the chilling thought: Had I taken my (filled, but still unused) prescription for 40 Tylenols with codeine, would I have been able to identify the pain in my leg? If I had regarded pain as a disease rather than a symptom, and tried to eradicate the pain rather than treat its causes, would I be sitting here today?

We in the medical industry have a chance — and a duty — to use our expertise toward eradicating something far worse than pain: an epidemic that destroys lives, eats through money, and endures through a perverse incentive structure to which no one in my field is fully immune. If we all took a bold step to commit to change and refuse the siren song of kickbacks, reimbursements and misaligned rewards, wouldn’t the lives we save be incentive enough?

The op-ed was published originally on USA Today.

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Dave Chase is the co-founder of the Health Rosetta (a LEED-like organization for healthcare), and author of the book, “The Opioid Crisis Wake-up Call: Health Care is Stealing the American Dream. Here's How We Take it Back.” Follow the link to the book for a free download of the book. Chase's TEDx talk was entitled "Healthcare stole the American Dream -- here's how we take it back." See the Health Rosetta website for how to get involved, resources and how to join others to support its mission.

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