The big hospital chains based in Nashville are accepting some of the blame for the country's opioid crisis, which grows more deadly by the year. They admit they were going overboard with opioids to make people as pain-free as possible. So in an effort to be part of the cure, they're issuing an uncomfortable warning to patients — you're going to feel some pain.
"I had the c-section, had the kiddo," says 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 addicts herself. She welcomed the high-dose intravenous narcotics while she was in the hospital. And as she went home, she gladly followed doctors' orders and kept ahead of the pain with her Percocet pills.
But then she needed stronger doses. And pretty 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 says. "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 was becoming like the addicts she transported by ambulance, lying to emergency room doctors to con a few extra doses.
Pretty soon she lost her job and her fiancé before going to rehab through Nashville-based American Addiction Centers and stitching her life back together.
A 180 On Opioids
It's a reality that has been completely disconnected from where it often starts — in a hospital. Anesthesiologist David Alfery in Nashville says he was rarely stingy with opioids.
"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 says.
Alfery's part of a working group at the Nashville-based consulting firm Health Trust, where hospitals have set aside some of their competitive interests to swap ideas.
"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 says.
That expectation exists in part because pain treatment was institutionalized. Hospitals have been graded on how well they keep someone's pain at bay. And doctors can feel some pressure.
"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," says Mike Schlosser, chief medical officer for HCA's national group of hospitals.
Schlosser spent a decade as a spinal surgeon putting his patients at HCA's flagship facility, Centennial Medical Center, through some of the most painful procedures in medicine, like correcting back curvature. He says he genuinely just 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 says.
Looking at company-wide data for the largest for-profit hospital chain in the country, he’s found that for orthopedic and back surgeries, the greatest risk isn’t infection or some other complication — it’s addiction.
So HCA 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 so that you have no pain really puts you at risk of becoming addicted to that narcotic," Schlosser tells patients.
Besides issuing the uncomfortable warning, limiting opioids also takes more work on the hospital's part — trying nerve blocks and finding the most effective blend of non-narcotics. 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 narcotics.
Managing The Optics
Of course business-wise, no one wants to be the hospital where it hurts more.
"You don't want to portray the fact that you're not going to treat people appropriately," says John Young, national medical director of cardiovascular services for LifePoint Hospitals. The Brentwood-based hospital chain is putting special emphasis on how it handles people coming into the ER looking for pain medicine.
Young says tightening up on opioids is 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 says.
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. She says it can be done.
"I mean, it hurt," she says. "But I lived."